Lymphedema is a common complication of axillary dissection for breast cancer. We investigated whether manual lymphatic drainage MLD could prevent or manage limb edema in women after breast-cancer surgery. We performed a systematic review and meta-analysis of published randomized controlled trials RCTs to evaluate the effectiveness of MLD in the prevention and treatment of breast-cancer-related lymphedema.
Edema vs. Lymphedema
The primary outcome for prevention was the incidence of postoperative lymphedema. The outcome for management of lymphedema was a reduction in edema volume. In total, 10 RCTs with patients were identified. Two studies evaluating the preventive outcome of MLD found no significant difference in the incidence of lymphedema between the MLD and standard treatment groups, with a risk ratio of 0.
Go With the Flow: Manual Lymphatic Drainage
Seven studies assessed the reduction in arm volume, and found no significant difference between the MLD and standard treatment groups, with a weighted mean difference of However, clinical and statistical inconsistencies between the various studies confounded our evaluation of the effect of MLD on breast-cancer-related lymphedema.
Lymphedema is defined as persistent tissue swelling caused by the blockage or absence of lymph drainage [ 1 ]. Lymphedema is a major concern for patients undergoing axillary lymph-node dissection for the treatment of breast cancer. Lymphedema may result in cosmetic deformity, loss of function, physical discomfort, recurrent episodes of erysipelas ,and psychological distress [ 4 , 5 ]. Thus, an effective treatment for lymphedema is necessary.
Previous surgical techniques for the treatment of lymphedema aimed to reduce limb volume using a debulking resection approach. With the advent of microsurgery, use of multiple lymphatic-venous anastomoses has become the most common surgical treatment [ 6 ].
However, convincing evidence of the success of lymphatic-venous anastomoses has not been demonstrated. Thus, most patients with lymphedema choose non-surgical treatments, such as the use of elastic stockings, especially in early stages of lymphedema [ 7 ]. Complex decongestive physiotherapy CDP is likely to reduce upper limb lymphedema in patients with breast cancer.
Evidence of the efficacy of other physiotherapy methods is limited [ 8 - 10 ]. Compression bandaging, manual lymphatic drainage MLD , physical exercise to maintain lymphatic flow, and skin care are combined in CDP [ 11 , 12 ].
In MLD, specialized rhythmic pumping techniques are used to massage the affected area and enhance the lymph flow. Gentle skin massage is thought to cause superficial lymphatic contraction, thereby increasing lymph drainage [ 13 ]. Vodder originally suggested the use of range-of-motion exercises to relieve various types of chronic edema, such as sinus congestion and catarrh [ 14 ], and the use of MLD has become a common treatment for lymphedema worldwide, especially in European hospitals and clinics.
History of Dr. Emil Vodder and the Manual Lymph Drainage
To date, several studies have been published investigating the effects of MLD in preventing and treating lymphedema after breast-cancer surgery [ 15 - 18 ].
However, these studies have been inconclusive, probably because of small sample sizes. Therefore, we conducted a systematic literature review and meta-analysis of randomized controlled trials RCTs to evaluate the effectiveness of MLD in the prevention and treatment of breast-cancer-related lymphedema.
For inclusion in our study, the trials were required to describe: 1 the inclusion and exclusion criteria used for patient selection, 2 the MLD technique used, 3 the compression strategy used, 4 the definition of lymphedema, and 5 the evaluation of lymphedema severity. We excluded trials that met as least one of the following criteria: 1 patients had not received axillary lymph-node dissection such as in studies in which only sentinel node sampling was used , 2 the clinical outcomes had not been clearly stated, or 3 duplicate reporting of patient cohorts had occurred.
No language restrictions were applied. The final search was performed in December We attempted to identify additional studies by searching the reference sections of any relevant papers and contacting known experts in the field. Two authors K-WT and T-WH independently extracted details of the RCTs pertaining to the participants, inclusion and exclusion criteria, manual lymph-drainage techniques used, arm lymphedema parameters, and complications.
The individually recorded decisions of the two reviewers were compared, and any disagreements were resolved based on the evaluation of a third reviewer S-HT. The two authors independently appraised the methodological quality of each study based on: 1 adequacy of the randomization, 2 allocation concealment, 3 blinding, 4 duration of follow-up, 5 number of drop-outs, and 6 performance of an intention-to-treat ITT analysis. The arm volume was assessed by submerging each arm in a container filled with water, and measuring the volume ml displaced [ 19 ].
The absolute edema volume was defined as the difference in volume between the arm with lymphedema and the contralateral arm [ 18 ]. Statistical analysis was conducted using Review Manager software version 5. When necessary, standard deviations SDs were estimated based on the reported confidence interval CI limits, standard error, or range values [ 23 ].
The effect sizes of dichotomous outcomes were calculated as risk ratios RR , and the mean difference was calculated for continuous outcomes.
A pooled estimate of the RR was calculated using the DerSimonian and Laird random-effects model [ 24 ]. This provided relatively wide CIs and an appropriate estimate of the average treatment effect for trials that were statistically heterogeneous, resulting in a conservative statistical claim.
The data were pooled only for studies that exhibited adequate clinical and methodological similarity. Statistical heterogeneity was assessed using the I 2 test, with I 2 quantifying the proportion of the total outcome variability that was attributable to variability among the studies. Our initial search yielded studies, of which 29 were deemed ineligible after screening of titles and abstracts.
Another reports were excluded from our final analysis for the following reasons: 58 were review articles, 3 were animal studies, 18 had used different comparisons, 33 discussed different topics, and 19 were not randomized trials.
The remaining 10 eligible RCTs [ 15 - 18 , 20 , 21 , 25 - 28 ] were included in our analysis. All patients had undergone mastectomy with axillary lymph-node dissection, and patient age ranged from 25 to 77 years.
Most of the trials had assessed MLD treatment using the Vodder method [ 14 ]. MLD was performed by specially trained physiotherapists, and was followed by skin care with moisturizers, multilayered short-stretch bandaging with appropriate padding, and exercise. The MLD extended to the neck, the anterior and posterior trunk, and the swollen arm.
One study did not fully describe the MLD method that was used [ 15 ]. In addition to the use of sleeve or glove compression, standard therapies also included educational information and recommendations on lymphedema, instructions for physical exercises to enhance lymph flow, education in skin care, and safety precautions. Most of the included trials had investigated whether the addition of MLD to the standard therapy after breast-cancer treatment improved clinical outcomes in women with lymphedema.
Two trials investigated the preventive effect of MLD on the development of lymphedema in women after breast-cancer surgery [ 16 , 21 ]. Five studies reported acceptable methods of randomization [ 16 , 21 , 25 - 27 ], four trials described the method of allocation concealment [ 16 , 25 - 27 ] three studies reported the blinding of the outcome assessors [ 16 , 21 , 25 ], and one trial reported the blinding of the patients [ 26 ]. Three studies used an ITT analysis [ 15 , 16 , 28 ].
The incidence of lymphedema was determined in two trials that evaluated the preventive outcome of MLD in patients after breast-cancer surgery [ 16 , 21 ]. No significant differences were found between the MLD and standard treatment groups, with an RR of 0. Forest plot of the comparison of the effect of standard treatment with or without manual lymphatic drainage MLD on the incidence of post-mastectomy lymphedema from 2 clinical trials. Seven studies provided data on the reduction in lymphedema volume [ 15 , 17 , 18 , 20 , 25 , 27 , 28 ] after MLD treatment.
In each of these studies, the volume of the arm was measured at the beginning of treatment, and at 1, 3, and 12 months after treatment using water displacement volumetry. To facilitate our comparisons, we converted the percentage reductions in arm volume after MLD treatment to absolute volume ml reductions.
Our analysis showed that there were no significant differences between the two treatment groups weight mean difference Forest plot of comparison of the effect of compression therapy with or without manual lymphatic drainage MLD on the reduction in post-mastectomy lymphedema volume from 6 clinical trials.
The data reported by Didem et al. In addition, a study of the effects of MLD with or without SPC reported no significant difference in arm volume reduction between the treatment groups at 1 and 2 months after treatment [ 28 ]. A physical treatment program combining MLD, skin care, exercise, compression bandaging, and sleeve or stocking compression is recognized as providing optimal lymphedema management [ 29 ].
Three systematic reviews concluded that combined physical therapy provides effective treatment for lymphedema [ 30 - 32 ].
Lymphatic System Basics
However, the effectiveness of the individual components of such programs has not been clearly established. The relatively high cost of MLD compared with compression bandaging warrants assessment of the efficacy of these individual components. The results of our systematic review and meta-analysis did not show a significant benefit for MLD in reducing lymphedema volume.
Although individual studies reported advantages associated with MLD, methodological inconsistencies between the studies confounded our attempts to conduct an overall comparison of the effects of MLD across the studies. The published reports of the effectiveness of MLD are conflicting.
Dvr ks 650m manual lymphatic drainage
One prospective study of individual cases in a single lymphology unit evaluated various treatments for lymphedema. The results indicated that the risk of failure for lymphedema therapy after intensive decongestive physiotherapy was primarily associated with younger age, higher weight, and higher body mass index.
By contrast, elastic sleeve and multilayer bandaging treatments were associated with a reduced risk of treatment failure, whereas the use of MLD as an adjunct to those therapeutic components was not [ 33 ].
One retrospective study of patients with lymphedema receiving palliative care showed clinical improvement in the intensity of pain and dyspnea in most patients after MLD treatment [ 34 ].
The advantage of the RCT design is that allocation bias is minimized, resulting in a balance between the known and unknown confounding variables in the assignment of treatments. Systematic review and meta-analysis of the clinical outcomes of therapy, as reported in the summaries of the RCT results to date, may help identify the effects that are common to these trials.
Such research more clearly distinguishes the effects of MLD in preventing and managing lymphedema. Our meta-analysis examined the results of six studies that assessed the effects of MLD in patients with post-mastectomy lymphedema, compared with compression therapy [ 15 , 17 , 18 , 20 , 25 , 27 ]. Compression bandaging has been shown to be effective in managing lymphedema. Badger et al. These authors reported a significantly greater reduction in limb volume at 24 weeks in the treatment group compared with the comparison group [ 4 ].
The studies that we reviewed had investigated several types of compression therapy. McNeely et al. Sequential intermittent pneumatic compression is another nonsurgical treatment for lymphedema [ 35 ]. Szolnoky et al. Thus, in the studies we investigated, there was a high level of heterogeneity regarding the variables measured to represent the reduction in lymphedema volume.
We included two studies in our analysis that compared MLD with SLD in the treatment of breast-cancer-related lymphedema [ 20 , 27 ].
Lymphatic Drainage Massage Tutorial
SLD can also be applied by the patient or a caregiver without requiring specialized training [ 27 ]. Of the ten RCT studies that we reviewed in our meta-analysis, only two investigated the effects of MLD for preventing lymphedema after breast-cancer surgery [ 16 , 21 ].
How to Perform Lymphatic Drainage Massage
Devoogdt et al. Patients received exercise therapy plus MLD or exercise therapy only for 6 months; the results showed no significant difference in the prevention of lymphedema between the two groups [ 16 ].
By contrast, Torres Lacomba et al. However, the individual contribution of MLD to the prevention of secondary lymphedema was unclear.
Variability in clinical factors and non-uniform reporting of clinical parameters contributed to the heterogeneity between the studies that we reviewed. First, the technique, duration, and frequency of MLD differed across the studies, and one study did not report the technical details of their MLD method [ 15 ].
Second, the experience of the physiotherapist and the characteristics of the individual patient can affect clinical outcomes.