Manual Lymph Drainage May Not Be a Necessary Component in Lymphedema Treatment

Complex physical therapy (CPT), which consists of education (specifically with emphasis on meticulous skin care), manual lymph drainage (MLD), intermittent pneumatic compression, compression bandaging (CB), and exercises (EX), is the treatment of choice in limb lymphedema. Despite well-known effectiveness,^,  CPT is time consuming and needs well-trained physiotherapists in MLD techniques, which form the central part of this program. It is unclear and there is little good-quality evidence whether the lymphedema reduction is mainly because of the MLD or the other components of CPT—CB and EX. In our clinic, approximately 1,600 patients with lymphedema (mainly women after radical mastectomy) have been treated by this method for 15 years. For the last two years, some of them have been treated without MLD because of their urgent needs and longer waiting time for the procedures. The results were surprisingly beneficial. Therefore, we conducted a study to compare MLD+CB+EX with CB+EX.

Fifty postmastectomy women were assigned according to the time since mastectomy, edema duration, and body mass index, into a CB+EX group (25 women) receiving only CB+EX, or an MLD+CB+EX group (25 women), which was treated with MLD+CB+EX. Approval for this study was gained from the Ethics Committee of the Chamber of Physicians in Krakow, Poland. Written informed consent was obtained from all patients. Participants were excluded if they had any of the following: evidence of cancer metastases or local recurrence, did not finish chemotherapy or radiotherapy, signs of infection in the affected limbs, history of contralateral breast cancer, prior massage-based therapy for arm lymphedema, clinical signs of heart disease, renal insufficiency, or vein thrombosis.

The CB+EX group was treated consecutively from Monday to Friday, in 10 sessions, with multilayer CB together with physical and breathing EX. Gradient pressure was achieved by applying more layers distally and gradually reducing the number and the overlap of the bandages as applied proximally along the arm. At the start, a cotton tube stockinet was placed on the arm, and the layer of gauze was applied to the fingers and hand. A layer of foam padding was placed on the hand and wrapped around the arm. Three or four short-stretch bandages were used and were sequentially placed around the limb. Bandages were not removed until the next scheduled treatment on the following day. Patients tolerated this procedure very well. An exercise program included active and self-supported EX, started from proximal part of the body, performed in bandaging, for 15 minutes in one session. The control group was treated similarly but additionally received 30 minutes of MLD based on the Vodder method. MLD started from unaffected quadrants of the trunk (the neck, chest, and abdomen), and after the healthy side preparation, the affected regions were treated. Finally, the limb was massaged in segments starting proximally at the shoulder and moving progressively down the limb. The techniques, which predominately involved stretching the skin, were performed slowly and gently. During MLD, deep breathing and breathing movements were performed. The whole therapy and measurements were provided by a physiotherapist qualified in MLD.

The groups did not differ in terms of time since mastectomy (mean: 56.4 months in the CB+EX group vs. 40.1 months in MLD+CB+EX group; P=0.2, by Student's t-test), edema duration (18.8 vs. 16.4 months, respectively; P=0.6), or body mass index (30.7 vs. 31.6 kg/m², respectively; P=0.5). Only a difference in age was observed (63.8 vs. 57.4 years, respectively; P=0.05). The limb volumes were calculated by the simplified formula for the frustum obtained with the circumference measurements (every 4 cm). Additionally, limb movements were measured by goniometer; physical symptoms (pain, heaviness, tightness, tingling, and numbness) were monitored according to Likert-type 4-point scales (none, slight, moderate, and severe); and health-related quality of life (HRQoL) was measured using the Edmonton Symptom Assessment System (ESAS). These measurements were taken before and after 10 days of management.

The study showed that both groups obtained a limb volume reduction (mean: 364.6 cm³ [11.7%] in CB+EX vs. 336.9 cm³ [10.5%] in MLD+CB+EX; P=0.7 by Student's t-test), shoulder flexion range improvement (mean: 7.4° vs. 7.6°, respectively; P=0.3), abduction range enhancement (mean: 7.2° vs. 5.4°, respectively; P=0.7), a gripping force increase (mean: 4.14% vs. 7.5%, respectively; P=0.7), mean physical symptom decrease (mean: 0.48 vs. 0.71, respectively; P=0.1), and HRQoL improvement (mean ESAS decrease: 0.94 on the 10-point scale vs. 0.85, respectively, P=0.5). Although we have not collected information about patient compliance formally, we observed excellent compliance in all patients during the study. A significant correlation between volume reduction and increase of flexion and abduction in shoulder joint was discovered only in the CB+EX group.

These observations emphasize the value of compression therapy and indicate that CB is an essential part of treatment in lymphedema. They further suggest that MLD may not be needed to obtain adequate results. Further randomized studies are needed to evaluate the role of CB and MLD in lymphedema therapy.