Lasinski, B.B., McKillip Thrift, K., Squire, D., Austin, M.K., Smith, K.M., Wanchai, A., … Armer, J.M. (2012). A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011. PM & R: The Journal of Injury, Function, and Rehabilitation, 4(8), 580–601.

To analyze the evidence on complete decongestive therapy (CDT) as a bundled intervention for the treatment of lymphedema

• Databases searched were PubMed, CINAHL, Cochrane Collaboration, PapersFirst, ProceedingsFirst, PEDro, National Guidelines Clearing House, DARE, and ACP Journal Club databases.
• Studies were included in the review if they sampled more than 10 people. Gray literature was excluded.

A total of 5,927 references were found and evaluated using the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) Levels of Evidence.

The final review involved 27 studies, 14 reviews, and 2 consensus documents.

Patients were undergoing multiple treatment phases of care.

Most studies considered CDT as a bundled intervention. Follow-up studies showed that pain decreased with longer length of treatment as well as patient adherence. Results of one long-term study in 356 patients after one year correlated with adherence in using compression sleeves by day or bandaging at least three nights per week. Findings regarding the effect of MLD as a component of CDT were contradictory. Discrepancies may be because of differences in lymphedema measurement and variations in how MLD was applied by both technique and dosage. Studies of compression bandaging showed that no differences were found between high- and low-pressure bandaging and that low pressure was better tolerated. One study showed that up to 48% of pressure loss under the bandage because of limb volume reduction. Adherence to compression bandage use has a direct correlation with reduction in volumes.

CDT is effective in the management of lymphedema; however, the relative roles of the components of CDT are unclear. Levels of evidence in this area are seen to be weak. The role of patient adherence requires further examination.

• Inconsistencies exist in defining and measuring lymphedema.
• Lack of blinding in research studies and small sample sizes are prone to type 2 errors. 
• Little research has been conducted regarding management of truncal and lower-extremity lymphedema.

CDT as a bundled intervention for lymphedema management appears to be effective. Patient adherence is a key component of treatment. Nurses need to educate and assist patients to maintain the use of compression garments and bandaging as prescribed to achieve effective lymphedema management. The evidence in this area is relatively weak, and further research continues to be needed. Research could benefit from more consistent definition and measurement approaches and examination of techniques for facial, breast, truncal, and genital lymphedema as well as effective risk reduction strategies. More standardization of treatment protocols would be helpful.