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Annals of Oncology18: 639646, 2007

doi:10.1093/annonc/mdl182

Published online 3 October 2006review

A systematic review of common conservative therapies

for arm lymphoedema secondary to breast cancer

treatmentA. L. Moseley1*, C. J. Carati2 & N. B. Piller3

1School of Nursing & Midwifery, University of South Australia, Adelaide; 2Department of Anatomy, School of Medicine, Flinders University, Adelaide; 3Department of

Surgery & Lymphoedema Assessment Clinic, Flinders University & Medical Centre, Adelaide, Australia

Received 10 April 2006; revised 13 June 2006; accepted 23 June 2006

Secondary arm lymphoedema is a chronic and distressing condition which affects a significant number of

women who undergo breast cancer treatment. A number of health professional and patient instigated

conservative therapies have been developed to help with this condition, but their comparative benefits are not

clearly known. This systematic review undertook a broad investigation of commonly instigated conservative

therapies for secondary arm lymphoedema including; complex physical therapy, manual lymphatic drainage,

pneumatic pumps, oral pharmaceuticals, low level laser therapy, compression bandaging and garments,

limb exercises and limb elevation. It was found that the more intensive and health professional based therapies,

such as complex physical therapy, manual lymphatic drainage, pneumatic pump and laser therapy generally

yielded the greater volume reductions, whilst self instigated therapies such as compression garment wear,

exercises and limb elevation yielded smaller reductions. All conservative therapies produced improvements in

subjective arm symptoms and quality of life issues, where these were measured. Despite the identified benefits,

there is still the need for large scale, high level clinical trials in this area.

Key words: breast cancer, conservative therapies, lymphoedema

introduction

Currently, secondary arm lymphoedema affects approximately30% of those who undergo breast cancer treatment [1] andresults in excess fluid accumulation in the interstitial space,detrimental tissue changes, limb swelling and quality of lifeissues. As this condition will generally worsen over time [2],a number of health professionals based and patient instigatedconservative therapies that aim to decrease the limb swelling andits associated problems have been developed. Two systematicreviews have investigated some of these therapies in upper andlower limb lymphoedema, including manual lymphaticdrainage, compression bandaging and garments [3] andbenzopyrones [4], with both studies finding it difficult to makedefinitive therapy recommendations. Due to the chronicity of

secondary arm lymphoedema there is still a need to determinethe comparative benefits of the different conservative therapiesfor this condition. Therefore this review aimed to undertakea broad investigation of commonly instigated conservativetherapies for this population, including; complex physicaltherapy, manual lymphatic drainage, pneumatic pumps, oral

pharmaceuticals, low level laser therapy, compressionbandaging and garments, limb exercises and limb elevation.

inclusion and exclusion criteria

All study participants had to have a formal diagnosis ofsecondary arm lymphoedema subsequent to breast cancersurgery (total or partial mastectomy) radiotherapychemotherapy. Studies which included participants withrecurrent cancer and/or primary lymphoedema were excluded.

conservative therapies

This systematic review focused on therapies that are commonly

administered to or undertaken by secondary arm lymphoedemapatients, and included the following:Complex physical therapy (CPT) involves 24 weeks of daily

manual lymphatic drainage (described below) followed bycompression bandaging (administered by a health professional)and skincare plus prescribed limb exercises undertaken by thepatient [5]. The patient is then fitted with a compressiongarment.

Manual lymphatic drainage (MLD) uses various light massagetechniques to encourage the removal of excess interstitial fluid,increase lymphatic transport and soften fibrotic induration

*Correspondence to: Ms A. L. Moseley, Institute of Womens Health, Department of

Gynaecological Oncology, University College London, London, UK;

E-mail: [email protected]

2006 European Society for Medical Oncology


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[68]. All methods start by clearing the areas distance oradjacent to the affected limb before moving to the limb rootthen to its most distal section and then back to the limb rootagain.

Self/partner massage: Health professionals often teach patients(or their significant other) a simplified version of manuallymphatic drainage which includes clearing of the adjacent areaand limb root followed by sweeping strokes over the limb

itself [9].Pneumatic pumps: These are single or multiple chambered

pumps that envelop the limb and inflate and deflate at differentcycles and pressures to encourage fluid drainage from the distalto the proximal end of the limb [12].

Oral pharmaceuticals encompass the alpha (a) Benzopyronessuch as the Coumarin derivatives and the gamma (c)Benzopyrones such as the flavones and flavonols [16].Benzopyrones may help lymphoedema by reducing vascularpermeability, protein and extracellular fluid accumulation[16, 17], stimulating lymph contractility and flow [16, 18] andreducing protein concentration and fibrotic induration in thetissues by stimulating proteolysis [19].

Low level laser therapyuses low intensity wave lengthsbetween 6501000 nm, either in a scanning or spot laser form.Research suggests that laser therapy increases the rate of lymphvessel pumping and promotes lymph vessel regeneration [13],reduces pain [14] and softens both fibrous tissue and surgicalscarring [15].

Compression bandaging consists of a gauze sleeve whichprotects the skin, soft cotton wrap or high density foam and23 layers of short-stretch bandaging. Compression helps todecrease the amount of interstitial fluid formation, preventlymph back flow and enhance the muscle pump by providinga relatively inelastic barrier for the muscle to work against [10].

Compression garments have a similar mode of action ascompression bandaging and are designed to be graduated, with

the greatest compression being at the distal end of the limb andthe least amount being at the proximal end.

Limb exercises can be progressive, resistive or sequential innature and are recommended as a way of varying total tissuepressure to encourage lymphatic drainage and for improvinglimb range of movement and strength [11].

Limb elevation reduces capillary exudation in to the tissuesand promotes lymphatic return. It is considered most useful inthe earlier (fluid) stage of lymphoedema [5].

literature search

The literature search was limited to English, with the followingdatabases searched; Cumulative Index to Nursing & AlliedHealth Literature (Cinahl), Medline, Academic ResearchPeriodicals, PubMed Clinical Queries (includingComplementary Medicine), CANCERLIT, EBM Reviews Cochrane Central Register of Controlled Trials, CochraneDatabase of Systematic Reviews (CDSR), American Collegeof Physicians (ACP) Journal Club, Database of Abstracts ofReviews of Effects (DARE), PREMEDLINE, Australian MedicalIndex, Physiotherapy Evidence Database (PEDro) and theNational Guidelines Clearing House.

The general terms used for all these search engines were asfollows:

Secondary lymphoedema/lymphedema Arm swelling/oedema/edema

These were then combined with the following terms:

Complex/complete, physical/decongestive therapy Manual lymphatic drainage/lymphatic massage/lymphatic

drainage Support hosiery Compression garment/sleeve Compression bandaging/bandage Pneumatic/compression/intermittent pump therapy Exercise/physical therapy Elevation Laser/low level laser/laser therapy

In addition, health institution websites and online lymphaticsocieties were also searched. The biennial congress proceedingsof The International Society of Lymphology (19772004) andthe Australian Lymphoedema Association (20002004) were

searched by hand. Primary authors were contacted whenpublications were difficult to source. The reference section ofeach article was also checked for relevant articles.

data extraction and quality assessment

Endnote 7 was used as the data extraction tool. Once thedata had been extracted and recorded, the quality of eachstudy was assessed and given a rating. The Quality ScaleAssessment tools used in this review were based upon a tooldeveloped by Mulrow and Oxman (1996) [20], with one toolbeing developed and used for the review of randomised trials(scored out of 10) and the other for non-randomised trials

(scored out of eight). The data extraction and rating wasundertaken by A. Moseley, with the process checked byN. Piller and C. Carati. The quality rating and level ofevidence [21] for each reviewed study is presented in Table 1.

analysis

This review included studies performed in the randomizedcontrolled, parallel and cross-over format plus case control andcohort studies. Case studies and anecdotal evidence were notreviewed. Due to treatment and data heterogeneity, a meta-analysis could not be performed. Therefore, only a narrative ofthe different conservative therapies for secondary arm

lymphedema is presented. For ease of comparison, anapproximate oedema reduction (%) has been calculated ineach case where the limb volume reduction is presented inmilliliters (ml).

results

The average percentage volume change at end of trial achievedby each reviewed conservative therapy is displayed in Figure 1.This demonstrates the magnitude of the reduction (average)that can be achieved by the different conservative therapies.

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complex physical therapy (CPT)

Five studies reviewed investigated standard CPT over a varyingtreatment period of 8 days to 3 months [9, 2225]. Participantnumbers ranged from 1678, with some studies having no statedexclusion criteria [22, 23] and others having a poorly statedcriterion [24, 25]. The reductions achieved from the fivestudies varied from 298652 ml (18.766%), with three studiesdemonstrating additional volume reductions over 612 months

follow up [9, 22, 25]. Two studies measured subjectivesymptoms, with one showing a reduction in pain [24] and theother in tightness, heaviness, pins and needles, cramps andtension [9].

One study investigated standard CPT (n = 13) in comparisonwith CPT plus 30 min of intermittent pump (50 mmHg)therapy (n = 14) [26]. After 10 days CPT alone yielded a3.1% mean volume reduction whilst the CPT + pneumaticgroup had a statistically greater reduction of 7.9%. Althougha reduction in symptoms was reported, it was not stated whatsymptoms were actually measured. The follow-upmeasurements over one and two months demonstrated acontinuing decrease in percentage volume in both treatment

groups (3.6% and 9.6% at 2 months). Two studies investigatedCPT in combination with intermittent pump therapy. Thefirst study [27] involved 1 hour of intermittent pump(4070 mmHg) therapy incorporated into the CPT regime(n = 188), with this regime yielding statistically significantpercentage reductions in all grades of lymphoedemas (gradeIIII, 43.419.3 %) after 5 weeks of treatment. The second studyinvolved a regime of CPT with a pump of


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treatments incorporated into the CPT regime, includingmechanical plus manual massage, hand grip exercises, thewearing of a compression garment and the addition of hotcompresses during one treatment phase [29]. All treatmentcombinations yielded similar actual oedema reductions in therange of 8.513%.

All the reviewed studies demonstrated that a reduction inlimb volume and/or percentage oedema can be achieved with

standard CPT, CPT plus pump therapy and a combination oftherapies, with five studies [9, 22, 25, 26, 28] demonstratinga continued volume reduction at follow up (range 112months). The three studies [9, 24, 26] which measuredsubjective symptoms demonstrated that these improved afterthe CPT regime, unfortunately none of these studies reportwhether these improvements were sustained at the follow upperiods. The study by Piller et al. (1996) also demonstrated thatvolume and subjective symptom reductions could be achievedwhen patients and their partners were taught how to applya regime of lymphatic massage and compression bandagingthemselves [9]. The optimal treatment period for CPTappears to be 1 month, however, two studies [22, 29] achieved

a volume reduction at the end of 78 days of treatment.

manual lymphatic drainage (MLD)

Two studies investigated the effect of MLD alone. These twostudies [30, 31] involved 1217 participants who received MLDand who experienced a volume reduction of 104156 ml(810%), with one study reporting that the volume reductionwas maintained at 6-months follow up [31]. The other studyreported reductions in heaviness and tension, but did not statethe inclusion/exclusion criteria or the length and frequency ofMLD [30]. Two studies investigated MLD in comparison toanother treatment modality. The first of these studies useda cross-over design to investigated a phase of MLD and self

massage (n = 27), each over a 3-week period [32]. Resultsshowed that MLD produced a statistically significant reductionof 71 ml and improvements in subjective heaviness, fullness andbursting whilst the self massage resulted in a non significantreduction of 30 mls. The second randomized study investigatedMLD (n = 20) in comparison to a control group whoundertook education, wearing a compression sleeve and limbexercises (n = 20) [33]. After 2 weeks the control group actuallyhad a greater percentage reduction in absolute oedema (60%) incomparison to the MLD group (48%). Both groups equallyexperienced a reduction in the symptoms of heaviness andtightness, whilst the control group also had a reduction inreported discomfort. The reduction in absolute oedema (66%)

was maintained at 12-months follow up (pooled data).Four studies investigated the effect of MLD in combination

with compression (bandaging or garment). All four studies hada clearly stated inclusion/exclusion criterion, with the first twostudies investigating MLD plus compression bandaging. Thesetwo studies [34, 35] involved 1824 women who received MLDplus compression bandaging over 1 week to 1 month. After 1week there was a significant volume reduction of 47 ml (11% inoedema) [34], whilst over 1 month the reduction was 260 ml(46.1%), with significant improvements in tension, heavinessand pain [35]. The third study investigated the effect of

a compression (3040 mmHg) sleeve worn for 2 weeks followedby 2 weeks of additional MLD (n = 12) [36]. Wearing the sleevealone resulted in a significant volume reduction of 49 ml (7%),with the addition of MLD resulting in a significant reduction of75 ml (15%). Both phases also significantly improved armtension and heaviness. The last study investigated MLD incombination with a compression garment or bandaging oncea week for 12 weeks [37]. Both treatment groups experienced

significant reductions in oedema of 84% and 78% respectively.One study compared MLD and pneumatic pump therapy

[38], with one group receiving 1 hour of MLD over 43 sessions(n = 27) and the other receiving 0.5 h of pump therapy(40 mmHg) followed by 0.5 h of MLD over 25 sessions (n = 62).Results showed that the MLD alone and when combinedwith pneumatic pump therapy yielded similar reductions inoedema volume (40% and 45% respectively), however, therewere no accompanying statistical values so significance is notknown. The follow up period in this study (1424 months)demonstrated an oedema volume increase of 33% in those whounderwent no further treatment, whilst those who underwentregular treatment (type not stated) experienced a slight

reduction (1%) in oedema volume.The volume reductions achieved by MLD alone varied from104156 ml, with the greatest percentage reduction being 48%[33]. Larger reductions were achieved from MLD incombination with compression, which varied from 47260 ml(784%), with these studies demonstrating that either form ofcompression (garment or bandaging) could be effectively usedin combination with MLD. MLD in combination withpneumatic pump therapy was also shown to be effective [38].The majority of volume reductions were achieved after a 4 weektreatment period, although volume reductions were also seento occur over 2 weeks of treatment [31, 33, 36]. Only threeof the reviewed studies included a follow up period whichdemonstrated that the initial volume reductions were

maintained [31, 33, 38]. The overall lack of follow up in thesestudies makes it difficult to formulate strong conclusions on thelong term benefits of MLD ( bandaging).

pneumatic pump therapy

Five studies were reviewed which investigated the effect ofpneumatic pump therapy. The first was a poorly reported studywhich involved a group that received a combination of MLD(0.5 h) and pump therapy (0.5 h) over 25 sessions (n = 62) andanother that received 6 hours of sequential (40 mmHg) pumptherapy (only) over 5 days (n = 14) [38]. Both groupsexperienced identical oedema volume reductions (45%), with

this reduction being achieved over a shorter treatment duration(5 days) in the pump only group. However, considering thisgroup had a sample size of 14, it is hard to determine whetherthis volume reduction is a true reflection of what can beachieved with this form of sequential (40 mmHg) pump. Szubaet al. (2002) performed two randomised studies whichinvestigated the use of a four-chambered, sequential pump as anadjunct therapy [39]. The first study compared 10 days ofcomplex physical therapy (CPT) alone (n = 11) and incombination with 30 min of 3040 mmHg pump therapy(n = 12). Results showed that the CPT plus pump therapy




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resulted in a greater and significant limb volume reduction incomparison to CPT alone (45.3% versus 26% respectively).Interestingly, the CPT plus pump therapy reduction was notmaintained at 1 month follow up (increase of 15%), whilst theCPT alone reduction was maintained. The second studyinvestigated a 1 month phase of arm self maintenance includingself massage and compression garment wear, followed by aphase of applying 1 hour of pump therapy for a further 1 month

period (n = 25). The self maintenance phase resulted in anarm volume increase of 32.7 ml (3.3%), with the addition ofthe 1 h of pump therapy resulting in a statistically significantreduction of 89.5 ml (9.0%). Some participants continuedusing the pump an average of four times a week for 6 months,with 19 participants having an additional reduction in limbvolume of 29.1 ml (3.0%) and five having an increase of 35 ml(3.5%). Why this sub-group of participants had a worseningin limb volume was not explored.

One study investigated 2 h of pump therapy (4060 mmHg)5 days a week for 2 weeks [36]. After this time there wasa non significant reduction in arm volume (28 ml; 7%) andreported tension and heaviness. One study investigated the

wearing of a compression (3040 mmHg) garment for 6 monthsthen 6 h of pump therapy (3560 mmHg) over 10 sessionsfollowed by the continued wear of the compression garment(n = 54) [40]. Results showed a significant 8% reduction afterwearing the compression garment and an additional 9%significant reduction after the pump therapy (with theassumption that the total edema reduction at this time pointwas 17%). A 6-month follow up demonstrated a 19.8%reduction in those who continued to wear the compressiongarment. The last study investigated 23 h of sequential(100150 mmHg) pump therapy, three times a day for 3 days(n = 25) [41]. After 3 days the percentage reduction rangedfrom 1244% (statistical values not stated). After trial cessation,2 h of maintenance therapy was applied onefour times a week

over the following 6 months. Follow up at this time showed thatthe initial treatment reductions had been maintained. However,it was not reported whether the maintenance of limb volumewas the result of one or four sessions of treatment per week.

Two studies [38, 41] demonstrated that volume reductionscould be achieved from pump therapy alone, although the highpressures (100150 mmHg) used by Zelikovski et al. (1980) [41]are above the 60 mmHg of pressure normally recommended forthe treatment of lymphoedematous limbs [42]. Three of thereviewed studies [36, 38, 40] demonstrated that better results involume reduction were achieved when the pneumatic pump wascombined with other therapies, including; manual lymphaticdrainage, compression garments and self massage. Three studies

[38, 40, 41] also demonstrated that continuing the pumptherapy or wearing a compression garment were beneficial inmaintaining the initial volume reductions.

oral pharmaceuticals

Five studies were reviewed that investigated the effect of oralpharmaceuticals. Two studies investigated Coumarin [43, 44],with the first study investigating two dosages; 90 mg (n = 23)and 135 mg (n = 30) over 12 months [43]. At trial end, bothgroups experienced a similar reduction in percentage limb

volume (14.9% and 13.2% respectively) and reductions inheaviness, pain and cramps. The second study used a cross overdesign to investigate a 6-month phase of Coumarin (400 mg)and a 6 month phase of a placebo (n = 138) [44]. Resultsdemonstrated a volume increase (and therefore worsening) of58 ml (6%) in the treatment phase and 21 ml (2.1%) in theplacebo phase. Despite this, participants reportedimprovements in arm swelling, pressure, tightness, heaviness

and mobility. The third study investigated Daflon (Diosminplus Hesperidin 1g, n = 46) or placebo (n = 48) over 6 months[45]. After this period the treatment group experienced a 7%volume reduction whilst the placebo group experienceda volume increase of 10%. Both groups experienced a significantreduction in reported discomfort, with the treatment group alsohaving a significant reduction in heaviness.

The fourth study investigated three capsules of Cyclo-Fort(Ruscus Aculeatus and Hesperidin Methyl Chalcone) threetimes a day (n = 27) compared to placebo (n = 30) over 3months, with the addition of MLD (2 week) in the first monthof the trial [46]. After the first month both the treatment andplacebo groups experienced volume reductions of 1.2% and

0.5% respectively. By 3 months the treatment (Cyclo-Fort)group had an overall volume reduction of 12.9% whilst theplacebo group had an increase of 2.5%. Both groupsexperienced improvements in heaviness and limb mobility, withthese being significant in the Cyclo-Fort group. The last studyused a cross over design to investigate a 6 month phase of 56Benzo-a-pyrone (200 mg) and placebo (n = 31) [47]. Resultsdemonstrated a volume reduction of 840 ml (35.6%) in thetreatment phase, with this reduction being significant incomparison to the control phase in which the limb increased involume by 490 ml (41.6%). A 1-month follow up demonstratedan additional decrease of 3.3% in oedema (treatment phase) andan additional increase of 1.2% (placebo phase).

The two studies which investigated Coumarin had

conflicting results, with one showing a decrease in armvolume (dosage 90 mg, 135 mg) [43] and the other showingan increase in volume (dosage 400 mg) [44]. As neither studyhad a follow up period it is not known whether the initialvolume reduction or increase would have continued. The otherreviewed studies [4547] demonstrated that varying volumereductions and subjective improvements could be obtainedfrom oral pharmaceuticals such as Daflon (1000 mg) andCyclo-fort, with the greatest limb reduction (840 ml, 35.6%)being obtained from the 56 Benzo-a-pyrone (200 mg) [47].It is also important to note that two studies [43, 47] reportedgastrointestinal upsets in 13.7% and 22.6% of participants.

low level laser therapy

Three studies were reviewed which investigated concentrated orscanning laser therapy. The first study was a double-blinded,randomised controlled trial involving one group which receivedtwo cycles of active laser to the axilla three times a week for 3weeks (n = 37) and another group who received one cycle ofplacebo laser and one cycle of active laser (n = 27) over the sametime periods [48]. At trial end there were volume reductions inall phases: placebo; 35 ml (3.5%), one cycle; 15 ml (1.5%),two cycles; 25 ml (2.5%). A 3-month follow up demonstrated

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a volume increase of 30 ml (3.0%) in those who receivedplacebo and volume reductions in the one cycle (10 ml 1.0%)and two cycle (90 ml 9.0%) phases. The two cycle phase alsoresulted in a significant reduction in the mean perceptual scoreand improvements in quality of life parameters. The secondstudy investigated 30 min of scanning laser, twice a week for6 weeks and then once a week for a further 4 weeks (n = 10)[49]. This resulted in a volume reduction of 19.3% and

progressive improvements in subjective symptoms. A followup study of these participants (n = 8) [50] demonstratedthat there were continued volume reductions of 397 ml(40%) at 6 months and 288 ml (29%) at 36 months,with subjective symptoms returning to pre-treatment levelsby the 36-month mark.

These three studies demonstrate that benefits includingvolume reduction, improved subjective symptoms and qualityof life can be derived from either concentrated or scanning lasertherapy. The best results in the Carati et al. (2003) study [48]were seen at 3 months post treatment, which suggests that theremaybe ongoing benefits from laser therapy. This is supportedby the Piller and Thelander (1998) study [50] (albeit with

a much smaller sample size), which found that there werecontinued reductions in arm volume and reported armtightness 6 months after treatment cessation.

compression

Four studies investigated the effect of compression (garment orbandaging) alone. Two studies [30, 35] which involved 3555participants investigated compression bandaging. Thesestudies demonstrated a volume reduction of 38 ml (7%) [30]and 20 ml (4% oedema) [35] respectively and significantimprovements in arm heaviness and tension. Two studiesinvestigated the effect of a 3040 mmHg compression garment.

The first study involved 12 participants who wore the garmentover a 2-week period [36], after which time there wasa significant volume reduction of 49 ml (5.0%) andimprovements in tension and heaviness. The second studyinvolved participants (n = 26) wearing the compressiongarment over a 6-month period [40]. Results showed an 8%reduction in actual oedema, however, at the 6-month pointonly 12 women remained in the study. Two studies investigatedthe effect of wearing a compression garment in combinationwith other activities. One study [33] demonstrated that after3 months of limb exercise and compression wear (n = 22)there was a 60% reduction in absolute oedema, with the otherstudy showing a 243 ml (24.4%) volume reduction after

4 weeks of self massage combined with compression wear [51].Neither study reported statistical values, so the significance ofthese volume reductions are not known.

Four of the reviewed studies [30, 35, 36, 40] demonstratedthat modest volume reductions of 2049 ml (48%) andsignificant improvements in heaviness and tension could beachieved when wearing compression (bandaging or garment)alone. However, none of these studies included a follow upperiod, so the ongoing effects of compression cannot bedetermined. Two studies [33, 51] demonstrated that greatervolume reductions of 243 ml (24.4%) and 60% could be

achieved when the wearing of a compression garment wascombined with limb exercise or self massage.

exercise

Five studies were reviewed which investigated a variety ofexercise regimes. The first study investigated a 10-minute armexercise and deep breathing regime (n = 38) [52] which resulted

in an arm volume reduction of 52 ml (5.8%) and improvementsin heaviness and tension, with some reductions maintained over24 h and 1 week follow up. After 1 month of performing thisregime (n = 24) there was a volume reduction of 101 ml (9%)and significant improvements in heaviness and perceived limbsize. Two studies investigated the effects of 4045 min ofhydrotherapy [11, 53], with neither study stating the exclusioncriteria. The first was a randomised study which involveda control group (n = 8) and a hydrotherapy exercise group (n =8) [53]. After 4 weeks there was a volume reduction of 48 ml(4.8%) in the hydrotherapy group, with continued reductionsat 3 and 6 weeks follow up (30 ml 2.9% and 86 ml 8.6%respectively). This in comparison to the control group, which

increased in limb volume. The exercise group also hadreductions in reported aching, heaviness, tightness, limbswelling, stiffness and heat intolerance. The second studyinvestigated hydrotherapy performed by seven participants intwo different pool temperatures (28 C; 82 F and 34 C; 93 F)[11]. After the first session (28 C) there was a decrease in armvolume of 32 ml (12% oedema change), whilst after the secondsession (34 C) there was a slight increase in volume of 2 ml(0.7% change). Subjective symptoms remained unchanged afterboth pool sessions. One study investigated a 30 min regime ofinstructed deep breathing, self massage and sequential limbexercises (n = 7) [54]. Directly after performing the regime therewas a slight increase in arm volume (12 ml, P= n.s.), with a netdecrease (12 ml, P= n.s.) experienced 20 minutes post regime.

Despite the minimal volume reduction, the group reportedimprovements in arm range of movement, subjective limbtemperature difference, heaviness and tightness.

Two studies investigated the effect of resistive arm exercises.The first of these studies involved a regime of shoulder flexionand abduction and elbow extension and flexion using 0.5 kghand weights, performed firstly with no compression garmentand secondly when wearing a compression garment (n = 23)[11]. Results showed an initial increase in arm volume afterperforming the regime, plus or minus garment wear (12 ml,0.5% and 10 ml, 0.3% respectively). However, at the 24 h followup the volume increases had been reversed, with both phasesdemonstrating a volume reduction of 15 ml (0.71.0%) at this

time point. Reported tension and heaviness remainedunchanged in both phases, however, when the regime wasperformed without a compression garment there wasa significant increase in reported physical exertion. The secondstudy investigated latissimus dorsi, bicep and tricep exerciseswith weights and the wearing of a compression garmentundertaken three times a week for 8 weeks (n = 7) [55]. Thisresulted in a limb volume reduction of 2% plus significantimprovements in physical functioning, general health and vitality.

The five studies reviewed demonstrated that exercise regimescan have a varying impact upon limb volume, ranging from




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12101 ml (0.49%), with three studies demonstratingimprovements in subjective symptoms [5254]. Sustainedvolume reductions were also seen to occur 24 h to 6 weeks afterexercise program cessation [11, 52, 53]. The hydrotherapy study[11] suggests that this form of exercise is best undertaken ina pool temperature of 28 C (82 F).

elevation

Only one study was reviewed that investigated the effects oflimb elevation [56]. It involved 33 women who elevated theirarm at 80 angle over a 5-h period. At the end of this time therewas a significant 3.1% reduction in arm volume. Subjectivesymptoms and adverse effects were not recorded, so it is notknown how well this regime was tolerated.

discussion

In recent times, sentinel lymph node biopsy (SLNB) has becomea more common procedure in breast cancer surgery, resulting inless arm morbidity [57], including lymphoedema [58].

However, there is still the possibility of developing armlymphoedema after SLNB, especially if the sentinel node islocated at the level of the axillary vein and lymphatic collectors[59] and if SLNB is combined with axillary radiotherapy [60].Although the number of women developing arm lymphoedemamaybe reduced as a consequence of SLNB, it is still important toknow the benefits of conservative therapies for the proportion ofwomen who do go on to develop this condition after breastcancer treatment.

The current review investigated conservative therapies forarm lymphoedema that can essentially be divided into intensivetreatments administered by trained health professionals andlimb maintenance therapies undertaken by the patient. Asdemonstrated by Figure 1, treatments that are predominantly

administered by health professionals, such as complex physicaltherapy, manual lymphatic drainage (with and withoutcompression), laser therapy and pneumatic pump therapygenerally yielded the larger percentage volume reductions.Maintenance therapies (normally undertaken by the patient),such as wearing a compression garment, limb exercises,elevation and self massage generally yielded smaller percentagereductions. There is some research to suggest that undertakingtherapies such as arm rehabilitation and exercise may preventthe onset of lymphoedema [61], but further research is requiredto determine the true benefits of such programs.

Although those therapies which would be categorised as selfmaintenance yielded smaller volume reductions, this review has

demonstrated that they are more beneficial than doing nothingat all for the lymphoedematous limb. This indicates that suchtherapies maybe useful when health professional based therapiesare not accessible or economically viable for the patient. Thereview also demonstrated the positive impact upon subjectivelimb complaints and quality of life issues, indicating that theseconservative therapies can be initiated by the health professionalor patient with the anticipation of some benefit. Follow upperiods (when incorporated) indicated that some form ofcontinuing therapy (intensive or patient based) needed to beundertaken to maintain the initial volume reductions, which

demonstrates the chronic nature of this condition. Despitethe range of positive outcomes identified in this review, theevidence to support them is, in some instances, poor. Therefore,there is still a need for large scale, high level clinical trials inthis area.

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