Lymphoedema is the build up of excess fluid in the body tissues because of obstruction of lymphatic drainage back into the bloodstream. The affected limb becomes swollen, distorted in shape with pain, discomfort all of which impair movement and daily activities. It can be caused by a congenital abnormality, chronic venous insufficiency, damage to the lymphatic system following treatment of cancer or filariasis, a parasitic infection endemic in parts of India and Africa. Skin care is important as the affected tissues gradually thicken and are susceptible to inflammation and infections. People are also encouraged to exercise regularly and control their weight. Different physical treatments aimed at improved lymph drainage include multi-layer bandaging, manual lymph drainage (MLD), self-administered massage and compression sleeves or hosiery.
The authors of this review, which aimed to assess the effect of physical treatment programmes on the long-term control of lymphoedema, identified only three controlled trials for inclusion. These randomised a total of 150 adults to different levels of physical treatment. One trial involved 42 women with unilateral lymphoedema of the upper limb following treatment for breast cancer. One group received eight sessions of MLD in two weeks and training in self-massage and both this group and the control group wore flat-knit compression sleeves. The reductions in excess arm volume and symptoms were similar in the two groups.
A second trial involved 25 women from a local follow-up breast clinic. They were trained in self-administered massage and randomised to wear an elastic compression sleeve or no additional treatment. The dropout rate was high, particularly in the control group, although the authors concluded that wearing a compression sleeve was beneficial. The third trial involved 83 mostly female participants from a lymphoedema clinic. Around two thirds had upper limb oedema. They were all taught self-administered massage. One group received a 19-day bandaging course before being fitted with hosiery. The other group wore hosiery from the start of the trial. The reduction in excess limb volume was consistently greater in those who started with multi-layer bandaging.
All three trials had methodological limitations, and as their data could not be combined, and they recruited only small numbers of participants, questions relating to the effect of this type of treatment could not be answered by this review.
All three trials have their limitations and have yet to be replicated, so their results must be viewed with caution. There is a clear need for well-designed, randomised trials of the whole range of physical therapies if the best approach to managing lymphoedema is to be determined.
Lymphoedema is the accumulation of excess fluid in the body caused by obstruction of the lymphatic drainage mechanisms. Management involves decongesting the reduced lymphatic pathways in order to reduce the size of the limb. There is a great deal of debate as to which components of a physical treatment programme are the most crucial.
To assess the effect of physical treatment programmes on:
volume, shape, condition and long-term control of oedema in lymphoedematous limbs;
We searched the Cochrane Breast Cancer Group trials register (October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2008), MEDLINE, EMBASE, CINAHL and the National Research Register (February 2008) and UnCover, PASCAL, SIGLE, reference lists produced by The British Lymphology Society and The International Society of Lymphology congress proceedings (September 2003).
Randomised controlled clinical trials that tested physical therapies with a follow-up period of at least six months.
Two blinded reviewers independently assessed trial quality and extracted data . Meta-analysis was not performed due to the poor quality of the trials.
Only three studies involving 150 randomised patients were included. Since none studied the same intervention it was not possible to combine the data. One crossover study of manual lymph drainage (MLD) followed by self-administered massage versus no treatment, concluded that improvements seen in both groups were attributable to the use of compression sleeves and that MLD provided no extra benefit at any point during the trial. Another trial looked at hosiery versus no treatment and had a very high dropout rate, with only 3 out of 14 participants in the intervention group finishing the trial and only 1 out of 11 in the control group. The authors concluded that wearing a compression sleeve is beneficial. The bandage plus hosiery versus hosiery alone trial, concluded that in this mixed group of participants bandage plus hosiery resulted in a greater reduction in excess limb volume than hosiery alone and this difference in reduction was maintained long-term.