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Efficacy of Manual Lymph Drainage in preventing Secondary Lymphedema following Breast Cancer Surgery

 

The results reported in a recent study published in the Journal of Lymphology1 emphasized the significant effect of Manual Lymph Drainage (MLD) in preventing the onset of secondary lymphedema of the upper extremity on the operated side following breast cancer surgery. The study showed that prophylactic application of MLD administered immediately following breast cancer surgery helped to prevent or considerably alleviate secondary lymphedema of the arm irrespective of the method of breast cancer treatment.

The study included 67 women with an age range of 34-81 years, who underwent breast cancer surgery. 40 women received breast conserving therapy and 27 women underwent modified mastectomy. A total of 32 women received sentinel lymph node dissection (SLND) with an average of 2 lymph nodes removed (1-10), and 35 women underwent axillary lymph node dissection (ALND) with an average of 17 (8-29) lymph nodes removed during the procedure. In addition, 47 individuals underwent post-operative external radiation therapy, and 28 women received chemo, or endocrine therapy.

In 33 randomly chosen women (mean age 60.3 years) MLD was administered beginning on the second day, and for a duration of 6 months following surgery.
34 women (mean age 58.6 years) represented the control group and did not receive MLD, but were instructed in the application of self-Manual Lymph Drainage.
The individuals in both groups were of similar age and had no statistically significant differences in body mass index (BMI) and fat distribution prior to the surgery and 6 months after the surgical procedure.

Chemotherapy, endocrine therapy and radiation were applied to 39, 42, and 67% of the women who received MLD, respectively, and to 44, 56, and 73% of the women in the control group.

Starting on the second post-operative day individuals of both groups received a standard protocol of physical therapy exercises, and among the 33 randomly chosen women MLD was administered five times a week for the first 2 post-operative weeks, and twice a week from day 14 to 6 months following the surgery.
The MLD treatments were administered by the same therapist following the standard treatment protocol for secondary lymphedema of the upper extremity.

The volumes of both arms of all women participating in the study were measured using the water displacement method and taken before surgery and on days 2, 7, 14, and at 3 and 6 months following the surgery.

Compared with the arm volume before surgery, a significant increase in the arm volume (10%) on the operated side was observed among the women who did not receive MLD treatment at 6 month following the breast cancer surgery. In this control group the mean arm volume values on the operated side showed a continual increase beginning on the second post-operative day; at 3 months following surgery a 6% increase in volume was demonstrated, which increased to 10% in volume difference after 6 months; 70.6% of the individuals in the this group suffered from lymphedema at that time.

In the group of women who received MLD, mean arm volumes on the operated side increased on the second post-operative day and resolved by day 7 after surgery. At 6 months following breast cancer surgery, no increase in volume was evident and lymphedema of the arm on the operated side did not occur.

This study demonstrates the effectiveness of MLD in preventing the onset of secondary lymphedema irrespective of the type of surgery performed, the number of lymph nodes removed (ALND/SLND), and if radiation was applied. Furthermore, even though further studies are needed, this study shows that MLD applied directly following surgery for breast cancer and over a certain time, should be considered for the prevention of the onset of secondary lymphedema.

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1. Zimmermann A, Wozniewski M, Szklarska A, Lipowicz A, Szuba A: Efficacy of Manual Lymph Drainage in preventing Secondary Lymphedema after Breast Cancer Surgery. Lymphology 45 (2012) 103-112

 

14 comments to Efficacy of Manual Lymph Drainage in preventing Secondary Lymphedema following Breast Cancer Surgery

  • Bob Weiss

    In my mind this is a groundbreaking study. It touches on a number of important issues relating to lymphedema treatment. The obvious issue addressed and the issue that the study was powered to resolve was whether professionally-provided MLD (Vodder/Asdonk/Földi) provided after breast cancer treatment can prevent development of upper limb lymphedema. Note that NO COMPRESSION was used in either of the trial groups (per the author in private correspondence), and favorable results were obtained in the professionally-treated arm none-the-less.

    The control group administered self-drainage during the six-month trial, and these results were significantly less effective than the professionally-provided MLD. This speaks to me as to the value of properly-trained lymphedema therapists in the effective treatment of lymphedema.

    The authors discuss another subject that has been one of my concerns for the last ten years — the high incidence of radiation-induced breast lymphedema even in cases involving sentinel-node biopsy (23%), but especially with axillary clearance (35-48%). This is a message which has been very slow to be heard by breast cancer treatment providers, and is a message not provided to patients in the process of making “informed” treatment decisions with their doctors.

    This paper is altogether a landmark, in my opinion.

  • Thank you for bringing this article to my attention. I completely agree with Bob’s comments, it is a landmark paper and I will be forwarding it on to the oncology teams in my area. I do worry about the awareness of radiation induced lympheodema….It is frustrating to see so many ladies who have ‘only’ had sentinel node surgery but then had radiotherapy and lymphoedema has never been mentioned to them along their treatment journey.
    Lymphoedema Guru, I read your posts often so just want to say again, Thank You for your continued stream of information.

  • Liz Romick, PT, DPT, CLT-LANA

    I completely agree thtis is a ground breaking study as it validates the importance of not only MLD but the application of the technique by a trained professional. However, for any study to be taken as true evidence and not assumption, a statistical analysis for significance is necessary to make a convincing case for the conclusions. Can you please report on whether such an analysis was done and what were the results? Thanks!

  • Carol

    For me, this study prompts two questions: 1)are patients in both groups being followed past the 6-month study period and 2) what kind of ‘standard PT’ was provided, starting on day 2? The Todd study found that immediate PT after ALND increased the risk of arm lymphedema 2.7 times, compared to patients whose shoulder exercises were delayed by 7 days; that study followed patients for a full year. This new study seems to suggest that any risk from immediate arm mobility work can be overcome by professional MLD. But I’m not prepared to buy into that based on just a six-month follow-up period.

    Groundbreaking, yes. I just wish that the study ran for more than six months.

  • carol

    This study is very interesting in spite of the 6 month only follow-up. My question would be: Why did the control group have a 70.6% incidence of lymphedema? In light of the 6 month period this % is much higher than in any other study I have seen.

    • Cydney

      Carol, could you please site the title and journal, vol, # etc of the “Todd” article. I’d like to get a full copy to read. Thanks

  • Sara Kent, PT, DPT, CLT-LANA, CWS

    I am wondering about the 70.6% incidence as well. I haven’t seen studies with incidence rates that high, or in my own practice (community hospital outpatient, affiliated with a small breast center). The study at the Bethesda Naval Medical Center breast center followed 196 women over a longer period with their surveillance study and found an incidence rate of 22% using perometry for volume measurement, and setting their threshold for diagnosis of lymphedema at 3%. I haven’t read the methods of the study in Lymphology; one immediate question that comes to mind is whether the persom measuring the participants was blinded to group assignment?
    From a devil’s advocate point of view and the perspective of being able to generalize the results of the study and make a strong case for intensive preventative care reimbursement, accuracy of incidence rates would be important in estimating the statistical NNT (number needed to treat for prevention of one case of lymphedema), something insurance companies are not likely to pay for if it involves an expensive, one on one treatment for a prolonged period of 6 months. A lower cost intervention (such as the use of a daytime elastic compression sleeve for those individuals exceeding the threshold for volume difference between arms in the Bethesda study) would be more likely to be reimbursed by an insurance company. Cost containment is and will increasingly become an issue with insurance reimbursed health care.

  • molly morris

    Joe,
    Interesting that this study is coming out at the same time the surgeons did their study. In my practice, this study rings more true than a study suggesting that women just worry too much about getting lymphedema and there’s not really a risk.

    thank you for all of your good work,
    molly morris, OTR/L, CLT

  • Jenny Hastreiter, PT

    Hi,
    I am looking for a good way to explain to a family practioner the reason why patients with stage three lymphedema do not having pitting edema. How would you explain that?

    • Joachim Zuther

      Lymphedema is protein-rich. Over time the protein molecules attract fibroblasts, which build connective tissue. Lymphedema, if left untreated, develops fibrotic tissue – consequently pitting diminishes

  • [...] This study shows that MLD (manual lymphatic drainage) applied directly, following surgery for breast cancer and over a certain time, should be considered for the prevention of the onset of secondary Lymphoedema. Source: Efficacy of Manual Lymph Drainage in preventing Secondary Lymphedema following Breast Cancer Surgery… [...]

  • barbara

    i was 63 when i was diagnosed with stage 1 breast cancer. surgery ( including removal of 3 nodes) was followed by radiation, and i have considered myself to be very fortunate in that i quickly regained full mobility in my right arm, little pain etc. very lucky! two years after surgery, i developed lymphedema…very mild, and the only way i was aware of the prob was that my ring became hard to remove. had some physical therapy. i do some mld, but use a pump at least once a day for an hour. i wear compression garments for the entire day and at night i switch off betwee ready wrap/ bandaging/ and then bare the third night. for those of you with issues in your arms, i have found a great website to purchase attractive compression sleeves and this company is starting to make matching compression gloves. will make you feel less like a ” patient” with these garments. not saying that they are inexpensive but check out lymphedivas.com. these are not for sleeping but you will feel better during the day about this condition in terms of how you look/ feel about your lymphedema. hope i have helped someone.

  • cris

    my husband has radiation induced Brachial plexopathy from H&N cancer.
    He has received about 28 sessions of massage therapy to break up scar tissue and it is amazing the difference in mobility. He can now lift his arm and breathe deeply. No slumped shoulders. I must say the break uo of scar tissue works!

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