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Advances in Wound Care Jan 2023Lymphedema is a common, distressing and debilitating condition with various etiologies. Effective diagnosis, assessment, and management rely on evidence-based clinical...
Lymphedema is a common, distressing and debilitating condition with various etiologies. Effective diagnosis, assessment, and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphedema diagnosis, assessment, and management. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphedema guidelines published in English since 2000. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE)-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence. This systematic review of 1,564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphedema, and four on cancer. Most ( = 13) guidelines recommended an integrated medical, psychological assessment, and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise, and compression. The underlying etiology of lymphedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphedema care. However, their suitability for low-resource settings is unclear.
Topics: Humans; Lymphedema; Manual Lymphatic Drainage; Massage; Exercise; Skin Care
PubMed: 35196892
DOI: 10.1089/wound.2021.0149 -
Journal of Clinical Oncology : Official... Mar 2022The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition. We offer a critical evaluation of the literature on prospective surveillance and early management for cancer-related lymphedema and evaluate the effect of such programs in preventing chronic lymphedema (CRD42019137965).
METHODS
Five databases and two registries were searched for randomized controlled trials or observational studies that assessed the incidence or prevalence of lymphedema associated with participation in a prospective surveillance program, published until February 26, 2021. Numbers triggered for early lymphedema management, resolved, and chronic lymphedema were extracted. Pooled relative risk (trials) and pooled rate (cumulative incidence; observational studies) of chronic lymphedema was calculated. Subgroup analyses assessed the effect of study design, length of follow-up, and extent of axillary surgery.
RESULTS
Twenty-three studies were included, of which 21 studies evaluated breast cancer-related arm lymphedema (BCRaL). Participation in prospective surveillance with early management reduced the risk of chronic BCRaL versus usual care (relative risk 0.31; 95% CI, 0.10 to 0.95; two randomized controlled trials; N = 106). The pooled rate of chronic BCRaL was 4% (95% CI, 3 to 6; 15 observational studies; N = 3,545), and 6% (95% CI, 4 to 9) when restricted to participants with axillary lymph node dissection (12 studies; N = 1,527).
CONCLUSION
The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic BCRaL. Only a minority of patients at high risk of lymphedema because of axillary surgery developed chronic lymphedema. More robust research is needed to determine whether prospective surveillance with early management can reduce the risk of chronic lymphedema, particularly among cancer survivors other than breast cancer.
Topics: Axilla; Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphedema; Prospective Studies
PubMed: 35077194
DOI: 10.1200/JCO.21.01681 -
Phlebology May 2022Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature....
BACKGROUND
Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology.
METHODS
In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved.
RESULTS
The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment.
CONCLUSION
This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.
Topics: Cardiology; Consensus; Delphi Technique; Expert Testimony; Humans; Lymphedema; United States
PubMed: 35258350
DOI: 10.1177/02683555211053532 -
Clinical Breast Cancer Oct 2022Upper limb impairments are common in women following surgery for breast cancer. Range of movement (ROM) exercises are commonly prescribed, but the optimal timing to... (Meta-Analysis)
Meta-Analysis Review
Rehabilitation for Women Undergoing Breast Cancer Surgery: A Systematic Review and Meta-Analysis of the Effectiveness of Early, Unrestricted Exercise Programs on Upper Limb Function.
Upper limb impairments are common in women following surgery for breast cancer. Range of movement (ROM) exercises are commonly prescribed, but the optimal timing to begin these exercises is not clear. The aim of this systematic review and meta-analysis was to evaluate the effectiveness of early ROM exercises (Early ROM) compared to delayed ROM exercises (Delayed ROM) or usual care (UC) in reducing common complications in women following breast cancer surgery. Cochrane Central Register of Controlled Trials, Pubmed, EMBASE, CINAHL, and PEDro were searched from date of inception until the 15th of February 2021, to identify randomized controlled trials which compared Early ROM to either Delayed ROM or UC in women following surgery for breast cancer. Outcomes included shoulder range, wound outcomes and lymphedema incidence. Risk of bias was evaluated with the PEDro scale. Data analysis was conducted in R (version 3.6.0), with a priori sensitivity analyses conducted for studies with low risk of bias and published after the year 2000. Of the 703 articles retrieved, 20 trials (2442 participants) were eligible for inclusion. There were few differences between groups in ROM, except for flexion ROM when more recent evidence was considered. Total drainage time and hematoma incidence were significantly higher in the Early ROM group compared to Delayed ROM (WMD 1·2 days [95%CI 0·7,1·7], and RR 1·6 [95%CI 1·1,2·3], respectively). When considering more recent evidence, there were no differences between groups for these outcomes. There were no differences between groups in other wound outcomes. Lymphedema incidence was higher in the Early ROM group compared to Delayed ROM in the short-term only (RR 3·7 [95% CI 1·3;10·9]), and there was no difference when compared to UC. The quality of evidence using the GRADE approach was generally low to very low. This review found that when considering more contemporary evidence, the timing of exercise may influence ROM, but not wound outcomes. Further research is recommended to understand the effect on lymphedema incidence. No funding was sought for this review. A protocol for this systematic review was posted on the Open Science Framework prior to commencement (DOI: 10.17605/OSF.IO/Q5FHS).
Topics: Breast Neoplasms; Exercise Therapy; Female; Humans; Lymphedema; Range of Motion, Articular; Upper Extremity
PubMed: 35902321
DOI: 10.1016/j.clbc.2022.06.001 -
Seminars in Pediatric Surgery Oct 2020Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue causing it to... (Review)
Review
Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue causing it to enlarge. Lymphedema is a specific disease and should not be used as a generic term for an enlarged extremity. The diagnosis is made by history and physical examination, and confirmed with lymphoscintigraphy. Intervention includes patient education, compression, and rarely, surgery. Patients are advised to exercise, maintain a normal body mass index, and moisturize / protect the diseased limb from incidental trauma. Conservative management consists of compression regimens. Operative interventions either attempt to address the underlying lymphatic anomaly or the excess tissue. Lymphatic-venous anastomosis and lymph node transfer attempt to create new lymphatic connections to improve lymph flow. Suction-assisted lipectomy and cutaneous excision reduce the size of the area by removing fibroadipose hypertrophy.
Topics: Child; Humans; Lymphedema
PubMed: 33069289
DOI: 10.1016/j.sempedsurg.2020.150972 -
Physical Therapy Mar 2022This study aimed to determine the effectiveness of a physical therapist-designed program tailored to axillary web syndrome (AWS) in women after breast cancer surgery. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
This study aimed to determine the effectiveness of a physical therapist-designed program tailored to axillary web syndrome (AWS) in women after breast cancer surgery.
METHODS
A prospective, single-center, assessor-blinded, randomized controlled trial was conducted at the Physiotherapy in Women's Health Research Unit of the Alcalá University (Madrid, Spain). Ninety-six women with AWS were assigned to the physical therapy group (manual lymph drainage [MLD] using resorption strokes and arm exercises as if performing median nerve neurodynamic glide exercises with no neural loading; n = 48) or the control group (standard arm exercises; n = 48), with both groups receiving treatment 3 times a week for 3 weeks. Both interventions included an educational component.
RESULTS
Compared with the control group, the physical therapy group showed significant and clinically relevant improvements in the primary outcome (self-reported pain intensity) at the primary and 3-month follow-ups. Significant and clinically relevant differences between groups were also found in the secondary outcomes (shoulder active range of motion, shoulder disability, and physical and functional aspects of health-related quality of life) at the primary follow-up and in the secondary outcomes as well as the trial outcome index at the 3-month follow-up. No significant differences were found at the 6-month follow-up in either primary or secondary outcomes.
CONCLUSION
The physical therapy program tailored to AWS was found to be effective for AWS symptoms in women after breast cancer surgery, both immediately after the program and after 3 months.
IMPACT
To our knowledge, this is the first appropriately designed study to demonstrate the effectiveness of MLD with progressive arm exercises for AWS. Clinicians and health service providers should consider how to provide survivors of breast cancer with AWS the opportunity to participate in physical therapy programs, including MLD with progressive arm exercises.
LAY SUMMARY
For axillary web syndrome following breast cancer surgery, a physical therapist can design a treatment program including manual lymph drainage and progressive arm exercises, which has been shown to result in reduced pain and improved motion compared with standard arm exercises.
Topics: Arm; Axilla; Breast Neoplasms; Female; Humans; Lymphatic Diseases; Lymphedema; Manual Lymphatic Drainage; Prospective Studies; Quality of Life
PubMed: 35079831
DOI: 10.1093/ptj/pzab314 -
Canadian Family Physician Medecin de... Oct 2023
Topics: Humans; Female; Lymphedema; Neoplasms; Breast Neoplasms
PubMed: 37833081
DOI: 10.46747/cfp.6910691 -
European Journal of Cancer Care Sep 2022The objective of this study is to compare the effectiveness of complex physical therapy combined with intermittent pneumatic compression (CPT + IPC) versus Kinesio... (Randomized Controlled Trial)
Randomized Controlled Trial
Intensive complex physical therapy combined with intermittent pneumatic compression versus Kinesio taping for treating breast cancer-related lymphedema of the upper limb: A randomised cross-over clinical trial.
OBJECTIVE
The objective of this study is to compare the effectiveness of complex physical therapy combined with intermittent pneumatic compression (CPT + IPC) versus Kinesio taping (KT) for breast cancer-related lymphedema.
METHODS
A cross-over clinical trial was conducted in 43 women with lymphedema. All participants received two interventions: CPT + IPC and KT, both lasting 3 weeks and a washout period. The main outcome variable was the relative volume change (RVC). The secondary variables were Satisfaction Questionnaire about Textile Therapeutic Devices used for Breast Cancer-Related Lymphedema, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, motion range of upper limb and lymphedema-related symptoms.
RESULTS
The RVC reduction was greater with CPT + IPC (-2.2%, SD = 4.7) versus KT (-0.9%, SD = 1.7) (P = 0.002). KT was more satisfactory than multilayer bandaging (8.9 points difference, P < 0.001) and improved DASH score more than CPT + IPC (14.3 points difference, P = 0.002). Regarding motion ranges, only shoulder movements showed significant improvement with CPT + IPC compared with KT (differences between 5.6° and 11.4°). Of the symptoms assessed, only pain reduction showed a significant improvement with KT versus CPT + IPC (0.5 points, P = 0.035).
CONCLUSIONS
CPT + IPC achieved higher RVC and greater improvement in th shoulder motion range than KT. Conversely, KT was more satisfactory than multilayer bandaging, obtained better DASH scores and relieved pain more than CPT + IPC.
CLINICAL REGISTRATION
ClinicalTrial registration number: NCT03051750 (date of registration 14 February 2017).
Topics: Breast Cancer Lymphedema; Breast Neoplasms; Female; Humans; Intermittent Pneumatic Compression Devices; Lymphedema; Pain; Physical Therapy Modalities; Treatment Outcome; Upper Extremity
PubMed: 35642305
DOI: 10.1111/ecc.13625 -
Lymphatic Research and Biology Oct 2021To define the profile of patients presenting with chronic edema (CE) in three centers in Italy (Lymphoedema IMpact and PRevalence INTernational). Data were collected...
To define the profile of patients presenting with chronic edema (CE) in three centers in Italy (Lymphoedema IMpact and PRevalence INTernational). Data were collected in patients referred for CE between September 2016 and July 2017. A total of 1637 were recruited, 86.7% (1419) outpatients and 13.3% (218) inpatients with 80.6% (1319) female and mean age 54 years. Primary lymphedema occurred in 28.2% (461). In the 71.8% (1176) with secondary CE cancer occurred in 72% (846) and 28% (330) due to other causes. Data showed that 84.2% (226) had full upper body mobility, 15.5% (41) had limited mobility and 0.2% (2) had lost all mobility. Lower limb mobility status: 90.4% (1205) complete mobility, 8.4% (112) reduced mobility and 1.2% (21) wheelchair bound. Concurrent leg ulceration occurred in 32.9% (322) with 3.1% (51) having antibiotics. Treatment patterns varied with only 32.4% (530) receiving instructions in skin care, 61.2% (1002) multilayer compression and a further 67.8% (1110) compression garment with 17.6% (288) having sequential pressure therapy. Only 1.4% (23) had received psychological support. Out of the total 481/1637 (29.4%) were not prescribed any treatment. Only 50.4% (825) had access to subsidized treatments within the National and Regional Health Care System, whereas 49.6% (81) had to pay themselves with only half (50.9%) having access to treatment centers that were near their home. Results from this study and active lobbying have led to changes in reimbursement of care for primary and secondary lymphedema in Italy; this has led to a much more optimistic picture for those affected.
Topics: Cellulitis; Diagnosis, Differential; Female; Humans; Italy; Lymphatic System; Lymphedema; Middle Aged; Quality of Life
PubMed: 34672792
DOI: 10.1089/lrb.2021.0062 -
Nature Reviews. Disease Primers Oct 2021
Topics: Humans; Lymphedema
PubMed: 34675211
DOI: 10.1038/s41572-021-00318-6