Manual lymphatic drainage after breast cancer
According to this study, more than 1 in 5 patients who undergo breast cancer treatment will develop lymphoedema associated with this treatment. Breast cancer related lymphoedema (BCRL) is treated with Complex Decongestive Therapy (CDT) which is a combination therapy of hands-on therapy (Manual Lymphatic Drainage, MLD), bandaging, exercise, and compression garments.
A Cochrane review was conducted to evaluate the effectiveness of MLD in isolation as well as in combination of other CDT on volumetric changes, adverse events as well as outcomes on function, subjective sensations, quality of life and cost of care. The authors also explored mild breast cancer related lymphoedema (BCRL) vs. moderate to severe, as well as the time since onset of the lymphoedema (1 year).
The following 6 trials were included:
- MLD + standard physiotherapy vs. standard physiotherapy: compression therapy in the form of decreasing sizes of compression garments along with exercises to promote lymphatic drainage, and this was combined with and without MLD;
- MLD + compression bandaging vs. compression bandaging: in which compression bandaging was giving to both groups, and MLD only to 1 group;
- MLD + compression therapy vs. non-MLD treatment + compression therapy: compression therapy given to both groups, and MLD to 1 group;
- Timing of addition of MLD: compression therapy given concurrently with MLD, versus administering compression before MLD;
- Combination of interventions: combinations of interventions were given: compression, exercise, and skin care education; MLD added to a group in conjunction with other therapies, but MLD alone was not compared;
- Types of compression therapy: bandaging versus compression sleeves were compared.
The above studies were chosen based on selection criteria that excluded any study that used an electric form of manual lymphatic drainage. Outcomes for each of the studies were assessed by limb volume (measured objectively immediately post-treatment by the assessors), as well as reported limb function. The authors determined the assessors looking at limb volumes and functional gains were blinded to the treatments administered. Subjective reportings on limb heaviness pre- and post-treatment were also recorded.
The authors noted that MLD was well tolerated and had added treatment benefit in the outcomes when combined with CDT. On top of that, the authors found that those with milder cases and with an early onset (<1 year) responded better to treatment than those with more severe cases or longer onset of lyphoedema. The authors noted that with the trials of non-MLD treatment, that “ volumetric outcomes were inconsistent within the same trial, and therefore, not generalizable.” Thus it remains unclear if MLD alone was the major beneficial factor in treatment. From this, it can be concluded that while there are several treatment options for the management of BCRL, a multi-modal approach that uses compression (specifically that of bandaging or custom garments) along with MLD has the best outcome.
The authors acknowledge one of the main limitations of this study is the inconsistency with functional outcome measurements. Further research would be beneficial to note specifically which combination of CDT would improve not only limb measurements, but also specific functional use of the upper extremity. However, for subjective symptoms such as heaviness of limb, it was noted that 60-80% of all participants noticed some improvement, regardless of their intervention. This further lends to the need for a multimodal approach when working with the complexities of lymphoedema.
> From: Ezzo et al., Cochrane Database Syst Rev 21 (2017-12-13 20:05:27) CD003475 (Epub ahead of print). All rights reserved to Cochrane Database Syst Rev. Click here for the online summary.