Manual Lymph Drainage

Manual Lymph Drainage

PEP Topic 
Lymphedema
Description 

Manual lymphatic drainage (MLD) is a treatment technique that uses a series of rhythmic light strokes to reduce swelling and improve the return of lymph to the circulatory system. It is intended to encourage fluid away from congested areas by increasing activity of normal lymphatics and bypassing ineffective or obliterated lymph vessels. MLD is an integral component of complete decongestive therapy and is widely advocated based on clinical expertise, but little research data conclusively support its stand-alone use. The most appropriate techniques, optimal frequency, indications for MLD, and benefits of treatment remain to be clarified. Performing MLD is a specialized skill that requires regular practice to maintain competence. Deep, heavy-handed massage should be avoided because it may damage tissues and exacerbate edema by increasing capillary filtration.

Badger, C., Preston, N., Seers, K. & Mortimer, P. (2004). Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database of Systematic Reviews, 4, CD003141.

Woods, M. (2003). The experience of manual lymph drainage as an aspect of treatment for lymphoedema. International Journal of Palliative Nursing, 9(4), 336-342.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Beck, M., Wanchai, A., Stewart, B.R., Cormier, J.N., & Armer, J.M. (2012). Palliative care for cancer-related lymphedema: A systematic review. Journal of Palliative Medicine, 15(7), 821–827.

doi: 10.1089/jpm.2011.0494
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Purpose:

To a conduct a systematic review of the published literature related to the effectiveness of cancer-related lymphedema management in palliative care

Search Strategy:

Databases searched were PubMed, MEDLINE, CINAHL, Cochrane Library databases, PapersFirst, Proceedings First, Worldcat, PEDro, National Guidelines Clearing House, ACP Journal Club, and Dare.

Search keywords were lymphedema (lymphoedema, lymphodema, elephantiasis, swelling, edema, and oedema) and palliative care (advanced disease and metastatic cancer).

Studies were included in the reivew if they related to lymphedema management in the setting of palliative care, including randomized controlled trials, cohort studies, case-control studies, meta-analyses, and systematic reviews.

Studies were excluded if they

  • Had no available English translation
  • Did not evaluate an intervention
  • Did not address lymphedema in the palliative care period
  • Were abstracts only, letters to the editor, cross-sectional studies, qualitative studies, or general lymphedema overviews.

Literature Evaluated:

  • Using the search terms, 31 references were retrieved.
  • The research was evaluated using the PEP categories of levels of evidence.

Sample Characteristics:

  • Eleven studies were included.
  • Samples sizes ranged from 1–90 across studies.
  • Samples included patients with various types of advanced or metastatic cancer and lymphedema.

Phase of Care and Clinical Applications:

Patients were undergoing end-of-life and palliative care.

Results:

The study identified four categories of lymphedema in the palliative care settings.

  • Five case studies addressed closed-controlled subcutaneous drainage.
  • One retrospective study dealt with manual lymphatic drainage (MLD).
  • Two case studies looked at compression therapy.
  • Three case studies addressed complete decongestive therapy (CDT).

Only a few studies (4 out of 11) included objective measures of outcomes. All studies were in the category of "Effectiveness Not Established" assessed by the Oncology Nursing Society Putting Evidence Into Practice classification.

Conclusions:

A lack of rigorously designed clinical research studies have been conducted pertaining to the treatment of lymphedema in patients with advanced or metastatic cancer.

Limitations:

  • Articles published prior to January 2004 were not included in this systematic review. The authors did not provide an explanation for this.
  • Articles with no available English translation were excluded. This exclusion criterion indicates that articles from non-English countries (e.g., Germany, China, and India) were not reviewed; however, the authors did not state the possible number of these non-English articles.

Nursing Implications:

This systematic review indicated that the identified procedures (closed-controlled subcutaneous drainage, MLD, compression therapy, and CDT) are relatively safe. Nurses may consider recommending these procedures to individuals with lymphedema and advanced or metastatic cancer. Nurse scientists need to conduct more rigorously designed studies to test the effectiveness of management of cancer-related lymphedema in palliative care.

Huang, T.W., Tseng, S.H., Lin, C.C., Bai, C.H., Chen, C.S., Hung, C.S., … Tam, K.W. (2013). Effects of manual lymphatic drainage on breast cancer-related lymphedema: A systematic review and meta-analysis of randomized controlled trials. World Journal of Surgical Oncology, 11, 1–8.

doi: 10.1186/1477-7819-11-15
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Purpose:

To examine the evidence on manual lymphatic drainage (MLD) in the prevention or management of limb edema in postsurgical women with breast cancer

Search Strategy:

  • Databases searched were PubMed, EMBASE, CINAHL, SCOPUS, Cochrane Central Register, ClinicalTrials.gov, and PEDro.
  • Search keywords were MeSH terms for manual lymph drainage, breast cancer, and lymphedema.
  • Studies were included in the review if they were randomized controlled trials or quasi-experimental and evaluated the outcome of MLD for prevention or management of lymphedema. All studies involved patients with breast cancer.
  • Studies were excluded from the review if they included patients who did not have axillary lymph node excision or clinical outcomes were not clearly stated.

Literature Evaluated:

The literature search retrieved 170 references. Authors independently evaluated methodological quality in terms of blinding, attrition, and use of intention-to-treat analysis. No specific tool for evaluation was described.

 

Sample Characteristics:

  • Ten studies were included in the review.
  • The total sample size was 536 patients, with a range of 24–158.
  • Age ranged from 25–77 years.
  • All patients had undergone axillary lymph node excision for breast cancer.

Phase of Care and Clinical Applications:

Patients were undergoing mutliple phases of care.

Results:

Some trials focused on prevention and others involved treatment of lymphedema. Nine studies were included in meta-analysis. Findings showed a risk ratio of 0.063 (95% CI 0.14, 2.83, p = 0.54). High heterogeneity existed. Standard mean difference (SMD) findings showed no benefit of MLD, with SMD = 75.12 (95% CI -9.34, 159.58). Findings showed that the addition of MLD to other individual components of complete rehabilitation such as compression bandaging does not show a significant benefit in reducing arm volume. Overall published reports of MLD show conflicting results. No significant differences were found in the incidence of lymphedema between patients treated with MLD or not.

Conclusions:

MLD does not add significant benefit for prevention or management of lymphedema in patients with breast cancer.

Limitations:

  • High heterogeneity existed between studies. 
  • Several trials were small.
  • Only half of the studies reported adequate randomization. 
  • In most studies, data collectors were not blinded.

Nursing Implications:

Findings suggest that MLD as an adjunctive treatment is not effective in preventing or managing arm lymphedema in women with breast cancer who have had axillary lymph node excision.

McNeely, M.L., Peddle, C.J., Yurick, J.L., Dayes, I.S., & Mackey, J.R. (2011). Conservative and dietary interventions for cancer-related lymphedema: A systematic review and meta-analysis. Cancer, 117(6), 1136–1148.

doi: 10.1002/cncr.25513
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Purpose:

To update evidence from randomized controlled trials (RCTs) regarding benefits of conservative and dietary interventions for all cancer-related lymphedema

Search Strategy:

Databases searched were MEDLINE, EMBASE, CINAHL, PubMed, Dissertation Abstracts, PEDro, and Cochrane Collaboration. Keywords were neoplasm, axillary dissection lymph node excision, lymphedema, conservative treatments (e.g., stockings compression, manual drainage), and publication types of random allocation and clinical trial. Studies were included in the review if they were RCTs with a sample of at least 80% patients with cancer comparing a conservative or dietary intervention to placebo, control, or comparison intervention in secondary lymphedema from cancer. Exclusion criteria were not specified.

Literature Evaluated:

Of the 157 papers that were initially retrieved, a final set of 25 were included. A modified Jadad scoring was used to evaluated the quality of the evidence. Only eight studies met criteria for high quality. Meta-analysis was done for studies examining the effect of manual lymph drainage (MLD)for upper-extremity lymphedema with breast cancer.

Sample Characteristics:

  • The final sample of 25 papers involved 1,018 participants.
  • Study sample sizes ranged from 11–90.
  • Of the 25 papers, 21 were in patients with breast cancer.

Results:

Results were synthesized in terms of effects on lymphedema volume and patient-rated outcomes of pain, heaviness, tenderness and quality of life for nine interventions. Most studies were limited to upper extremities; where lower extremities were included is stated below.

  • Strong evidence from three studies on exercise showed neutral impact on volume and benefit in symptoms and quality of life with upper extremities.
  • There was moderate evidence from one study on compression bandaging for lower- and upper-extremity volume reduction and no evidence related to symptoms
  • Compression Garments
  • Moderate evidence found volume reduction for upper and lower extremities with compression garments. No evidence was found related to symptoms.
  • Three studies had no evidence of benefit of MLD for symptoms; volume of lymphedema was not reported.
  • One study showed moderate benefit related to short-term volume for deep mechanical oscillation with MLD and moderate evidence of benefit for symptoms in the short term but not at follow up.
  • One study showed no evidence of any benefits from mechanically stimulated MLD.
  • One study showed limited short-term benefit in lymphedema volume, but no evidence of benefit for symptoms with dietary modification.
  • Four studies showed limited evidence of benefit in the short and long term for laser therapy ,and three showed limited evidence for benefit related to pain.
  • One study provided no evidence of benefit from electrically-stimulated lymphatic drainage
  • Four studies provided conflicting evidence, with two showing benefit in volume and two showing no benefit from intermittent pneumatic compression.
  • Meta-analysis results found five studies including 198 cases examined the addition of MLD to compression therapy alone or compression therapy along with other interventions. 
  • Analysis showed that the addition of MLD was beneficial (SD = 0.37, 95% CI 0.07–0.67, p = 0.02)

Conclusions:

Meta-analysis demonstrated significant but relatively small benefit from the addition of MLS in patients with breast cancer-related lymphedema. Findings support the growing body of evidence that participation in exercise does not exacerbate lymphedema and can reduce the severity of symptoms. Only two studies were found that examined nutrition and dietary interventions; these reported benefit in terms of volume reduction, but were of relatively low quality. Evidence suggests that compression garments and bandaging are effective in reducing limb volume with various types of cancer.

Limitations:

Only eight studies in this review were deemed to be of high quality.

Nursing Implications:

Inclusion of MLD provides a relatively small added benefit and may be associated with substantial costs. It is not clear if the benefits outweigh the cost and MLD may be most useful for patients who do not achieve sufficient improvement with other effective approaches. Findings related to dietary interventions are promising, pointing to the value of additional research in this area. Breast cancer continues to be the most frequently studied group. Research in other groups and with lower-limb lymphedema is needed.
 

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

Sadoon, M., & Al-Atiyyat, N. (2013). The efficacy of manual lymph drainage for breast cancer–related lymphoedema. British Journal of Community Nursing, 18(Suppl.), S18–S22.

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Purpose:

STUDY PURPOSE: To assess existing research on the effectiveness of manual lymphatic drainage (MLD) as a means of preventing and/or managing lymphedema

 

TYPE OF STUDY:  Systematic review

Search Strategy:

DATABASES USED: Google Scholar, PubMed, CINAHL


KEYWORDS: manual lymph drainage, breast cancer–related lymphoedema


INCLUSION CRITERIA: Each article had to be available in full text, published in English from 2008 to the present, regarding patients with lymphedema after breast cancer treatment. Each article needed to define lymphedema, to describe the inclusion and exclusion criteria used for patient selection, the MLD technique used, the compression strategy used, and an evaluation of severity of lymphedema.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: Nine references were retrieved.


EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Level of evidence based on the Oxford Centre for Evidence-Based Medicine (Level 1: two systematic reviews; level 2: five randomized, controlled studies; level four: one cross-sectional descriptive study, one longitudinal observation study). 

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED =  9
  • TOTAL PATIENTS INCLUDED IN REVIEW: 1,850 (final sample); 1,807 with upper extremity, 43 with lower extremity

Phase of Care and Clinical Applications:

PHASE OF CARE:  Mutliple phases of care

Results:

Conflicting information regarding the effectiveness of MLD with variability in the application, duration, and frequency of MLD in the different studies

Conclusions:

Authors suggested that MLD is unlikely to produce significant volume reduction when added to compression and exercise therapy. The characteristics of individual patients can affect the clinical outcomes.

Limitations:

Further research into the efficacy of MLD is needed.

Nursing Implications:

The current standard of care for lymphedema is complete decongestive therapy, which includes MLD, compression, skin care, and exercise. Current research on individual modalities are conflicting regarding MLD. More research is needed.

Research Evidence Summaries

Bergmann, A., da Costa Leite Ferreira, M.G., de Aguiar, S.S., de Almeida Dias, R., de Souza Abrahao, K., Paltrinieri, E.M., . . . Andrade, M.F. (2014). Physiotherapy in upper limb lymphedema after breast cancer treatment: A randomized study. Lymphology, 47, 82–91.

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Study Purpose:

To compare the effects of physical treatment with and without manual lymphatic drainage (MLD) on lymphedema in breast cancer survivors after lymphadenectomy

Intervention Characteristics/Basic Study Process:

Patients were randomized into three groups. Group 1 received MLD, skin care, bandaging, and remedial exercises. Group 2 received soft touch (a sliding touch on chest and upper limbs), skin care, bandaging, and remedial exercises. Group 3 received skin care, bandaging, and remedial exercises. Groups 2 and 3 were combined after an initial analysis revealed no differences, and additional patients were randomized into the two groups. A physiotherapist trained in lymphedema therapy administered treatments three times per week to all patients in two phases. In phase 1, all patients received skin care, compressive bandaging, and remedial exercises, and group 1 received 30 minutes of MLD using the Vodder technique while group 2 did not receive any MLD. When arm volume plateaued for one week, patients from both groups moved to phase 2, which consisted of skin care, exercises, and fitted garments. Volume was assessed at randomization, after each treatment session, and at each follow-up visit. For both groups, phase 1 lasted approximately 24 days.

Sample Characteristics:

  • N = 57  
  • AVERAGE AGE = 62 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: Most participants were overweight (body mass index mean = 29.75).

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Brazil

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Study Design:

Randomized, controlled trial

Measurement Instruments/Methods:

  • Volume was measured using the truncated cone formula with circumferences at 7, 14, and 21 cm under and 7 and 14 cm above the cubital fold
  • Volume excess
  • Absolute volume excess

Results:

Patients in group 1 completed phase 1 in an average of 21.54 days, and patients in group 2 completed it in an average of 27.34 days. A significant reduction in limb volume was seen during phase I for both groups (p < .001), but no difference was seen between the groups. Patients in groups 1 and 2 had an average volume excess reduction of 15.02%. In both groups, 73.7% of participants reported subjective feelings of improvement in swelling.

Conclusions:

The results of this study do not support the addition of MLD to treatment protocols for lymphedema after breast cancer. Patients in both groups of this study showed a statistically significant reduction in total arm volume after phase 1, and there were no differences in arm volume reduction between groups. Patients in group 1 did complete phase 1 in fewer days than patients in group 2.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding)

 

Nursing Implications:

This study does not support the use of MLD to treat lymphedema in breast cancer survivors after lymphadenectomy. Nurses should regularly assess patients who have completed breast cancer treatment for lymphedema and should provide appropriate referrals for treatment, give education about completing exercises at home, advise patients about wearing compression garments, and explain how to properly conduct skin care for a limb affected by lymphedema.

Clemens, K.E., Jaspers, B., Klaschik, E., & Nieland, P. (2010). Evaluation of the clinical effectiveness of physiotherapeutic management of lymphoedema in palliative care patients. Japanese Journal of Clinical Oncology, 40(11), 1068–1072.

doi: 10.1093/jjco/hyq093
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Study Purpose:

To determine the effectiveness and frequency of manual lymphatic drainage (MLD) in patients with lymphedema secondary to advanced stage cancer undergoing palliative care

Intervention Characteristics/Basic Study Process:

Patients were included in the study if they had lymphedema-related symptoms, pain, and dyspnea. The intervention strategy consisted of utilizing demographic information and disease-related data to calculate and compare the effects of MLD on lymphedema-related symptoms. MLD was performed daily on patients until discharge, and the effects were documented.

Sample Characteristics:

  • The study sample (N = 90) was comprised of 36.7% male and 63.3% female patients.
  • Mean age was 65.5 years. 
  • Patients had a variety of cancer types, including thoracic, gastrointestinal, genitourinary, breast, and pancreatic. 
  • Seventy-four percent of patients reported pain, 88.1% reported somatic pain, 11.9% reported somatic and neuropathic pain, and 25.6% reported dyspnea.

Setting:

The study took place in an in-patient setting in a palliative care unit from January to December 2007.

Phase of Care and Clinical Applications:

Patients were undergoing active treatment for lymphedema. The study has clinical applicability for palliative care.
 

Study Design:

The study used a retrospective, reflexive control design.

Measurement Instruments/Methods:

  • A numeric rating scale was used to measure pain and dyspnea.
  • A four-point Likert scale assessed lymphedema reduction.
  • The Karnofsky Performance Scale Index determined the level of functional impairment.
  • SPSS Statistics evaluated data.

Results:

Sixty-seven patients reported pain (59 somatic, 8 somatic and neuropathic) and 23 patients reported dyspnea. Patients in the study received an average of seven MLD treatments. MLD treatment lasted an average of 41.3 minutes. The treatment was tolerated well in 92.2% of patients. Ninety-four percent of patients reported a reduction of pain and 73.9% of patients reported a reduction of dyspnea  post-treatment. Four of the eight patients with reported neuropathic pain had to discontinue the MLD intervention because of increased intensity of pain during treatment. The patient self-report of lymphedema reduction on the Likert scale was reported as 18.9% as little, 64.4% as good, and 16.7% as good.

Conclusions:

The study suggests a positive correlation between a significant decrease in pain and dyspnea after MLD in patients with advanced disease or cancer undergoing palliative care but increased pain with MLD in patients with neuropathic pain.

Limitations:

  • The sample size was small, with less than 100 patients.
  • The study had a risk of bias because there was no control group, blinding, random assignment, or an appropriate attentional control condition. 
  • Because opioid analgesics were given a few days prior to the intervention (although they were discontinued before beginning), patients' perception of pain may have been altered.

Nursing Implications:

In patients undergoing palliative care, the top priority is comfort. Given the positive outcomes of the study, nurses may recommend that their patients partake in MLD as a mechanism to alleviate burden because of their disease process, if the pain is not of neuropathic origin. It should be recognized that some patients experienced increased pain with MLD, so nurses need to be aware of assessing these effects if MLD is used. Further studies should be completed using a more rigorous study design and larger sample size to further support findings reported in the study.

Devoogdt, N., Christiaens, M.R., Geraerts, I., Truijen, S., Smeets, A., Leunen, K., . . . Van Kampen, M. (2011). Effect of manual lymph drainage in addition to guidelines and exercise therapy on arm lymphoedema related to breast cancer: randomised controlled trial. BMJ (Clinical Research Ed.), 343, d5326.

doi: 10.1136/bmj.d5326
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Study Purpose:

To determine the effect of manual lymph drainage (MLD) in addition to exercise compared to exercise alone for management of lymphedema in patients with breast cancer

Intervention Characteristics/Basic Study Process:

After surgery, patients with axillary node dissection were recruited to the study and randomized to receive exercise, guidelines for self-care and MLD, or exercise and guidelines alone. MLD was begun one week after removal of axillary drains and 5 weeks after surgery and was provided for 20 weeks. All patients received the same guidelines and 30-minute individual exercise sessions. Standardized MLD sessions took half an hour, and patients received 40 treatments during the study period. Patient assessments were done at 1, 3, 6, and 12 months after surgery.

Sample Characteristics:

  • The study sample was comprised of 158 patients who followed for the first six months and 154 who completed the study after 12 months.
  • Most patients in the study were female (99%).
  • Mean age was 55.15 years.
  • Sixty-eight percent of the sample had breast conserving surgery, 85% also had radiotherapy, 67% had chemotherapy, and 76% had endocrine treatment.
  • Median increase in arm volume before allocated treatment was 8 ml in both study groups.

 

Setting:

The study took place at a singe outpatient site in the Netherlands.

Phase of Care and Clinical Applications:

Patients were undergoing multiple phases of care.

Study Design:

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

Measurement Instruments/Methods:

  • Arm volume was measured using water displacement.
  • Arm circumference was measured.
  • Lymphedema was defined as increase of 200 ml or more.
     

Results:

There were no differences between groups in incidence of arm lymphedema, time to lymphedema development, or maximal increase in arm circumference.

Conclusions:

 The addition of MLD to a program of patient guidelines and education and exercise did not have an effect on prevention of arm lymphedema in patients with breast cancer after axillary node dissection.

Limitations:

  • Key sample group differences could influence results.
  • No analysis of group baseline differences was provided, and patients in the intervention group had higher percentage with level 1–3 axillary surgery. 
  • The maximum percentage of patients who developed lymphedema by month 12 was 24%, so not all patients were at risk in the sample. 
  • It is not known if there were substantial differences in surgeries performed that could have affected results.

Nursing Implications:

Findings show that the addition of MLD to a program of exercise and patient guidelines for self-management had no benefit to prevent lymphedema development.

Koul, R., Dufan, T., Russell, C., Guenther, W., Nugent, Z., Sun, X., & Cook, A.L. (2007). Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer. International Journal of Radiation Oncology, Biology, Physics, 67(3), 841–846.

doi: 10.1016/j.ijrobp.2006.09.024
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Intervention Characteristics/Basic Study Process:

Medical records for 250 patients referred for lymphedema treatment during the first two years of the program were analyzed. Data from the charts of 138 patients were included if their affected arms were larger than their unaffected arms at baseline and one-year and follow-up measurements were available. Pre- and post-volumetric measurements were compared, and the correlation with age; body mass index; and type of surgery, chemotherapy, and radiotherapy was determined. Treatment was stratified on the basis of the treatment modality used for breast cancer management. The therapy could include all four components of CDT or some components could be omitted at the discretion of the therapists. Fifty-five percent of patients received all four components; 32% received manual lymphatic drainage (MLD) alone; and 13% with mild lymphedema received instructions and counseling for the home program, which included self-administered lymph drainage and exercises. All patients received compression wraps during the intensive phase. Data from 250 patients was reviewed, and 138 were included in the final analysis.

Sample Characteristics:

Mean age of the study sample was 54.3 years.

Setting:

The study took place at an outpatient lymphedema clinic staffed by two certified Vodder therapists in Winnipeg, Canada.

Measurement Instruments/Methods:

Circumference was measured from the wrist to the axilla every 4 cm.

Results:

Complete decongestive therapy and MLD with exercises were associated with a significant reduction in lymphedema volume. The mean affected arm pretreatment volume was 2,929 ml, with a range of 1,474–5,879. The normal arm range volume was 1,320–4,299 with mean volume 2,531 ml. The mean difference at base line was 398 ml. The number of MLD or CDT sessions was related to mastectomy (versus lumpectomy) and chemotherapy. One year after treatment an absolute volume reduction of 188 ml to 2,741 ml was found.

Limitations:

  • The study had a risk of bias because of no randomization or control group.
  • The study is retrospective.
  • The components could not be qualified.

Martin, M.L., Hernandez, M.A., Avendano, C., Rodriguez, F., & Martinez, H. (2011). Manual lymphatic drainage therapy in patients with breast cancer related lymphoedema. BMC Cancer, 11, 94.

doi: 10.1186/1471-2407-11-94
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Study Purpose:

To determine the effectiveness of manual lymph drainage (MLD) in reducing lymphedema in patients with breast cancer

Intervention Characteristics/Basic Study Process:

Participants were randomly assigned to a control group and an experimental group. The control group received standard lymphedema treatment as well as a month of ambulatory treatment, daily bandaging from hand to shoulder for the first four weeks (removed at night), compression garments, and patient education regarding prevention guidelines and exercises to perform at home. The experimental group received the standard treatment plus MLD. MLD was performed before the bandaging occurred.

Sample Characteristics:

  • The study sample (N = 58) was comprised of White female patients with breast cancer who had ipsilateral axillary lymphedema.
  • Al patients
    • Had prior mastectomy, tumerectomy, or quadrantectomy and axillary lymphadenectomy
    • Finished radiotherapy or chemotherapy six months prior to study
    • Did not have rehab within three months prior to recruitment.

Setting:

The study took place at a rehabilitation facility in Brazil.

Phase of Care and Clinical Applications:

Patients were undergoing active lymphedema treatment.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • The measurement used to determine the effectiveness of MLD was the percentage of volume reduction after treatment using the water-displacement method.
  • The investigators defined a good response to treatment as a 20% or more reduction in volume of the effected extremity.
  • Measurements were taken at baseline and one, three, and six months.
  • Patients also took a quality-of-life questionnaire for cancer in general and for breast cancer.

Results:

At 12 months the incidence of lymphedema in the intervention group was very similar to the control group: 24% and 19%, respectively. This difference is not considered statistically significant. There were no incidence differences at three and six months. There was also no difference in the time taken to develop lymphedema, secondary outcome measures of arm circumference, health-related quality of life, and patient reports.

Conclusions:

Because of the lack of statistically significant changes in lymphedema incidence between control and intervention groups, it can be concluded that MLD is not effective in preventing lymphedema in the first year post-operatively in patients with breast cancer.

Limitations:

The study had a small sample size, with less than 100 participants.

Nursing Implications:

The study indicates that MLD does not provide a statistically significant improvement in limb volume in patients with lymphedema. One of the greatest limitations of the study is the sample size. If the results of a repeated randomized controlled trial with a larger sample size yields similar results, MLD should not be taught to lymphedema patients because studies suggest it is unnecessary and ineffective.

McNeely, M.L., Magee, D.J., Lees, A.W., Bagnall, K.M., Haykowsky, M., & Hanson, J. (2004). The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: A randomized controlled trial. Breast Cancer Research and Treatment, 86(2), 95–106.

doi: 10.1023/B:BREA.0000032978.67677.9f
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Study Purpose:

To compare the reduction in arm lymphedema volume achieved from manual lymphatic drainage (MLD) in combination with compression bandaging (CB) to that achieved by CB alone

Intervention Characteristics/Basic Study Process:

All subjects receive four weeks of allocated treatment, which also included standard education on proper arm and skin care. The MLD and CB group received 45 minutes of daily MLD Monday through Friday each week. Both groups receive CB.

Sample Characteristics:

Patients were included in the study if they

  • Were female
  • Had a breast cancer diagnosis
  • Previously had unilateral surgery with axillary node dissection
  • Were diagnosed with lymphedema
  • Had not received treatment for lymphedema within six months prior to study.

Patients were excluded from the study if they

  • Had distant metastases or local recurrence
  • Were at the time receiving treatment with chemotherapy or radiotherapy
  • Had any sign of infection in affected limb
  • Had contraindications to intervention therapy.

Setting:

The study took plact at the Cross Cancer Center in Edmonton, Canada.

Study Design:

The study used a prospective, randomized controlled study design.

Measurement Instruments/Methods:

  • Water displacement volumetric and calculated volume determined from measurement of circumference were used to assess lymphedema volume.
  • The primary outcome was the volume of lymphedema in the affected arm.
  • Each person’s unaffected arm served as a control.
  • Change score was represented by difference in volumes from the initial measurement to the final measurement at the end of four weeks.
  • Data were analyzed comparing baseline characteristics using independent samples t-tests for continuous data and Pearson’s chi-squared test for categorical data.
  • Outcome data was analyzed using the independent samples t-tests to compare changes between groups in outcomes from baseline to post-intervention.
  • The rate of reduction was analyzed using a two-way analysis of variance repeated measures.
  • Alpha level was set at p < 0.05.

Results:

A total of 45 participants completed the study. A significant reduction in lymphedema volume was found over a four-week period for both groups. No significant difference was noted in volume reduction (p = 0.812) or percent reduction (p = 0.297) between the groups. Therefore, a reduction in lymphedema volume occurred over the time period irrespective of the treatment group. The findings from the calculated volume determined from circumference measurements were consistent with the water displacement findings.

Conclusions:

Findings suggest that CB alone should be considered as a primary treatment option in reducing lymphedema arm volume. It also suggests that treatment of lymphedema should be implemented as soon as possible after onset of the condition when treatment is likely to be more effective.

Limitations:

  • Treatment on lymphedema volume over a one-month period with no further follow-up.
  • Upper-extremity range of motion was not assessed.
  • The study did not assess of effects of treatment on pain, function, body image, and quality of life.
  • Staff that is knowledgeable in the application of CB is required for the intervention.
  • Therapists certified in MLD are required.
  • Staff must be trained and certified.
  • CBs can be costly.

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.

Vignes, S., Porcher, R., Arrault, M., & Dupuy, A. (2011). Factors influencing breast cancer-related lymphedema volume after intensive decongestive physiotherapy. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 19(7), 935–940.

doi: 10.1007/s00520-010-0906-x
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Study Purpose:

To analyze factors associated with treatment failure and success in lymphedema

Intervention Characteristics/Basic Study Process:

All patients underwent complete decongestive therapy (CDT) with manual drainage, multilayer low-stretch bandages and specific exercises and skin care as recommended in international consensus guidelines. Patients were followed at 6 and 12 months and then yearly.  At each patients were questioned about actual treatments used and responses were recorded

Sample Characteristics:

  • The sample (N = 682) was comprised of female patients with lymphedema.
  • Of the sample, 47.8% had mastectomy and 97.4% had radiation therapy.
  • Median time to lymphedema onset was 22 months and duration was 32 months.
  • All patients had initial lymphedema volume of more than 250 ml. 

 

Study Design:

The study used a descriptive design.

Measurement Instruments/Methods:

  • Arm circumference was measured.
  • Treatment failure was defined as a lymphedema volume increase of more than or equal to 50% of total reduction obtained during the first intensive CDT.
     

Results:

  • Median lymphedema volume was 936 ml prior to therapy and 335 ml after CDT (p < 0.0001).
  • Median duration of follow up was 28 months.
  • Volume increased after initial intensive phase CDT throughout the first year.
  • Analysis gave hazard ratios of: MLD alone = 1.91, p = 0.03; elastic sleeve alone = 0.65, p = 0.1; MLD and elastic sleeve = 1.09, p = 0.73; bandage and elastic sleeve = 0.53, p = 0.004; MLD, bandage, and elastic sleeve = 0.73, p = 0.14. 
  • Lymphedema volume mainly reflected treatment compliance.
  • MLD alone was associated with increased risk of failure and adding MLD did not reduce the risk of failure. 
  • Being overweight was associated with increased risk of failure.
  • Compression therapy with an elastic sleeve during the day and bandaging at night were the main means to stabilize lymphedema volume. 
  • Body mass index was associated with higher risk of treatment failure.

Conclusions:

MLD did not appear to reduce the risk of treatment failure for lymphedema. Compression therapy appears to be the main factor in stabilizing lymphedema volume.

Limitations:

  • The study did not have a control group, blinding, or random assignment. 
  • Measurement and methods were not well described.
  • It is unclear if multiple people did measurement.
  • Measurement validity and reliability were questionable.
  • Patient self-report of compliance is not well described.
  • How relevant data was coded for analysis is not described.

Nursing Implications:

Findings add to the growing body of evidence pointing to the critical nature of patient compliance with compression sleeves and bandaging over time for ongoing effective management of lymphedema. Findings suggested that being overweight may also contribute to potential for treatment failure. Nursing measures to provide support for treatment adherence and weight control are important areas for patient care.  Interventions to facilitate adherence to compression therapy should be researched.

Zimmermann, A., Wozniewski, M., Szklarska, A., Lipowicz, A., & Szuba, A. (2012). Efficacy of manual lymphatic drainage in preventing secondary lymphedema after breast cancer surgery. Lymphology, 45(3), 103–112.

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Study Purpose:

To evaluate effectiveness of manual lymphatic drainage (MLD) for prevention of secondary lymphedema after breast cancer surgery

Intervention Characteristics/Basic Study Process:

From the second post-operative day, women received a standard program of exercises. Thirty-three women were randomly chosen to also receive MLD five times a week for the first two weeks, then twice a week until six months after surgery. The other control group women applied self-drainage. Data were collected prior to surgery and at six months postoperatively. Arm volume measurements were done on days 2, 7, 14, and 3 and 6 months.

Sample Characteristics:

  • The study sample (N = 67) was comprised of female patients with breast cancer.
  • Mean age was 59.4 years.
  • In the sample, 80% had breast conserving surgery and 40% had modified radical mastectomy; 52% had axillary lymph node dissection.
  • In the control group, 74% had radiotherapy, compared to 67% in the MLD group. 
  • More women in the control group also received other adjuvant therapy, compared to the MLD group.

 

Setting:

The study took place at a single outpatient site in Poland.

Phase of Care and Clinical Applications:

The patients were undergoing multiple phases of care.

Study Design:

The study used a prospective trial design.

Measurement Instruments/Methods:

Water displacement was used to measure arm volume.

Results:

Women in the MLD group showed a reduction of 14 ml volume (SD = 470 ml) on the operated-side arm over six months. Women in the control group showed an overall increase in arm volume of 16 ml (SD = 470, p = 0.0033). Analysis of variance showed significant effect of having MLD (p = 0001) and radiotherapy (p = 0.0499) on arm volume.

Conclusions:

Findings showed that use of MLD may have some benefit for prevention of lymphedema secondary to breast cancer surgery. Several study limitations suggest that findings should be used with caution.

Limitations:

  • The sample size was small, with less than 100 participants.
  • The baseline sample and group differences could influence results.
  • The study had a risk of bias because of no binding and no random assignment.
  • The ample included various surgical types. 
  • It is not clear that patients were randomly assigned to groups. 
  • Adherence to MLD and self-management are not discussed, and no other interventions that may affect lymphedema are discussed. 
  • The control group had a higher percent of women receiving radiotherapy, which was shown to predict arm volume increase.
  • There was high variability in arm volume results in both groups compared to mean changes observed.

Nursing Implications:

Findings of the study do not provide strong support for effectiveness of MLD to prevention lymphedema after breast surgery because of the multiple study design and results limitations.


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