Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily L, Tuppo CM, Williams AF, Karadibak D, et al.
The Cochrane database of systematic reviews. Date of publication 2015 May 21;volume (5):CD003475.
1. Cochrane Database Syst Rev. 2015 May 21;(5):CD003475. doi:
10.1002/14651858.CD003475.pub2.
Manual lymphatic drainage for lymphedema following breast cancer treatment.
Ezzo J(1), Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily
L, Tuppo CM, Williams AF, Karadibak D.
Author information:
(1)Research Director, JME Enterprises, 1905 West Rogers Ave, Baltimore, Maryland,
USA, 21209.
BACKGROUND: More than one in five patients who undergo treatment for breast
cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a
result of breast cancer surgery and/or radiation therapy. BCRL can negatively
impact comfort, function, and quality of life (QoL). Manual lymphatic drainage
(MLD), a type of hands-on therapy, is frequently used for BCRL and often as part
of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment
which includes MLD, compression therapy (consisting of compression bandages,
compression sleeves, or other types of compression garments), skin care, and
lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is
to maintain the reduced swelling.
OBJECTIVES: To assess the efficacy and safety of MLD in treating BCRL.
SEARCH METHODS: We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health
Organization's International Clinical Trial Registry Platform), and Cochrane
Breast Cancer Group's Specialised Register from root to 24 May 2013. No language
restrictions were applied.
SELECTION CRITERIA: We included randomized controlled trials (RCTs) or quasi-RCTs
of women with BCRL. The intervention was MLD. The primary outcomes were (1)
volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2)
subjective sensations, (3) QoL, (4) cost of care.
DATA COLLECTION AND ANALYSIS: We collected data on three volumetric outcomes. (1)
LE (lymphedema) volume was defined as the amount of excess fluid left in the arm
after treatment, calculated as volume in mL of affected arm post-treatment minus
unaffected arm post-treatment. (2) Volume reduction was defined as the amount of
fluid reduction in mL from before to after treatment calculated as the
pretreatment LE volume of the affected arm minus the post-treatment LE volume of
the affected arm. (3) Per cent reduction was defined as the proportion of fluid
reduced relative to the baseline excess volume, calculated as volume reduction
divided by baseline LE volume multiplied by 100. We entered trial data into
Review Manger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed
continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We
also explored subgroups to determine whether mild BCRL compared to moderate or
severe BCRL, and BCRL less than a year compared to more than a year was
associated with a better response to MLD.
MAIN RESULTS: Six trials were included. Based on similar designs, trials
clustered in three categories.(1) MLD + standard physiotherapy versus standard
physiotherapy (one trial) showed significant improvements in both groups from
baseline but no significant between-groups differences for per cent reduction.(2)
MLD + compression bandaging versus compression bandaging (two trials) showed
significant per cent reductions of 30% to 38.6% for compression bandaging alone,
and an additional 7.11% reduction for MLD (MD 7.11%, 95% CI 1.75% to 12.47%; two
RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06).
LE volume was not significant. Subgroup analyses was significant showing that
participants with mild-to-moderate BCRL were better responders to MLD than were
moderate-to-severe participants.(3) MLD + compression therapy versus nonMLD
treatment + compression therapy (three trials) were too varied to pool. One of
the trials compared compression sleeve plus MLD to compression sleeve plus
pneumatic pump. Volume reduction was statistically significant favoring MLD (MD
47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent
reduction was borderline significant (P=0.07), and LE volume was not significant.
A second trial compared compression sleeve plus MLD to compression sleeve plus
self-administered simple lymphatic drainage (SLD), and was significant for MLD
for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31
participants) but not for volume reduction or per cent reduction. A third trial
of MLD + compression bandaging versus SLD + compression bandaging was not
significant (P = 0.10) for per cent reduction, the only outcome measured (MD
11.80%, 95% CI -2.47% to 26.07%, 28 participants).MLD was well tolerated and safe
in all trials.Two trials measured function as range of motion with conflicting
results. One trial reported significant within-groups gains for both groups, but
no between-groups differences. The other trial reported there were no significant
within-groups gains and did not report between-groups results. One trial measured
strength and reported no significant changes in either group.Two trials measured
QoL, but results were not usable because one trial did not report any results,
and the other trial did not report between-groups results.Four trials measured
sensations such as pain and heaviness. Overall, the sensations were significantly
reduced in both groups over baseline, but with no between-groups differences. No
trials reported cost of care.Trials were small ranging from 24 to 45
participants. Most trials appeared to randomize participants adequately. However,
in four trials the person measuring the swelling knew what treatment the
participants were receiving, and this could have biased results.
AUTHORS' CONCLUSIONS: MLD is safe and may offer additional benefit to compression
bandaging for swelling reduction. Compared to individuals with moderate-to-severe
BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding
MLD to an intensive course of treatment with compression bandaging. This finding,
however, needs to be confirmed by randomized data.In trials where MLD and sleeve
were compared with a nonMLD treatment and sleeve, volumetric outcomes were
inconsistent within the same trial. Research is needed to identify the most
clinically meaningful volumetric measurement, to incorporate newer technologies
in LE assessment, and to assess other clinically relevant outcomes such as
fibrotic tissue formation.Findings were contradictory for function (range of
motion), and inconclusive for quality of life.For symptoms such as pain and
heaviness, 60% to 80% of participants reported feeling better regardless of which
treatment they received.One-year follow-up suggests that once swelling had been
reduced, participants were likely to keep their swelling down if they continued
to use a custom-made sleeve.
DOI: 10.1002/14651858.CD003475.pub2
PMCID: PMC4966288
PMID: 25994425 [Indexed for MEDLINE]
