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Evidence In Practice |
Charles D Ciccone, PT, PhD, is Professor, Department of Physical Therapy, Ithaca College, Ithaca, NY
A 57-year-old woman with a history of breast cancer was referred to our clinic for treatment of lymphedema in the right upper extremity. Cancer was detected originally in her right breast in 1996, and she was treated surgically by lumpectomy at that time. The cancer recurred, however, and she underwent a right radical mastectomy in July 1999. The mastectomy was followed by a series of irradiation treatments to the right axilla, starting in September 1999 and ending in December 1999. She also has been receiving tamoxifen (Nolvadex) continuously since the mastectomy (20 mg administered orally once per day). Over the past year, the patient developed 3 infections in her right upper extremity. She described these infections as "painful, fiery red blotches" that covered various areas of her upper thorax, arm, forearm, and hand. These infections were usually treated by oral administration of penicillin (eg, penicillin V, 250 mg 3 times each day).
I examined this patient and found a noticeable increase in the size of her right upper extremity. Limb girth was measured at 11 standard sites, and, in terms of the total girth difference, the right upper extremity was 51 cm greater than the left upper extremity. The patient also reported feelings of tightness and heaviness in the right upper extremity, and muscle force and joint range of motion were reduced throughout the upper extremity, especially at the shoulder (eg, she could actively flex her shoulder only to 80 degrees).
The increase in limb size was consistent with chronic lymphedema secondary to a radical mastectomy. This lymphedema was very upsetting to the patient, and she stated that she did not want "people staring at my arm all the time." The patient also wanted to reduce the size of her upper extremity to help increase function and, if possible, help prevent infections. Given the degree of swelling and the increased risk of infection, I wanted to initiate an intervention program that would reduce limb size, improve joint mobility, and reduce the incidence of infection. Such a program obviously should combine several interventions that are designed to resolve specific impairments, including some form of external compression to reduce swelling and an exercise program designed to increase range of motion and muscle force. I was aware that this type of program is described in the literature using several terms such as "complex physical therapy," "complex decongestive physical therapy," and "complete decongestive physical therapy." I wanted to find evidence that such a program is successful in reducing these impairments in people with lymphedema following breast cancer treatment. I decided to search for articles that document the effectiveness of comprehensive lymphedema management programs.
 | Database used for search: CINAHL |
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At my college's medical library, I accessed CINAHL through ProQuest* (www.il.proquest.com), a vendor that provides access to several databases including CINAHL. Within ProQuest, I clicked on the option Search Professional Research Collections Only (CINAHL) and then clicked on CINAHL. This search was performed on December 1, 2001.
| Initial keywords: lymphedema AND physical therapy |
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 TopDatabase used for search:... Initial keywords: lymphedema AND... Selection of articles for...Clinical decision:References |
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The search engine also offered several options or fields (located on the left side of the screen) for my search, including the ability to search CINAHL in the basic index field or by another criterion such as the abstract, author, source (eg, journal articles, books), subject, and title. I performed the search in the basic index field because, according to CINAHL's definition, this field "contains all the terms used to index certain database fields" in each citation, including article titles, abstract, main subject headings, and minor subject headings. The basic index field is also useful when it is unclear how terms might be spelled or how they might appear in the database. The basic field index, therefore, seemed to be a comprehensive way to begin this search.
The initial result was 40 articles or "hits." Although this number of articles was not excessive, I noticed that I could click on a small checkbox labeled Limit Search to: Peer Reviewed that was located toward the right side of the search screen. This action presumably would select only those articles that had been published after being reviewed by someone with expertise in this subject. I selected this option by clicking on the checkbox, and I then clicked the Search button located just above the checkbox. At this point, the search retrieved 25 articles. This number of articles was certainly manageable, and a quick look at the titles indicated that many of these articles seemed appropriate to answer my question.
I was curious whether any of these papers focused specifically on the ability of physical therapy to prevent infection in people with lymphedema. I placed the cursor in the query box and added the term AND infection to the original keywords. I then clicked on the Search button. The following message appeared on the screen: "Search Did Not Find Any Records." Obviously, adding the term "infection" was not successful in isolating specific articles; therefore, I removed AND infection from the query box and repeated my original search, retaining the option for only peer-reviewed articles. The citations from these articles are listed at the bottom of this page.
Citations Retrieved by Search Using the Keywords "Lymphedema" and "Physical Therapy"
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| Selection of articles for review: |
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TopDatabase used for search:...Initial keywords: lymphedema AND...Selection of articles for...Clinical decision:References |
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Wozniewski M; Jasinski R; Pilch U; Dabrowska G. Complex physical therapy for lymphoedema of the limbs. Physiotherapy 2001 May;87(5): 252–256.A total of 208 women aged 17 to 83 years (mean 50.8) were treated for lymphoedema with complex physical therapy (CPT)—intermittent pneumatic compression, exercise and manual lymph drainage. Of these patients, 188 (90%) had secondary lymphoedema of the upper limb following radical mastectomy; 20 (10%) had lymphoedema of the lower limb, of whom 12 patients had secondary lymphoedema following lymphangectomy for malignant melanoma and eight patients had lymphoedema of unknown origin.
The volume of the upper limbs and circumferences at nine levels of the lower limbs were measured before and after CPT. Complete resolution of lymphoedema of the upper limb was achieved in 32 patients (17%). The average decrease in lymphoedema was 43% in patients with minimal oedema, 33% in those with moderate oedema, and 19% in women with severe oedema. Complete resolution of primary lymphoedema of the lower limb was achieved in four patients. Average decrease in circumference was 13%. Complete resolution of secondary oedema of the lower limb was obtained in four patients with an average decrease in circumference of 23%. CPT is an effective form of conservative treatment for limb lymphoedema, particularly in patients with secondary lymphoedema of the upper limb. Reduction depends on the type of lymphoedema and the limb affected, with smaller effects demonstrated in lower limbs. The combination of intermittent pneumatic compression and manual techniques improves the results of treatment of lymphoedema.
[Abstract reprinted with permission of The Chartered Society of Physiotherapy.]
Because the full text of this article was not available through CINAHL directly, I obtained a copy of the article from my institution's medical library. This study lacked a control group; therefore, we cannot say conclusively that these interventions caused the reduction in limb size seen in these patients. Nonetheless, the authors described the use of a comprehensive regimen that included intermittent (mechanical) pneumatic compression, massage techniques, exercises, and the wearing of an elastic garment. This regimen, identified by these authors as complex physical therapy (CPT), was associated with a statistically significant reduction in limb size in this patient cohort. It was not clear, however, exactly how long CPT was administered. The authors indicated that intermittent pneumatic compression was applied "for one hour, five times a week for five weeks," but they also indicated that an elastic sleeve or garment was worn for "about six months."
Nevertheless, this study lends insight into the use of a combination of interventions in people with lymphedema. Most of the patients in this study (90%) had lymphedema that occurred following a radical mastectomy, and this patient subgroup had a mean age of 54 years. Therefore, the people in this subgroup were reasonably similar to my patient in terms of age and the cause of lymphedema. This study, however, did not compare CPT with another intervention or one of the components of the CPT program. The article's lack of a comparison concerned me. For example, I could not be sure that CPT would produce a greater decrease in limb size than using only one component of the CPT program such as intermittent pneumatic compression. Likewise, the authors measured limb size, but they did not assess any other outcomes such as a reduction in the incidence of infection after undergoing this CPT regimen. I, therefore, was interested in what results might be found in other articles obtained from this search.
Harris SR; Hugi MR; Olivotto IA; Levine M, et al. Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema CMAJ: Canadian Medical Association Journal 2001 Jan; 164(2):191–199Objective: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer. Options: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments. Outcomes: Symptom control, quality of life, cosmetic results. Evidence: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000.
Recommendations:
- * Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles.
- * Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out.
- * Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema.
- * One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone.
- * Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone.
- * Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight.
[A patient version of these guidelines appears in Appendix 2.]
Validation: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Sponsor: The steering committee was convened by Health Canada. Completion date: October 2000.
[Abstract reprinted with permission of the Canadian Medical Association.]
A full-text version of this review article was available through CINAHL, and I accessed the complete article by clicking on the article title on the search screen. This review dealt with many issues concerning the treatment of lymphedema that can occur in women treated for breast cancer. The authors systematically reviewed the literature and briefly summarized the results of relevant studies. From these summaries, they developed recommendations and guidelines for treating various aspects of lymphedema in these patients. They based these guidelines on the design and scientific rigor of the articles retrieved from their search, and they used the rules of evidence developed by Sackett1 to grade experimental studies according to the strength of evidence. These grades ranged from studies presenting strong evidence (level I studies: large randomized controlled trials with low false-positive or false-negative errors) to studies where evidence was weakest because extraneous variables were not controlled (level V studies: case series without controls).
In this review article, the authors specifically addressed the issue of CPT. They described CPT as "a treatment regimen that includes meticulous skin hygiene, manual lymph drainage, bandaging, exercises, and support garments." As indicated in the abstract, the authors retrieved only one study2 that met the level I criteria (ie, randomized controlled trial). This study did not find any additional benefit to adding manual lymph drainage and self-massage to a standard regimen that included custom-made compression garments, instruction in exercises, and patient education about skin care and other issues related to lymphedema. Harris et al also identified several other studies that investigated various aspects of CPT, and they categorized each study as having evidence between level II and level V according to each study's design. They stated, however, that "interpretation of the results is limited by the methodology of these studies." In other words, these studies differed from each other in how they manipulated the independent variables. For example, one study compared compression bandaging plus manual drainage versus compression bandaging alone, whereas another study compared manual lymph drainage plus compression garment use versus pneumatic compression plus compression garment use.
This review article did not recommend conclusively that CPT should be used instead of other interventions nor did it conclude that CPT was more effective than individual components of the CPT regimen (eg, use of compression garments alone). In addition, the ability of these interventions to reduce the risk of infection was not addressed in this review. The results from individual studies described in this review were based mostly on a reduction of limb size and other symptoms (eg, decreased pain, increased range of motion). I considered a second review article.
Megens A; Harris SR. Physical therapist management of lymphedema following treatment for breast cancer: a critical review of its effectiveness. Physical Therapy 1998 Dec; 78(12): 1302–1311.The purpose of this review is to analyze the research literature that has examined the effectiveness of physical therapy in the management of lymphedema following treatment for breast cancer. Thirteen studies met the criteria for experimental research, which were then categorized according to Sackett's levels of evidence. One study was graded at level II, 5 studies were graded at level III, and the remaining 7 studies were graded at level V. One grade B recommendation and 6 grade C recommendations were developed from the levels of evidence. The 13 selected studies were also graded according to 6 criteria to evaluate scientific rigor. Clinical recommendations and future research directions are provided.
[Abstract reprinted with permission of the American Physical Therapy Association.]
As member of APTA, I have a subscription to Physical Therapy, and I retrieved a copy from the back issues that I keep in my office. A full-text version of this article was also available through CINAHL. This review article, published in 1998, had a purpose and format that was similar to the more recent review described above. The coauthor of this review, in fact, was the lead author of the previous review article. As this abstract indicates, the authors retrieved 13 articles from the literature, categorized these articles from level II to level V according to Sackett's rules,1 and made recommendations based on the scientific merit of these articles. These recommendations were graded according to criteria that were also developed by Sackett.1 A grade A recommendation was based on evidence from at least one level I study, a grade B recommendation was based on at least one level II study, and a grade C recommendation was based on evidence from level III, IV, or V studies.
The authors could not make any grade A recommendations because none of the 13 studies produced level I evidence. The single grade B recommendation from these studies did not pertain directly to CPT, but indicated that long-term (6 months) use of compression garments can reduce limb size and that adding electrical stimulation to this intervention offered no additional benefits. The authors indicated, however, that a grade C recommendation could be made for using CPT. That is, CPT consisting of exercise, massage techniques, compression bandaging or garments, and skin care was successful in reducing limb size according to the results of 2 level V studies. It is worth noting, however, that one of these level V studies,3 which I obtained from my college library, indicated that a fairly intensive program of CPT (daily treatments of massage and compression bandaging, lasting at least 1 hour each day for 5 days each week for 4 weeks) seemed as effective as a modified program that was performed twice each week and used compression garments in place of bandaging. Similarly, another grade C recommendation from this review article suggested that combining other interventions such as massage, pneumatic pumps, and compression garments may also "show promising results in the treatment of people with lymphedema."
This review article nicely characterized the ability of CPT and other treatment combinations to reduce limb size in people with lymphedema. This review article, however, did not specifically address the issue of infection because the studies it examined apparently did not use incidence of infection as one of the primary outcome measures.
| Clinical decision: |
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TopDatabase used for search:...Initial keywords: lymphedema AND...Selection of articles for...Clinical decision:References |
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I selected massage techniques and compression bandaging as the crux of the plan of care. Massage techniques (also called manual lymph drainage or Foldi massage by some therapists) are intended to help reduce limb size before compression bandaging. Given this patient's tendency toward infection, I felt that massage offered some degree of control and safety over a pneumatic compression pump because I could carefully observe the patient's response to this treatment while I was administering the massage. I likewise elected to use compression bandaging at the beginning of treatment rather than a commercial compression garment. I thought that using bandaging as an initial method to reduce limb size would allow a custom-fit garment to be ordered when limb size was successfully reduced (ie, when this regimen produced no further decrease in limb size).
I decided to schedule this regimen of massage and bandaging twice each week for the first 4 weeks. I based this decision on the results of Matthews and Smith3 (an article addressed in the Megens and Harris review), where twice weekly treatments were found to be as effective as daily treatments. The patient also would be instructed in how to massage and bandage her upper extremity on the days that I did not see her. I planned to develop a home exercise program that included active range-of-motion and isometric exercises to maintain joint mobility and to facilitate lymph drainage via the muscle pump. The patient likewise would be educated about skin care and hygiene and safety precautions to prevent injury to the affected limb.
The issue of infection was never really addressed by the literature. I could not find any information that directly supported the use of physical therapy as a means to reduce the incidence of infection in people with lymphedema. However, I believe that we can reasonably assume that a reduction in lymphedema (as indicated by a reduction in limb size) would have beneficial effects on tissue perfusion. Edema that collects in the interstitium between the tissues and vasculature impedes the delivery of oxygen and nutrients, retards the removal of waste products, and serves as a protein-rich medium for the growth of the bacteria that lead to infection. Consequently, a logical outcome of reducing lymphedema would be improved tissue perfusion and a better chance of resisting a local infection. In my opinion, a comprehensive treatment program that reduces limb volume and helps the patient protect her arm seems to be a logical way to reduce the risk of local infection. I will examine this patient carefully at each visit to see if there are fewer episodes of infection.
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| Footnotes |
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* ProQuest Information and Learning Co, 300 N Zeeb Rd, Ann Arbor, MI 48106-1346.] 
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TopDatabase used for search:...Initial keywords: lymphedema AND...Selection of articles for...Clinical decision:References |
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