Complete Decongestive Physiotherapy Research Articles

New insights in breast cancer-related lymphedema

Upper limb lymphedema after breast cancer treatment including axillary dissection occurs in almost 20% of women. Its treatment consists of complete decongestive physiotherapy based on low-stretch bandage to reduce volume, followed by elastic compression to maintain it. In this article, we will detail recent data on lymphedema risk factors with possible genetic predisposition, prevention (surgical, compression), manual lymphatic drainage, physical activity, weight, advice, and treatments including gene therapy.

Actualisation des indications et des techniques de prise en charge du lymphœdème après chirurgie du cancer du sein

ObjectivesUpper limb lymphedema secondary to breast cancer treatment is the leading cause of lymphedema in France. Despite improved surgical practices and de-escalation of radiotherapy, the risk of lymphedema after breast cancer still affects 5–20% of patients, with this variation depending on the measurement method used and the population studied. Lymphedema has a negative impact on quality of life and body image, and their possible occurrence remains a major concern for all women treated for breast cancer. The Sénologie Commission of the Collège national des gynécologues et obstétriciens français (CNGOF) asked four specialists in breast surgery or lymphology to prepare a summary on the prevention, medical and surgical management of lymphedema after breast cancer treatment, and to discuss the medical and surgical innovations currently being evaluated. MethodsThis synthesis was based on national and international guidelines on the management of upper limb lymphedema after breast surgery and a recent review of the literature focusing on the years 2020–2023. ResultsFrom a preventive point of view, the restrictive instructions imposed for a long time (reduction in physical activity or the carrying of loads, air travel, exposure to the sun or cold, etc.) have altered patients’ quality of life and should no longer be recommended. A good understanding of risk factors enables us to target preventive actions. Examples include obesity, a sedentary lifestyle, axillary clearance, radiotherapy of the axillary fossa in addition to axillary clearance, total mastectomy, taxanes or anti-HER-2 therapies in the adjuvant phase. Resumption of physical activity, minimally invasive axillary surgery, de-escalation of radiotherapy and breast-conserving surgical procedures have all demonstrated their preventive value. When lymphedema does occur, early management, through complete decongestive physiotherapy, can help reduce its volume and prevent its long-term worsening. ConclusionSurgical (lymph node transplants, lympho-vascular anastomoses) and medical (prolymphangiogenic growth factors) approaches to lymphedema treatment are numerous, but require long-term evaluation of their efficacy and adverse effects.

Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema.

Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.

Abstract P3-14-08: The impact of a structured surveillance protocol using bioimpedance spectroscopy (BIS) on preventing breast cancer related lymphedema (BCRL) in high-Risk patients

Abstract Background: We evaluated the impact of structured surveillance using bioimpedance spectroscopy (BIS) to prevent clinical BCRL in a group of high-risk (axillary lymph node dissection) patients. Methods: From April 2010 through November 2016, 93 patients who were treated with axillary lymph node dissection (ALND) were prospectively monitored with BIS using L-Dex (Impedimed). Patients received a pre-operative baseline L-Dex measurement followed by post-operative assessments at regular intervals. An elevated L-Dex score was defined as an increase of ≥10 points above baseline (considered subclinical BCRL). Intervention consisted of applying an over the counter (OTC) sleeve for 4 weeks followed by re-evaluation. The need for complete decongestive physiotherapy (CDP) represented a surrogate for the development of clinically significant, chronic BCRL. Results: Median follow-up was 24 months (range: 0.3-206.4 months). The median number of nodes removed was 19 (range: 5-41) and the median number of positive nodes was 3. Median age was 53 years old. Eighty five percent of patients underwent mastectomy and the remainder breast conserving therapy. 55% of patients received taxane based chemotherapy, 24% received some form of axillary RT (15% high tangents and 9% comprehensive regional nodal RT) and 74% had an elevated body mass index (BMI, > 25). Overall, 75% of these patients had at least one additional high-risk feature, 48% had at least two, and 6% had 3 (either taxane chemotherapy, axillary RT or elevated BMI). Thirty-three patients (35.4%) developed an elevated L-Dex score at some point during follow up. Overall, 10 patients (11%) required CDP at any point after treatment. Conclusions: The results of this analysis support previously published data on the efficacy of prospective BCRL surveillance and early intervention using BIS. Of the 93 high-risk patients prospectively followed and managed in this structured BCRL protocol, 11% required CDP. These results compare favorably to all contemporary studies reporting BCRL rates in high-risk patients. Citation Format: Whitworth P, Cooper A, Shah C, Vicini F. The impact of a structured surveillance protocol using bioimpedance spectroscopy (BIS) on preventing breast cancer related lymphedema (BCRL) in high-Risk patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-14-08.

Reducing chronic breast cancer-related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy.

This single-institution experience evaluated the use of bioimpedance spectroscopy to facilitate early detection and treatment of breast cancer-related lymphedema (BCRL) in a cohort of 596 patients (79.6% high risk). Seventy-three patients (12%) developed an elevated L-Dex score with axillary lymph node dissection (P<.001), taxane chemotherapy (P=.008), and regional nodal irradiation (P<.001) associated. At last follow-up, only 18 patients (3%) had unresolved clinically significant BCRL requiring complete decongestive physiotherapy. This rate of BCRL is lower than reported in contemporary studies, supporting recent NCCN guidelines promoting prospective screening, education and intervention for BCRL.

Reducing chronic breast cancer related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy (BIS).

10117 Background: Breast cancer related lymphedema (BCRL) represents a major side effect that can significantly impact quality of life. Current guidelines support prospective surveillance to allow for early diagnosis and treatment of BCRL at a subclinical, reversible stage. This current large, single institution experience evaluated the use of bioimpedance spectroscopy (BIS) to monitor patients for the development and treatment of BCRL. Methods: From April 2010 through Nov 2016, 596 patients (79.6% with high-risk features) were evaluated with BIS.Patients received a pre-operative baseline L-Dex measurement and post-operatively at regular intervals. Elevated L-Dex scores were defined as an increase of ≥10 points above baseline (considered subclinical BCRL). Intervention then consisted of applying an over the counter (OTC) sleeve for 4 weeks followed by re-evaluation. The need for complete decongestive physiotherapy (CDP) represented a surrogate for the development of clinically significant, chronic BCRL. Results: Median follow-up for all patients was 17 months. Seventy-three patients (12%) developed an elevated L-Dex score with axillary lymph node dissection (ALND) (p &lt; 0.001), taxanes (p = 0.008), and (regional nodal irradiation (RNI) (p &lt; 0.001) associated. At last follow-up, only 18 patients (3%) had unresolved clinically significant BCRL requiring CDP. Mastectomy (p = 0.02), ALND (p &lt; 0.001), taxanes (p = 0.05), and RNI (p &lt; 0.001) were associated with requiring CDP. Conclusions: Our results demonstrate that prospective monitoring using BIS, with intervention (using a simple OTC sleeve for 4 weeks) triggered by a ≥10-point L-Dex elevation, resulted in only a 3% rate of chronic, clinically significant BCRL. These results are lower than reported in contemporary studies and validate recent guidelines supporting prospective screening and intervention for BCRL.

Les lymphœdèmes : du diagnostic au traitement

Lymphedema results from impaired lymphatic transport with increased limb volume. Lymphedema are divided in primary and secondary forms. Upper-limb lymphedema secondary to breast cancer treatment is the most frequent in France. Primary lymphedema is sporadic, rarely familial or associated with complex malformative or genetic disorders. Diagnosis of lymphedema is mainly clinical and lymphoscintigraphy is useful in primary form to assess precisely the lymphatic function of the two limbs. Erysipelas (cellulitis) is the main complication, but psychological or functional discomfort may occur throughout the course of lymphedema. Lipedema is the main differential diagnosis, defined as an abnormal accumulation of fat from hip to ankle. Lymphedema management is based on complete decongestive physiotherapy (multilayer low-stretch bandage, manual lymph drainage, skin care, exercises). The first phase of treatment leads to a reduction of lymphedema volume and the second phase stabilizes the volume. Multilayer low-stretch bandage and elastic compression is the cornerstone of the complete decongestive physiotherapy. Patient-education programs, including self-management, aim to improve patient autonomy.

Intensive complete decongestive physiotherapy for cancer-related upper-limb lymphedema: 11 days achieved greater volume reduction than 4

BackgroundUpper-limb lymphedema (ULL) occurs in 15–20% of women after breast-cancer treatment. Its intensive therapy relies on complete (complex) decongestive physiotherapy (CDP), whose duration is not well-established. ObjectiveDetermine optimal intensive-phase CDP duration for lymphedema-volume reduction and factors predicting its success, with the hope of halving it from 11 to 4days. MethodsAll patients with ULL (08/2011–06/2012) after breast-cancer treatment referred to our Department of Lymphology in a rehabilitation facility for 11days of CDP were eligible. Lymphedema volume was calculated using the truncated-cone formula. Volume reduction considered clinically relevant after 4days was defined as ≥75% of the total reduction obtained after 11days. ResultsWe included 129 women (median age: 64 (range: 42–88) years). Mean (sd) lymphedema volume was 907 (558) ml at CDP onset, decreased to 712 (428) ml after 4days (vs. onset, P<.0001) and 606 (341) ml after 11days (vs. 4, P<.0001), corresponding to 33% total lymphedema-volume reduction. For all patients, 4days of CDP achieved 63% (sd 40%) of that total reduction, with ≥75% for 50 (39%) patients. Surgery-to-lymphedema-onset interval >2years was the only factor significantly associated with 4days achieving ≥75% of the total lymphedema-volume reduction. ConclusionIntensive phase CDP for 11days obtained significantly more volume reduction of breast cancer-related ULL than 4.

Systematic review of quality of life and patient reported outcomes in patients with oncologic related lower extremity lymphedema.

Lower limb lymphedema (LLL) is a common complication of cancer treatment. The disease is chronic and progressive with no cure. Although a common and significant source of morbidity, the impact of this condition on health-related quality of life (HRQOL) has only recently been addressed. In effort to identify valid treatment strategies for LLL, we performed a systematic review, identifying studies describing HRQOL outcomes in patients with LLL secondary to cancer. Seven medical databases were searched to identify reports using validated Patient Reported Outcome (PRO) instruments on patients with cancer-related LLL. Studies were classified by levels of evidence set by the Agency for Healthcare Research and Quality (AHRQ) and evaluated using the Efficace criteria. 25 studies were identified, 6 met inclusion criteria. Levels of evidence included: no level I studies, level II (n=3), level III (n=1), and level 4 (n=2). 50% of studies were compliant with the Efficace criteria. 5 PRO HRQOL instruments were used, but only 1 was specific to cancer-related lymphedema. Treatment strategies assessed included complete decongestive physiotherapy (CDP), exercise, and compression bandaging. CDP yielded significant enhancements in HRQOL. There is a deficit in high quality studies for HRQOL in patients with LLL secondary to cancer. Furthermore, of the studies present, most did not conform to guidelines set for assessment of HRQOL, nor did they use lymphedema condition specific PRO instruments. New measures specific to assessing LLL are necessary to gain more accurate evaluation of how this debilitating disorder affects HRQOL.

Prise en charge des lymphœdèmes des membres

Lymphedema results from impaired lymphatic transport with increased limb volume. Cellulitis is the main complication, but psychological or functional discomfort may occur throughout the course of lymphedema. Lymphedema management is based on complete decongestive physiotherapy (multilayer low stretch bandage, manual lymph drainage, skin care, exercises). First phase of treatment leads to a reduction of lymphedema volume. The second phase stabilizes the volume and is based on elastic compression. Resection surgery is a useful tool in external genitalia lymphedema.

Thyroid dermopathy localized to areas of injury and responsive to complete decongestive physiotherapy

To the Editor: Thyroid dermopathy is defined by the deposition of acid glycosaminoglycans in the dermis.1 It is the primary cutaneous manifestation of Graves disease, which can also present with opthalmopathy, goiter, or thyroid acropachy.2 Although thyroid dermopathy is most commonly manifested on the legs as pretibial myxedema, other sites of involvement are possible. We report a case of extensive myxedema of the upper and lower extremities that was localized to skin previously traumatized by burns and skin grafting and successfully treated with complete decongestive physiotherapy.

What's New in Lymphedema Therapy in America?

There is much confusion among American medical professionals regarding the treatment of lymphedema. Much of it has to do with the fact that lymphedema "falls between the cracks" of all standard specialties in modern American practice. Partially for this reason and because of a general misconception among American physicians that lymphedema is not a "serious" problem, the condition has been virtually ignored and deprioritized for many decades. This study is intended to clarify the confusion and reasons for apathy toward the subject of lymphedema and its treatment. Lymphedema, for the most part ignored or poorly treated in the United States, is currently being effectively treated by complete (or complex) decongestive physiotherapy (CDP) in many American facilities. CDP was introduced to the United States by the author in 1989 and is a gentle, effective, cost-effective, safe, and noninvasive treatment. It is and must be performed by specially trained therapists under the supervision of lymphologists with expertise in lymphedema, its diagnosis, treatment, complications, and natural history. This article describes the author's experience in treating 1000 upper and 1000 lower extremity lymphedema patients by the CDP method. These patients were treated between 1989 and 1995 for an average of 25 treatments, each patient returning for a follow-up examination 1 year after the completion of his or her course of treatment. The variables recorded in this study were as follows: the patient's sex, type of lymphedema, and volumetric reduction achieved immediately following treatment and as measured 1 year after treatment. The therapy and follow-up procedures are explained in detail and examples (before and after photos) of actual cases are included. Based on the results of this study and others, it is the author's opinion that CDP therapy is superior to any surgical procedures currently being used and to the pneumatic pump therapies often erroneously recommended for this condition.

Prise en charge des lymphœdèmes des membres

Lymphedema results from impaired lymphatic transport with increased limb volume. Cellulitis is the main complication, but psychological or functional discomfort may occur throughout the course of lymphedema. Lymphedema management is based on complete decongestive physiotherapy (multilayer low stretch bandage, manual lymph drainage, skin care, exercises). First phase of treatment leads to a reduction of lymphedema volume. The second phase stabilizes the volume and is based on elastic compression. Resection surgery is a useful tool in external genitalia lymphedema.

Complete Decongestive Physiotherapy for Older People With Chronic Venous Insufficiency

Complete Decongestive Physiotherapy for Older People With Chronic Venous Insufficiency

A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema [ISRCTN76522412

BackgroundProspective investigations of complete decongestive lymphatic physiotherapy (CDPT), including manual lymphatic drainage (MLD), have validated the efficacy of these interventions for the initial reduction of edema and long-term maintenance of limb volume in lymphedema. However, CDPT demands substantial time and effort from patients to maintain these benefits; the treatments are not always well-accepted, and patients may suffer from a deterioration in quality-of-life or a time-dependent loss of initial treatment benefits. A new device designed for home use by the patient, the Flexitouch™, has been developed to mechanically simulate MLD. We have undertaken a prospective, randomized, crossover study of the efficacy of the Flexitouch™, when compared to massage, in the self-administered maintenance therapy of lymphedema.MethodsA prospective, randomized, crossover study of maintenance therapy was performed in 10 patients with unilateral breast cancer-associated lymphedema of the arm. Each observation phase included self-administered treatment with the Flexitouch™ or massage, 1 hour daily for 14 days, respectively, followed by crossover to the alternate treatment phase. Each treatment phase was preceded by a 1 week treatment washout, with use of garment only. The sequence of treatment was randomly assigned. The potential impact of treatment modality on quality of life was assessed with serial administration of the SF-36.ResultsStatistical analysis disclosed that the order of treatment had no outcome influence, permitting 10 comparisons within each treatment group. Post-treatment arm volume reduced significantly after the Flexitouch™, but not after self-administered massage. The patients' mean weight decreased significantly with Flexitouch™ use, but not with massage. The Flexitouch™ device was apparently well-tolerated and accepted by patients. Serial SF-36 administration showed no deterioration in physical or psychosocial scores compared to baseline measurements; there were no statistical differences in scores when the two treatment modalities were compared.ConclusionThis short-term prospective evaluation of the Flexitouch™ suggests that the device may provide better maintenance edema control than self-adiminstered massage in breast cancer-associated lymphedema. The apparent ease of use and reliability of response to the device suggest that further broad-scale testing is warranted.

The effectiveness of complete decongestive physiotherapy for the treatment of lymphedema following groin dissection for melanoma.

Groin dissection is performed for the treatment of melanoma and other malignancies. Lymphedema rates as high as 47% have been reported. In 1996, we began using complete decongestive physiotherapy (CDP) in selected patients with lymphedema following groin dissection. Here, we review our results in a small cohort of patients. A retrospective review of the medical records of 14 patients, treated with CDP for lymphedema secondary to groin dissection for melanoma was conducted. All patients were treated with CDP at Roswell Park Cancer Institute (RPCI), between 1996 and 2002. Of the 14 patients, 12 underwent groin dissection at RPCI. Response to therapy was measured by limb volume determinations. Patient gender, age, body mass index (BMI), type of operation, type of adjuvant therapy, time to treatment, patient compliance, lymphedema stage, and initial edema were analyzed for association with response to treatment. Incidence was estimated by a review of the operative logs. Fourteen patients were treated with CDP for lymphedema secondary to groin dissection for melanoma, with a median decrease in lymphedema of 60% (range: 35-145%; P = 0.0003). Increased BMI was associated with a decreased response to treatment (P = 0.02). Response to CDP was not effected by time to treatment, patient compliance, lymphedema stage, and initial edema. During this time, 39 groin dissections were done at RPCI. The incidence of lymphedema treated with CDP at RPCI was 31% (12/39; standard error 7.4%). With a decrease in lymphedema of 60%, CDP may provide relief for patients with lymphedema following groin dissection. Elevated BMI was associated with a decreased response to CDP.

Elephantiasic pretibial myxedema: A novel treatment for an uncommon disorder

Pretibial myxedema is a known manifestation of Graves' disease. Much less common is the elephantiasis nostras variant, which is often refractory to treatment. We therefore elected to try a new therapy, often used for the management of chronic lymphedema, called complete decongestive physiotherapy. After 6 weeks of intensive treatment, our patient lost 37 pounds and had reduced her edema volume by 47%. Her skin softened with decreased lymph seepage and she became mobile for the first time in years. At a 2-year follow-up visit, she exhibited sustained improvement. This case demonstrates that complete decongestive physiotherapy can provide effective, long-term control of this disease process. We suggest that complete decongestive physiotherapy be considered in patients with severe forms of pretibial myxedema, as well as those with refractory lymphedema. (J Am Acad Dermatol 2002;46:723-6.)

Complete decongestive physiotherapy and the Lerner Lymphedema Services Academy of Lymphatic Studies (the Lerner School).

Lymphedema is more common than most physicians realize. It is also an incurable, life long condition that has never been treated effectively in the past in our country. The author describes complete decongestive physiotherapy (CDP) and his contribution to making it available all across the United States. This was done by establishing a network of outpatient CDP clinics where patients can be treated effectively and a training school, the Lerner Lymphedema Services Academy of Lymphatic Studies (the Lerner School), where physicians and therapists can be trained in all facets of the lymphedema problem and where the CDP method with all of its components is taught. The superiority of CDP to pneumatic pumps and to surgical procedures used to treat lymphedema is discussed. A description of the Lerner School's philosophy and curriculum is included.

Current status of education and treatment resources for lymphedema.

Secondary lymphedema (LE) resulting from breast cancer surgery has continued to be an ignored medical diagnosis in U.S. medicine. Subsequently, the majority of women/men undergoing axillary lymph node dissection have not received education in pre- or postoperative LE prevention, causing hundreds of thousands of patients to develop LE. As a result of this ignorance, once the LE develops, these patients receive no or harmful treatment. Over the last decade, the National Lymphedema Network (NLN) has created awareness in the medical community, among patients, and in the general public through information dissemination, educational materials, a national conference, and the activism of patients and a small group of concerned professionals. Complete decongestive physiotherapy (CDP), which includes manual lymph drainage, is a successful treatment for LE that has now been introduced. Slowly, the U.S. medical community is beginning to recognize and support this condition and its treatment, and secondary LE has now become an acceptable diagnosis (ICD9-457.0). Subsequently, due to patient and medical activism and the work of the NLN, Medicare now covers 2 weeks of CDP treatment (in Florida), and two landmark bills (AB-12 and S-609) that will cover LE treatment for postbreast carcinoma patients are currently pending (as of February 22, 1998). In the last decade, the NLN has developed a strong foundation of knowledge and has planted LE on the medical map in the United States. With collaboration between the NLN and all breast carcinoma groups and LE specialists, it is hoped that lymphology will become a standard course of study in medical schools across the country and that LE will become a household word, with proper treatment available for postbreast carcinoma LE patients in the United States.

Effective treatment of lymphedema of the extremities.

To define the immediate and long-term volumetric reduction following complete decongestive physiotherapy (CDP) for lymphedema. Prospective study of consecutively treated patients. Freestanding outpatient referral centers. Two hundred ninety-nine patients referred for evaluation of lymphedema of the upper (2% primary, 98% secondary) or lower (61.3% primary, 38.7% secondary) extremities were treated with CDP for an average duration of 15.7 days. Lymphedema reduction was measured following completion of treatment and at 6- and 12-month follow-up visits. Complete decongestive physiotherapy is a 2-phase noninvasive therapeutic regimen. The first phase consists of manual lymphatic massage, multilayered inelastic compression bandaging, remedial exercises, and meticulous skin care. Phase 2 focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises. Average limb volumes in milliliters were calculated prior to treatment, at the end of phase 1, and at 6- to 12-month intervals during phase 2 to assess percent volume reduction. Lymphedema reduction averaged 59.1% after upper-extremity CDP and 67.7% after lower-extremity treatment. With an average follow-up of 9 months, this improvement was maintained in compliant patients (86%) at 90% of the initial reduction for upper extremities and lower extremities. Noncompliant patients lost a part (33%) of their initial reduction. The incidence of infections decreased from 1.10 infections per patient per year to 0.65 infections per patient per year after a complete course of CDP. Complete decongestive physiotherapy is a highly effective treatment for both primary and secondary lymphedema. The initial reductions in volume achieved are maintained in the majority of the treated patients. These patients typically report a significant recovery from their previous cosmetic and functional impairments, and also from the psychosocial limitations they experienced from a physical stigma they felt was often trivialized by the medical and payor communities.