Annals of Oncology 18: 639–646, 2007

review doi:10.1093/annonc/mdl182
Published online 3 October 2006

A systematic review of common conservative therapies

for arm lymphoedema secondary to breast cancer
treatment
A. L. Moseley1*, C. J. Carati2 & N. B. Piller3
1
School 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

review
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 pharmaceuticals, low level laser therapy, compression

Currently, secondary arm lymphoedema affects approximately
30% of those who undergo breast cancer treatment [1] and
results in excess fluid accumulation in the interstitial space,
detrimental tissue changes, limb swelling and quality of life
issues. As this condition will generally worsen over time [2],
a number of health professionals based and patient instigated
conservative therapies that aim to decrease the limb swelling and
its associated problems have been developed. Two systematic
reviews have investigated some of these therapies in upper and
lower limb lymphoedema, including manual lymphatic
drainage, compression bandaging and garments [3] and
benzopyrones [4], with both studies finding it difficult to make
definitive therapy recommendations. Due to the chronicity of
secondary arm lymphoedema there is still a need to determine
the comparative benefits of the different conservative therapies
for this condition. Therefore this review aimed to undertake
a broad investigation of commonly instigated conservative
therapies for this population, including; complex physical
therapy, manual lymphatic drainage, pneumatic pumps, oral
*Correspondence to: Ms A. L. Moseley, Institute of Women’s Health, Department of
Gynaecological Oncology, University College London, London, UK;
E-mail: amanda.moseley@yahoo.com.au
bandaging and garments, limb exercises and limb elevation.
inclusion and exclusion criteria
All study participants had to have a formal diagnosis of
secondary arm lymphoedema subsequent to breast cancer
surgery (total or partial mastectomy) ± radiotherapy ±
chemotherapy. Studies which included participants with
recurrent 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 lymphoedema
patients, and included the following:
Complex physical therapy (CPT) involves 2–4 weeks of daily
manual lymphatic drainage (described below) followed by
compression bandaging (administered by a health professional)
and skincare plus prescribed limb exercises undertaken by the
patient [5]. The patient is then fitted with a compression
garment.
Manual lymphatic drainage (MLD) uses various light massage
techniques to encourage the removal of excess interstitial fluid,
increase lymphatic transport and soften fibrotic induration

ª 2006 European Society for Medical Oncology

review
[6–8]. All methods start by clearing the areas distance or
adjacent to the affected limb before moving to the limb root
then to it’s most distal section and then back to the limb root
again.
Self/partner massage: Health professionals often teach patients
(or their significant other) a simplified version of manual
lymphatic drainage which includes clearing of the adjacent area
and 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 different
cycles and pressures to encourage fluid drainage from the distal
to the proximal end of the limb [12].
Oral pharmaceuticals encompass the alpha (a) Benzopyrones
such as the Coumarin derivatives and the gamma (c)
Benzopyrones such as the flavones and flavonols [16].
Benzopyrones may help lymphoedema by reducing vascular
permeability, protein and extracellular fluid accumulation
[16, 17], stimulating lymph contractility and flow [16, 18] and
reducing protein concentration and fibrotic induration in the
tissues by stimulating proteolysis [19].
Low level laser therapy uses low intensity wave lengths
between 650–1000 nm, either in a scanning or spot laser form.
Research suggests that laser therapy increases the rate of lymph
vessel pumping and promotes lymph vessel regeneration [13],
reduces pain [14] and softens both fibrous tissue and surgical
scarring [15].
Compression bandaging consists of a gauze sleeve which
protects the skin, soft cotton wrap or high density foam and
2–3 layers of short-stretch bandaging. Compression helps to
decrease the amount of interstitial fluid formation, prevent
lymph back flow and enhance the muscle pump by providing
a relatively inelastic barrier for the muscle to work against [10].
Compression garments have a similar mode of action as
compression bandaging and are designed to be graduated, with
the greatest compression being at the distal end of the limb and
the least amount being at the proximal end.
Limb exercises can be progressive, resistive or sequential in
nature and are recommended as a way of varying total tissue
pressure to encourage lymphatic drainage and for improving
limb range of movement and strength [11].
Limb elevation reduces capillary exudation in to the tissues
and promotes lymphatic return. It is considered most useful in
the earlier (fluid) stage of lymphoedema [5].
literature search
The literature search was limited to English, with the following
databases searched; Cumulative Index to Nursing & Allied
Health Literature (Cinahl), Medline, Academic Research
Periodicals, PubMed Clinical Queries (including
Complementary Medicine), CANCERLIT, EBM Reviews –
Cochrane Central Register of Controlled Trials, Cochrane
Database of Systematic Reviews (CDSR), American College
of Physicians (ACP) Journal Club, Database of Abstracts of
Reviews of Effects (DARE), PREMEDLINE, Australian Medical
Index, Physiotherapy Evidence Database (PEDro) and the
National Guidelines Clearing House.
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Annals of Oncology
The general terms used for all these search engines were as
follows:
• 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 lymphatic
societies were also searched. The biennial congress proceedings
of The International Society of Lymphology (1977–2004) and
the Australian Lymphoedema Association (2000–2004) were
searched by hand. Primary authors were contacted when
publications were difficult to source. The reference section of
each article was also checked for relevant articles.
data extraction and quality assessment
Endnote 7
was used as the data extraction tool. Once the
data had been extracted and recorded, the quality of each
study was assessed and given a rating. The Quality Scale
Assessment tools used in this review were based upon a tool
developed by Mulrow and Oxman (1996) [20], with one tool
being 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 was
undertaken by A. Moseley, with the process checked by
N. Piller and C. Carati. The quality rating and level of
evidence [21] for each reviewed study is presented in Table 1.
analysis
This review included studies performed in the randomized
controlled, parallel and cross-over format plus case control and
cohort studies. Case studies and anecdotal evidence were not
reviewed. Due to treatment and data heterogeneity, a meta-
analysis could not be performed. Therefore, only a narrative of
the different conservative therapies for secondary arm
lymphedema is presented. For ease of comparison, an
approximate oedema reduction (%) has been calculated in
each case where the limb volume reduction is presented in
milliliters (ml).
results
The average percentage volume change at end of trial achieved
by 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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Annals of Oncology review
Table 1. Quality rating and level of evidence of the reviewed
conservative therapy studies

Treatment Quality Level of

rating evidence
CPT
Szolnoky et al. [26] 4 III-3
Wozniewski et al. [27] 5 III-3
Szuba et al. [22] 4 III-3
Piller et al. [9] 5 III-3
Boris et al. [23] 4 III-3
Bunce et al. [28] 4 III-3
Caroll & Rose [24] 3 III-3
Casley-Smith & Casley-Smith [25] 3 III-3
Swedborg [29] 4 III-3
MLD
McNeeley et al. [34] 8 III-3
DuBois [33] 2 III-3
Korpon et al. [30] 2 III-3
Ang et al. [37] 6 III-3
Williams et al. [32] 5 III-3
Andersen et al. [33] 5 III-2
Johansson et al. [35] 6 III-2
Johansson et al. [36] 5 III-3 Figure 1. The average percentage volume change at end of trial of each
Piller et al. [31] 5 III-3 conservative therapy.
Pneumatic pumps
DuBois [33] 2 III-3
Szuba et al. [39] 6 III-3 complex physical therapy (CPT)
Johansson et al. [36] 5 III-3
Swedborg [40] 5 III-3 Five studies reviewed investigated standard CPT over a varying
Zelikovski et al. [41] 4 III-3 treatment period of 8 days to 3 months [9, 22–25]. Participant
Oral pharmaceuticals numbers ranged from 16–78, with some studies having no stated
Burgos et al. [43] 7 III-3 exclusion criteria [22, 23] and others having a poorly stated
Loprinzi et al. [44] 7 II criterion [24, 25]. The reductions achieved from the five
Pecking et al. [45] 4 II studies varied from 298–652 ml (18.7–66%), with three studies
Cluzan et al. [40] 7 II demonstrating additional volume reductions over 6–12 months
Casely-Smith et al. [47] 8 II follow up [9, 22, 25]. Two studies measured subjective
Low level laser symptoms, with one showing a reduction in pain [24] and the
Carati et al. [48] 8 II other in tightness, heaviness, pins and needles, cramps and
Piller & Thelander [50] 5 III-3 tension [9].
Piller & Thelander [49] 5 III-3 One study investigated standard CPT (n = 13) in comparison
Compression with CPT plus 30 min of intermittent pump (50 mmHg)
Korpon et al. [30] 2 III-3 therapy (n = 14) [26]. After 10 days CPT alone yielded a
Andersen et al. [33] 5 III-2
3.1% mean volume reduction whilst the CPT + pneumatic
Johansson et al. [35] 6 III-2
group had a statistically greater reduction of 7.9%. Although
Johansson et al. [36] 5 III-3
a reduction in symptoms was reported, it was not stated what
Hornsby [51] 1 III-2
symptoms were actually measured. The follow-up
Swedborg [40] 5 III-3
Exercise
measurements over one and two months demonstrated a
Moseley et al. [52] 5 III-3
continuing decrease in percentage volume in both treatment
Box et al. [53] 4 III-2 groups (3.6% and 9.6% at 2 months). Two studies investigated
Buckley et al. [54] 4 III-3 CPT in combination with intermittent pump therapy. The
Johansson et al. [11] 4 III-3 first study [27] involved 1 hour of intermittent pump
McKenzie & Kalda [55] 5 III-2 (40–70 mmHg) therapy incorporated into the CPT regime
Elevation (n = 188), with this regime yielding statistically significant
Swedborg et al. [56] 6 III-3 percentage reductions in all grades of lymphoedemas (grade
I–III, 43.4–19.3 %) after 5 weeks of treatment. The second study
involved a regime of CPT with a pump of <60 mmHg (n = 25)
[28]. After 1 month there was a reduction of 40% in excess limb
volume, with this reduction being maintained at 12 months
follow up. The last study investigated a combination of

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review
treatments incorporated into the CPT regime, including
mechanical plus manual massage, hand grip exercises, the
wearing of a compression garment and the addition of hot
compresses during one treatment phase [29]. All treatment
combinations yielded similar actual oedema reductions in the
range of 8.5–13%.
All the reviewed studies demonstrated that a reduction in
limb volume and/or percentage oedema can be achieved with
standard CPT, CPT plus pump therapy and a combination of
therapies, with five studies [9, 22, 25, 26, 28] demonstrating
a continued volume reduction at follow up (range 1–12
months). The three studies [9, 24, 26] which measured
subjective symptoms demonstrated that these improved after
the CPT regime, unfortunately none of these studies report
whether these improvements were sustained at the follow up
periods. The study by Piller et al. (1996) also demonstrated that
volume and subjective symptom reductions could be achieved
when patients and their partners were taught how to apply
a regime of lymphatic massage and compression bandaging
themselves [9]. The optimal treatment period for CPT
appears to be 1 month, however, two studies [22, 29] achieved
a volume reduction at the end of 7–8 days of treatment.
manual lymphatic drainage (MLD)
Two studies investigated the effect of MLD alone. These two
studies [30, 31] involved 12–17 participants who received MLD
and who experienced a volume reduction of 104–156 ml
(8–10%), with one study reporting that the volume reduction
was maintained at 6-months follow up [31]. The other study
reported reductions in heaviness and tension, but did not state
the inclusion/exclusion criteria or the length and frequency of
MLD [30]. Two studies investigated MLD in comparison to
another treatment modality. The first of these studies used
a cross-over design to investigated a phase of MLD and self
massage (n = 27), each over a 3-week period [32]. Results
showed that MLD produced a statistically significant reduction
of 71 ml and improvements in subjective heaviness, fullness and
bursting whilst the self massage resulted in a non significant
reduction of 30 mls. The second randomized study investigated
MLD (n = 20) in comparison to a ‘control’ group who
undertook education, wearing a compression sleeve and limb
exercises (n = 20) [33]. After 2 weeks the ‘control’ group actually
had a greater percentage reduction in absolute oedema (60%) in
comparison to the MLD group (48%). Both groups equally
experienced a reduction in the symptoms of heaviness and
tightness, whilst the ‘control’ group also had a reduction in
reported 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 had
a clearly stated inclusion/exclusion criterion, with the first two
studies investigating MLD plus compression bandaging. These
two studies [34, 35] involved 18–24 women who received MLD
plus compression bandaging over 1 week to 1 month. After 1
week there was a significant volume reduction of 47 ml (11% in
oedema) [34], whilst over 1 month the reduction was 260 ml
(46.1%), with significant improvements in tension, heaviness
and pain [35]. The third study investigated the effect of
642 | Moseley et al.
Annals of Oncology
a compression (30–40 mmHg) sleeve worn for 2 weeks followed
by 2 weeks of additional MLD (n = 12) [36]. Wearing the sleeve
alone resulted in a significant volume reduction of 49 ml (7%),
with the addition of MLD resulting in a significant reduction of
75 ml (15%). Both phases also significantly improved arm
tension and heaviness. The last study investigated MLD in
combination with a compression garment or bandaging once
a 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 combined
with pneumatic pump therapy yielded similar reductions in
oedema volume (40% and 45% respectively), however, there
were no accompanying statistical values so significance is not
known. The follow up period in this study (14–24 months)
demonstrated an oedema volume increase of 33% in those who
underwent no further treatment, whilst those who underwent
regular treatment (type not stated) experienced a slight
reduction (1%) in oedema volume.
The volume reductions achieved by MLD alone varied from
104–156 ml, with the greatest percentage reduction being 48%
[33]. Larger reductions were achieved from MLD in
combination with compression, which varied from 47–260 ml
(7–84%), with these studies demonstrating that either form of
compression (garment or bandaging) could be effectively used
in combination with MLD. MLD in combination with
pneumatic pump therapy was also shown to be effective [38].
The majority of volume reductions were achieved after a 4 week
treatment period, although volume reductions were also seen
to occur over 2 weeks of treatment [31, 33, 36]. Only three
of the reviewed studies included a follow up period which
demonstrated that the initial volume reductions were
maintained [31, 33, 38]. The overall lack of follow up in these
studies makes it difficult to formulate strong conclusions on the
long term benefits of MLD (± bandaging).
pneumatic pump therapy
Five studies were reviewed which investigated the effect of
pneumatic pump therapy. The first was a poorly reported study
which involved a group that received a combination of MLD
(0.5 h) and pump therapy (0.5 h) over 25 sessions (n = 62) and
another that received 6 hours of sequential (40 mmHg) pump
therapy (only) over 5 days (n = 14) [38]. Both groups
experienced identical oedema volume reductions (45%), with
this reduction being achieved over a shorter treatment duration
(5 days) in the pump only group. However, considering this
group had a sample size of 14, it is hard to determine whether
this volume reduction is a true reflection of what can be
achieved with this form of sequential (40 mmHg) pump. Szuba
et al. (2002) performed two randomised studies which
investigated the use of a four-chambered, sequential pump as an
adjunct therapy [39]. The first study compared 10 days of
complex physical therapy (CPT) alone (n = 11) and in
combination with 30 min of 30–40 mmHg pump therapy
(n = 12). Results showed that the CPT plus pump therapy
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Annals of Oncology
resulted in a greater and significant limb volume reduction in
comparison to CPT alone (45.3% versus 26% respectively).
Interestingly, the CPT plus pump therapy reduction was not
maintained at 1 month follow up (increase of 15%), whilst the
CPT alone reduction was maintained. The second study
investigated a 1 month phase of arm self maintenance including
self massage and compression garment wear, followed by a
phase of applying 1 hour of pump therapy for a further 1 month
period (n = 25). The self maintenance phase resulted in an
arm volume increase of 32.7 ml (3.3%), with the addition of
the 1 h of pump therapy resulting in a statistically significant
reduction of 89.5 ml (9.0%). Some participants continued
using the pump an average of four times a week for 6 months,
with 19 participants having an additional reduction in limb
volume of 29.1 ml (3.0%) and five having an increase of 35 ml
(3.5%). Why this sub-group of participants had a worsening
in limb volume was not explored.
One study investigated 2 h of pump therapy (40–60 mmHg)
5 days a week for 2 weeks [36]. After this time there was
a non significant reduction in arm volume (28 ml; 7%) and
reported tension and heaviness. One study investigated the
wearing of a compression (30–40 mmHg) garment for 6 months
then 6 h of pump therapy (35–60 mmHg) over 10 sessions
followed by the continued wear of the compression garment
(n = 54) [40]. Results showed a significant 8% reduction after
wearing the compression garment and an additional 9%
significant reduction after the pump therapy (with the
assumption that the total edema reduction at this time point
was 17%). A 6-month follow up demonstrated a 19.8%
reduction in those who continued to wear the compression
garment. The last study investigated 2–3 h of sequential
(100–150 mmHg) pump therapy, three times a day for 3 days
(n = 25) [41]. After 3 days the percentage reduction ranged
from 12–44% (statistical values not stated). After trial cessation,
2 h of maintenance therapy was applied one–four times a week
over the following 6 months. Follow up at this time showed that
the initial treatment reductions had been maintained. However,
it was not reported whether the maintenance of limb volume
was the result of one or four sessions of treatment per week.
Two studies [38, 41] demonstrated that volume reductions
could be achieved from pump therapy alone, although the high
pressures (100–150 mmHg) used by Zelikovski et al. (1980) [41]
are above the 60 mmHg of pressure normally recommended for
the treatment of lymphoedematous limbs [42]. Three of the
reviewed studies [36, 38, 40] demonstrated that better results in
volume reduction were achieved when the pneumatic pump was
combined with other therapies, including; manual lymphatic
drainage, compression garments and self massage. Three studies
[38, 40, 41] also demonstrated that continuing the pump
therapy or wearing a compression garment were beneficial in
maintaining the initial volume reductions.
oral pharmaceuticals
Five studies were reviewed that investigated the effect of oral
pharmaceuticals. 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, both
groups experienced a similar reduction in percentage limb
Volume 18 | No. 4 | April 2007
review
volume (14.9% and 13.2% respectively) and reductions in
heaviness, pain and cramps. The second study used a cross over
design to investigate a 6-month phase of Coumarin (400 mg)
and a 6 month phase of a placebo (n = 138) [44]. Results
demonstrated a volume increase (and therefore worsening) of
58 ml (6%) in the treatment phase and 21 ml (2.1%) in the
placebo phase. Despite this, participants reported
improvements in arm swelling, pressure, tightness, heaviness
and mobility. The third study investigated Daflon (Diosmin
plus 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 experienced
a volume increase of 10%. Both groups experienced a significant
reduction in reported discomfort, with the treatment group also
having a significant reduction in heaviness.
The fourth study investigated three capsules of Cyclo-Fort
(Ruscus Aculeatus and Hesperidin Methyl Chalcone) three
times a day (n = 27) compared to placebo (n = 30) over 3
months, with the addition of MLD (2 · week) in the first month
of the trial [46]. After the first month both the treatment and
placebo 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 the
placebo group had an increase of 2.5%. Both groups
experienced improvements in heaviness and limb mobility, with
these being significant in the Cyclo-Fort group. The last study
used a cross over design to investigate a 6 month phase of 5–6
Benzo-a-pyrone (200 mg) and placebo (n = 31) [47]. Results
demonstrated a volume reduction of 840 ml (35.6%) in the
treatment phase, with this reduction being significant in
comparison to the control phase in which the limb increased in
volume by 490 ml (41.6%). A 1-month follow up demonstrated
an additional decrease of 3.3% in oedema (treatment phase) and
an additional increase of 1.2% (placebo phase).
The two studies which investigated Coumarin had
conflicting results, with one showing a decrease in arm
volume (dosage 90 mg, 135 mg) [43] and the other showing
an increase in volume (dosage 400 mg) [44]. As neither study
had a follow up period it is not known whether the initial
volume reduction or increase would have continued. The other
reviewed studies [45–47] demonstrated that varying volume
reductions and subjective improvements could be obtained
from oral pharmaceuticals such as Daflon (1000 mg) and
Cyclo-fort, with the greatest limb reduction (840 ml, 35.6%)
being obtained from the 5–6 Benzo-a-pyrone (200 mg) [47].
It is also important to note that two studies [43, 47] reported
gastrointestinal upsets in 13.7% and 22.6% of participants.
low level laser therapy
Three studies were reviewed which investigated concentrated or
scanning laser therapy. The first study was a double-blinded,
randomised controlled trial involving one group which received
two cycles of active laser to the axilla three times a week for 3
weeks (n = 37) and another group who received one cycle of
placebo laser and one cycle of active laser (n = 27) over the same
time periods [48]. At trial end there were volume reductions in
all phases: placebo; 35 ml (3.5%), one cycle; 15 ml (1.5%),
two cycles; 25 ml (2.5%). A 3-month follow up demonstrated
doi:10.1093/annonc/mdl182 | 643
review
a volume increase of 30 ml (3.0%) in those who received
placebo and volume reductions in the one cycle (10 ml 1.0%)
and two cycle (90 ml 9.0%) phases. The two cycle phase also
resulted in a significant reduction in the mean perceptual score
and improvements in quality of life parameters. The second
study investigated 30 min of scanning laser, twice a week for
6 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 follow
up study of these participants (n = 8) [50] demonstrated
that 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 levels
by the 36-month mark.
These three studies demonstrate that benefits including
volume reduction, improved subjective symptoms and quality
of life can be derived from either concentrated or scanning laser
therapy. The best results in the Carati et al. (2003) study [48]
were seen at 3 months post treatment, which suggests that there
maybe ongoing benefits from laser therapy. This is supported
by the Piller and Thelander (1998) study [50] (albeit with
a much smaller sample size), which found that there were
continued reductions in arm volume and reported arm
tightness 6 months after treatment cessation.
compression
Four studies investigated the effect of compression (garment or
bandaging) alone. Two studies [30, 35] which involved 35–55
participants investigated compression bandaging. These
studies demonstrated a volume reduction of 38 ml (7%) [30]
and 20 ml (4% oedema) [35] respectively and significant
improvements in arm heaviness and tension. Two studies
investigated the effect of a 30–40 mmHg compression garment.
The first study involved 12 participants who wore the garment
over a 2-week period [36], after which time there was
a significant volume reduction of 49 ml (5.0%) and
improvements in tension and heaviness. The second study
involved participants (n = 26) wearing the compression
garment over a 6-month period [40]. Results showed an 8%
reduction in actual oedema, however, at the 6-month point
only 12 women remained in the study. Two studies investigated
the effect of wearing a compression garment in combination
with other activities. One study [33] demonstrated that after
3 months of limb exercise and compression wear (n = 22)
there was a 60% reduction in absolute oedema, with the other
study 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 of
these volume reductions are not known.
Four of the reviewed studies [30, 35, 36, 40] demonstrated
that modest volume reductions of 20–49 ml (4–8%) and
significant improvements in heaviness and tension could be
achieved when wearing compression (bandaging or garment)
alone. However, none of these studies included a follow up
period, so the ongoing effects of compression cannot be
determined. Two studies [33, 51] demonstrated that greater
volume reductions of 243 ml (24.4%) and 60% could be
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Annals of Oncology
achieved when the wearing of a compression garment was
combined with limb exercise or self massage.
exercise
Five studies were reviewed which investigated a variety of
exercise regimes. The first study investigated a 10-minute arm
exercise and deep breathing regime (n = 38) [52] which resulted
in an arm volume reduction of 52 ml (5.8%) and improvements
in heaviness and tension, with some reductions maintained over
24 h and 1 week follow up. After 1 month of performing this
regime (n = 24) there was a volume reduction of 101 ml (9%)
and significant improvements in heaviness and perceived limb
size. Two studies investigated the effects of 40–45 min of
hydrotherapy [11, 53], with neither study stating the exclusion
criteria. The first was a randomised study which involved
a 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 reductions
at 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 had
reductions in reported aching, heaviness, tightness, limb
swelling, stiffness and heat intolerance. The second study
investigated hydrotherapy performed by seven participants in
two different pool temperatures (28 C; 82 F and 34 C; 93 F)
[11]. After the first session (28 C) there was a decrease in arm
volume of 32 ml (12% oedema change), whilst after the second
session (34 C) there was a slight increase in volume of 2 ml
(0.7% change). Subjective symptoms remained unchanged after
both pool sessions. One study investigated a 30 min regime of
instructed deep breathing, self massage and sequential limb
exercises (n = 7) [54]. Directly after performing the regime there
was a slight increase in arm volume (12 ml, P = n.s.), with a net
decrease (12 ml, P = n.s.) experienced 20 minutes post regime.
Despite the minimal volume reduction, the group reported
improvements in arm range of movement, subjective limb
temperature difference, heaviness and tightness.
Two studies investigated the effect of resistive arm exercises.
The first of these studies involved a regime of shoulder flexion
and abduction and elbow extension and flexion using 0.5 kg
hand weights, performed firstly with no compression garment
and secondly when wearing a compression garment (n = 23)
[11]. Results showed an initial increase in arm volume after
performing the regime, plus or minus garment wear (12 ml,
0.5% and 10 ml, 0.3% respectively). However, at the 24 h follow
up the volume increases had been reversed, with both phases
demonstrating a volume reduction of 15 ml (0.7–1.0%) at this
time point. Reported tension and heaviness remained
unchanged in both phases, however, when the regime was
performed without a compression garment there was
a significant increase in reported physical exertion. The second
study investigated latissimus dorsi, bicep and tricep exercises
with weights and the wearing of a compression garment
undertaken three times a week for 8 weeks (n = 7) [55]. This
resulted in a limb volume reduction of 2% plus significant
improvements in physical functioning, general health and vitality.
The five studies reviewed demonstrated that exercise regimes
can have a varying impact upon limb volume, ranging from
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Annals of Oncology
12–101 ml (0.4–9%), with three studies demonstrating
improvements in subjective symptoms [52–54]. Sustained
volume reductions were also seen to occur 24 h to 6 weeks after
exercise program cessation [11, 52, 53]. The hydrotherapy study
[11] suggests that this form of exercise is best undertaken in
a pool temperature of 28 C (82 F).
elevation
Only one study was reviewed that investigated the effects of
limb elevation [56]. It involved 33 women who elevated their
arm at 80 angle over a 5-h period. At the end of this time there
was a significant 3.1% reduction in arm volume. Subjective
symptoms and adverse effects were not recorded, so it is not
known how well this regime was tolerated.
discussion
In recent times, sentinel lymph node biopsy (SLNB) has become
a more common procedure in breast cancer surgery, resulting in
less arm morbidity [57], including lymphoedema [58].
However, there is still the possibility of developing arm
lymphoedema after SLNB, especially if the sentinel node is
located 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 lymphoedema
maybe reduced as a consequence of SLNB, it is still important to
know the benefits of conservative therapies for the proportion of
women who do go on to develop this condition after breast
cancer treatment.
The current review investigated conservative therapies for
arm lymphoedema that can essentially be divided into intensive
treatments administered by trained health professionals and
limb maintenance therapies undertaken by the patient. As
demonstrated by Figure 1, treatments that are predominantly
administered by health professionals, such as complex physical
therapy, manual lymphatic drainage (with and without
compression), laser therapy and pneumatic pump therapy
generally 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 percentage
reductions. There is some research to suggest that undertaking
therapies such as arm rehabilitation and exercise may prevent
the onset of lymphoedema [61], but further research is required
to determine the true benefits of such programs.
Although those therapies which would be categorised as ‘self
maintenance’ yielded smaller volume reductions, this review has
demonstrated that they are more beneficial than doing nothing
at all for the lymphoedematous limb. This indicates that such
therapies maybe useful when health professional based therapies
are not accessible or economically viable for the patient. The
review also demonstrated the positive impact upon subjective
limb complaints and quality of life issues, indicating that these
conservative therapies can be initiated by the health professional
or patient with the anticipation of some benefit. Follow up
periods (when incorporated) indicated that some form of
continuing therapy (intensive or patient based) needed to be
undertaken to maintain the initial volume reductions, which
Volume 18 | No. 4 | April 2007
review
demonstrates the chronic nature of this condition. Despite
the range of positive outcomes identified in this review, the
evidence to support them is, in some instances, poor. Therefore,
there is still a need for large scale, high level clinical trials in
this area.
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