Prerpints.org logo
Preprint
Communication

Liphedema Rehabilitation after Breast Cancer Surgery Using Combined Physiotherapy Techniques

This version is not peer-reviewed.

Submitted:

22 May 2023

Posted:

24 May 2023

You are already at the latest version

Abstract
(1) Background: Breast cancer-associated lymphedema (BCRL) is a major complication of breast cancer treatment, affects the quality of life of breast cancer survivors who develop it. Manual lymphatic drainage has a beneficial result in combating lymphedema in patients who have undergone breast cancer surgery. The hypothesis consists in complete decongestive therapy reduces the lymphedema at the level of the upper limb on the side of mastectomy. (2) Methods: Twenty-five patients with radical mastectomy and upper limb lymphedema on the mastectomy side were included in this study. Upper limb circumferences were measured with a tape measure at the following levels: metacarpophalangeal joint; distal radioulnar joint; 10 cm distal to lateral epicondyle; 5 cm proximal to elbow joint; 10 cm proximal to lateral epicondyle. (3) Results: Patients received twice weekly manual lymphatic drainage, multi-layer compression bandaging and upper limb muscle stimulation exercises on the mastectomy side twice weekly. The circumference assessed at the level of the metacarpophalangeal joints and distal radio-carpal joint decreased at the final evaluation. Forearm perimetery - 5 and 10 cm distal to the lateral epicondyle the circumference decreased at the final assessment. (4) Conclusions: Patients with breast cancer-related lymphedema should receive comprehensive decongestive therapy in the early stage of lymphedema to achieve rapid clinical results and improved quality of life
Keywords: 
breast cancer
;  
lymphedema management
;  
manual lymph drainage
;  
liphedema rehabilitation after mastectomy
Subject: 
Medicine and Pharmacology  -   Oncology and Oncogenics

1. Introduction

Lymphedema is the accumulation of lymph fluid in the tissue with hypervolemia of the affected area. The subject has the following symptoms: pain, decreased mobility of the scapulohumeral joint, and a sensation of pressure in all the joints of the upper limb. After chemotherapy, patients experience the development of lymphoedema in the upper limbs and also in the chest [1].
The design of post-mastectomy adjuvant treatment is intended to minimize the risk of neoplasm recurrence or metastasis. Although the administration of chemotherapy and local radiotherapy reduces mortality, these treatments have negative effects on the body, like, cardiotoxicity, respiratory disorders, decreased shoulder mobility (especially in the case of local radiotherapy), premature infertility, peripheral neuropathy, lymphatic edema, insomnia, anxiety, nausea, vomiting (when chemotherapy is administered). [2,3,4,5].
According to the US National Cancer Institute, a diagnostic criterion for lymphedema has not been validated. A difference of 2 cm, however, between measurements of the healthy upper limb and those of the affected limb indicates lymphatic edema.
Norman et al. identify 3 stages of lymphoedema progression: mild, moderate, or severe [6]. Tretbar et al. present 4 stages of progression of lymphatic edema as follows: stage 0 (reversible), stage 1 (appropriately treated returns to the original form), stage 2 (tissue fibrosis, eczema, lymphatic fistulas, and erysipelas may occur), and stage 3 (elephantiasis, is an irreversible form) [7]:
Harris et al., Kayiran et al., and Torgbenu et al. provide indications and recommendations on the management and treatment of lymphedema secondary to mastectomy. All these data provide physiotherapists and patients with an early diagnosis of certainty, correct assessment of edema, and implementation of full decongestive therapy.
Lymphoedema management includes all physiotherapy tools that can be used in the treatment of lymphoedema secondary to mastectomy. The most commonly used therapy is complete decongestive therapy and consists of manual lymphatic drainage, multi-layer compression bandaging, and upper limb muscle stimulation exercises on the side of surgery [8,9,10].
The removal of lymph nodes in the axillary and pectoral region with mastectomy results in the obstruction of lymph circulation [11]. In conclusion, the application of lymphatic drainage massage increases the effectiveness of the physiotherapy protocol [12]. According to current studies, lymphatic drainage massage contributes to pain relief for patients who develop post-mastectomy edema [13].
Manual lymphatic drainage therapy also facilitates the prophylaxis of lymphatic edema. Massage techniques include stationary circular maneuvers (applied to the lymph nodes as well as to the arm and forearm with the fingertips and palmar facets of fingers 2-5 or with the help of the thumb), pumping techniques (performed with the palmar face of the fingers to create gentle upward pressure), arm pressures (performed by applying interdigital space between the thumb and index finger; upward pressure is applied with proximal to distal application direction).
Foldi and Strossenreuther also recommend the use of effleurage at the beginning of the massage and vibration at the end to stimulate the deep lymphatic vessels [14]. Specialists opt for a treatment initiated by a series of 10 consecutive sessions and followed by sessions performed at 2 per week. In addition, self-massage plays an important role in the daily management of lymphatic edema, which is why patients will learn self-massage techniques.
Complete decongestive therapy applied in the early stages of lymphoedema and secondary to breast cancer has long-term beneficial effects. It contributes to a considerable decrease in the volume of lymphoedema but also improves the range of motion of the affected upper limb [15,16,17].

2. Materials and Methods

A total of 25 subjects, who underwent surgery for breast cancer and who presented with upper limb lymphatic edema on the side of the surgery, were included in this study. The patients were evaluated by the medical doctor and treated by the physiotherapist at the Medical Rehabilitation Centre of the National University of Physical Education and Sport in Bucharest. The study was conducted following the principles of scientific research set out in the Declaration of Helsinki. The study was approved by the Ethics and Deontology Commission of the National University of Physical Education and Sport in Bucharest, with the number 19/27.09.2022.
Inclusion criteria: patients with lymphoedema after unilateral radical mastectomy surgery, who are surgically healed, do not present fever, and have no altered values of inflammatory blood markers.
Exclusion criteria: patients with integumentary lesions and altered tumor markers. Subjects who did not properly follow the physiotherapy protocol were excluded.
Circumference of the upper limb was assessed with metric tape at the metacarpophalangeal joint, distal radioulnar joint, at the forearm - 10 cm distal to the elbow joint, at the arm - 5, 10 cm proximal to the elbow joint, respectively.
A complete decongestive therapy program was performed twice a week, consisting of special massage to facilitate lymphatic stimulation, multi-layer compressive bandaging, and exercises to stimulate the muscles of the upper limb to reduce muscle hypotonia.

Hypothesis

Terapia decongestică complete diminuează edemul limfatic la nivelul membrului superior de partea intervenției chirurgicale de mastectomie.

3. Results

Perimetry - metacarpophalangeal joints

At the metacarpophalangeal joint level, there was a decrease in the mean values obtained at the initial assessment compared to the final assessment, the difference being 0.7 cm (3.8%) from 19.0 to 18.3. The mean circumference value of the unaffected upper limb at this level is 18.5, 0.2 cm less than that of the affected upper limb.
The values obtained in the 2 assessments are homogeneously dispersed, as the coefficient of variation is constant, i.e., 5.6%. As for the minimum value, a decrease was observed from the initial assessment (17.0 cm) to the final assessment (16.5). A statistically significant difference was found between the two means (initial and final assessment), as expressed by the two-tailed t-test, where the value of the statistical significance threshold p<0.001<0.05 and the t-value is 7.86. The effect size (1.57) highlights the decrease in circumference at this level (Table 1).

Perimetry - distal radio-ulnar joint

The mean circumference measured at the distal radio-ulnar joint shows a difference of 1.5 cm (7.9%) between the initial (18.5 cm) and final (17.0 cm) assessment. At this level, the mean value identified in the unaffected upper limb (16.7 cm) is lower compared to the affected upper limb by 0.3 cm.
Following statistical processing of the data, the values obtained indicate a homogeneous dispersion, as evidenced by the coefficient of variance, which at the initial assessment is 11.1% and at the final assessment 8.2%. Both minimum and maximum values decreased from 15.0 to 14.0 and from 24 to 19.5 respectively.
We also noted the existence of a statistically significant difference between the mean values, which was underlined in the two-tailed t-test by the significance threshold p<0.001<0.05, the t-value being 5.19. The effectiveness of the applied protocol is also evidenced by the effect size, which is 1.04 (Table 2).

Forearm - 10 cm distal to the elbow joint

Statistical processing of the data revealed a difference between the initial (25.8 cm) and final (23.2 cm) assessment of 2.6 cm in the circumference assessment of the affected upper limb. The mean value of the unaffected upper limb is 22.4 cm, which is 0.8 cm less than the mean value obtained in the final assessment of the affected limb.
There is a statistically significant difference, given that the bilateral dependent t-test found a significance threshold of p<0.001<0.05 and a t-value of 6.55. The coefficient of variation shows that the data are homogeneously dispersed, both at baseline (11.6%) and at final assessment (9.7%). The yield of the physiotherapy protocol is evidenced by the effect size (1.31) (Table 3).

Arm perimetry - 5 cm proximal to the elbow joint

The data collected from the initial and final assessments were statistically and mathematically processed, and at 5 cm proximal to the elbow joint, as shown in Table 4, there is a difference of 2.5 cm (8%) between the mean values of the two assessments (31.6 - initial, 29.0 - final). The assessment was performed bilaterally for comparison. We also identified a difference of 0.9 cm between the circumference at this level of the unaffected upper limb (28.1 cm) and that of the contralateral upper limb (29 cm). The mid-and maximum values decreased from 27 to 24 and 41 to 35.5, respectively.
The data are also homogeneously dispersed, as shown by the coefficient of variance value of 11.5% at baseline and 10.1% at an endpoint. A statistically significant difference can be observed between the two mean values, which is evident when the two-tailed dependent t-test is applied, where the statistical significance threshold p-value is less than 0.001<0.05. The magnitude of the effect (1.41) suggests that the treatment applied is effective (Table 4).

Arm perimetry - 10 cm proximal to the elbow joint

Mathematical processing of the data obtained for arm circumference measured at 10 cm proximal to the elbow joint revealed a difference in mean values of 1.8 cm (5.1%) between the initial test (34.5 cm) and the final test (32.7 cm). The arm circumference of the unaffected upper limb, measured at the same level, showed a difference in mean values of 0.4 cm between it (32.3 cm) and the contralateral upper limb (32.7 cm).
Statistically, the difference between the mean values is significant, which is identified in the two-tailed dependent t-test, where the significance threshold p-value is less than 0.001<0.05. According to the coefficient of variation, the data are dispersed homogeneously, both in the initial (12%) and final (13.7%) assessments (Table 5).

4. Discussions

According to Ha et al., the combination of lymphatic denudation massage and neuro-proprioceptive facilitation techniques is a potential therapeutic strategy applied to patients with breast neoplasm, considering the synergistic effects they have on edema volume, pain, range of motion in the scapula-humeral joint, and quality of life. Therefore, the incorporation of proprioceptive facilitation techniques may facilitate the physiotherapy protocol [18].
Patient management of lymphedema is a decisive factor in the prophylaxis and treatment of lymphatic edema [19]. Therefore, we consider that patients should be taught different techniques of self-massage, low-intensity exercise, dry brushing, hydration, and an edema-specific diet.
At first, this type of massage was applied to treat sinusitis as well as for cosmetic purposes. Nowadays, this type of therapy is applied post-mastectomy. It consists of the rhythmic and slow application of gentle and gentle maneuvers, taking into account the directions in which lymph fluid moves toward the lymph nodes [20].

5. Conclusions

Decreased range of motion in the upper limb joints on the side of the mastectomy procedure is caused by keloid scarring, which occurs after surgery. The pain experienced by patients could be caused by ligament and muscle damage following surgery.
Chemotherapy and radiotherapy are also the main factors involved in the chronicity of pain and its possible exacerbation. This chronic, persistent pain can be a disabling factor considering the peripheral neuropathy and phantom pain experienced following surgery.
We believe that post-mastectomy, patients with edema should be offered full decongestive therapy in the early stages of lymphatic edema.
Regarding perimetry at the metacarpophalangeal joints, the bilateral dependent t-test indicates a statistically significant result. The effect size indicates a decrease in edema at this level.
The perimetry performed at the distal radioulnar joint shows a homogeneous dispersion of the data collected during the two tests: initial and final.
For forearm circumference measured at 10 cm distal to the elbow joint, the effect size (1.31) shows a quantitative difference between the mean values obtained in the assessment of the subjects. At the same time, at the arm level, both at 5 cm and 10 cm proximal to the elbow joint, respectively, the bilateral dependent t-test revealed a statistically significant difference between the two mean values.
Thus, we can affirm that the applied physiotherapy protocol is effective and the hypothesis of the study is confirmed.

Author Contributions

All authors have read and agreed to the published version of the manuscript.

Funding

The work of Daniel Andrei Iordan was supported by the project “PRO-INVENT”, Contract no. 62487/03.06.2022 - POCU/993/6/13 - Code 153299, financed by The Human Capital Operational Programme 2014–2020 (POCU), Romania.

Institutional Review Board Statement

The study was conducted in accordance with the principles set out in the Declaration of Helsinki. Written informed consent was obtained from all participants. The study was approved by the Ethics Commission of the National University of Physical Education and Sport in Bucharest, with no. 19/27.09.2022.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data are contained within the main text of the article.

Acknowledgments

All authors have equally contributed to this article as senior authors.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Koelmeyer, L.A. , Gaitatzis, K., Dietrich, M.S., Shah, C.S., Boyages, J., McLaughlin, S.A., & Ridner, S.H. Risk factors for breast cancer–related lymphedema in patients undergoing 3 years of prospective surveillance with intervention. Cancer, 2022, 128, 3408–3415. [Google Scholar] [CrossRef] [PubMed]
  2. Shapiro, C.L. , & Recht, A. Side Effects of Adjuvant Treatment of Breast Cancer. New England Journal of Medicine, 2001, 344, 1997–2008. [Google Scholar] [CrossRef] [PubMed]
  3. Partridge, A.H. , & Ruddy, K.J. Fertility and adjuvant treatment in young women with breast cancer. The Breast, 2007, 16, 175–181. [Google Scholar] [CrossRef]
  4. Benchiha, N.N. , Chama, Z., Saddek, S., Matmour, D., Berrahal, C., Hachemi, B. and Elhabachi, B. Prognostic Factors, Survival and Benefit of Neoadjuvant Chemotherapy in Operable Breast Cancer in Women from Northwest Algeria. Egyptian Academic Journal of Biological Sciences. C, Physiology and Molecular Biology, 2023, 15, 73–83. [Google Scholar] [CrossRef]
  5. Johnsson, A. , Fugl-Meyer, K., Bordas, P., Åhman, J., & Von Wachenfeldt, A. Side Effects and Its Management in Adjuvant Endocrine Therapy for Breast Cancer: A Matter of Communication and Counseling. Breast Cancer: Basic and Clinical Research 2023, 17. [Google Scholar] [CrossRef]
  6. Norman, S.A. , Localio, A.R., Potashnik, S.L., Simoes Torpey, et al. Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms, Journal of Clincal Oncology, 2009, 27, 390–7. [Google Scholar]
  7. Tretbar, L. , Morgan, C.L., Lee, B.B., Simonian, S.J., Blondeau, B. Lymphedema Diagnosis and Treatment, Springer: Kansas City, 2008, 21-31.
  8. Buragadda, S. , Alhusaini, A. A., Melam, G. R. and Arora, N. Effect of complete decongestive therapy and a home program for patients with post mastectomy lymphedema. Journal of physical therapy science, 2015, 27, 2743–2748. [Google Scholar] [CrossRef] [PubMed]
  9. Janavlekar, M. G. , Verma, C. V., & Mistry, H. M. Effect of Complete Decongestive Therapy on Lymphoedema, Sleep Quality and Quality of Life in Metastatic Breast Cancer Patient–A Case Study. Indian Journal of Palliative Care, 2022, 28, 439–442. [Google Scholar] [CrossRef] [PubMed]
  10. Tatar, K.K. , & Turhan, B. The effects of complex decongestive therapy on pain and functionality in individuals with breast cancer who developed adhesive capsulitis due to lymphedema: an evaluation by an isokinetic computerized system. The Korean Journal of Pain, 2022, 35, 280–290. [Google Scholar] [CrossRef] [PubMed]
  11. Ezzo, J. , Manheimer, E., McNeely, M.L., Howell, D.M., Weiss, R., Johansson, K. I., et. al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database of Systematic Reviews, 2015, 5. [Google Scholar] [CrossRef]
  12. Shao, Y. , & Zhong, D. S. Manual lymphatic drainage for breast cancer-related lymphoedema. European journal of cancer care 2017, 26, e12517. [Google Scholar]
  13. Lin, Y. , Yang, Y., Zhang, X., Li, W., Li, H., and Mu, D. Manual lymphatic drainage for breast cancer-related lymphedema: a systematic review and meta-analysis of randomized controlled trials. Clinical Breast Cancer, 2022, 22, 664–e673. [Google Scholar] [CrossRef] [PubMed]
  14. Foldi, M. and Strossenreuther, R. Foundations of Manual Lymph Drainage, Elsevier Mosby, Munchen, 2003, 130-133.
  15. Keswani, S. , Kalra, S., and Kanupriya, H. K. Utilizing Complete Decongestive Therapy and Pneumatic Compression on Patients with Breast Carcinoma for Treatment of Postoperative Arm Lymphedema–A Review. Executive Editor. Journal of Physiotherapy & Occupational Therapy, 2019, 13, 66. [Google Scholar] [CrossRef]
  16. Keskin, D. , Dalyan, M., Ünsal-Delialioğlu, S. and Düzlü-Öztürk, Ü. The results of the intensive phase of complete decongestive therapy and the determination of predictive factors for response to treatment in patients with breast cancer related-lymphedema. Cancer Reports, 2020, 3, e1225. [Google Scholar] [CrossRef] [PubMed]
  17. Borman, P. , Yaman, A., Yasrebi, S., İnanlı, A. P. and Dönmez, A.A. Combined complete decongestive therapy reduces volume and improves quality of life and functional status in patients with breast cancer-related lymphedema. Clinical Breast Cancer, 2022, 22, e270–e277. [Google Scholar] [CrossRef] [PubMed]
  18. Ha, K. J. , Lee, S. Y., Lee, H., & Choi, S. J. Synergistic effects of proprioceptive neuromuscular facilitation and manual lymphatic drainage in patients with mastectomy-related lymphedema. Frontiers in physiology, 2017, 8, 959. [Google Scholar] [CrossRef] [PubMed]
  19. Temur, K. and Kapucu, S. The effectiveness of lymphedema self-management in the prevention of breast cancer-related lymphedema and quality of life: A randomized controlled trial. European Journal of Oncology Nursing, 2019, 40, 22–35. [Google Scholar] [CrossRef] [PubMed]
  20. Williams, A. Manual lymphatic drainage: exploring the history and evidence base. British journal of community nursing, 2010, 15, 18–24. [Google Scholar] [CrossRef] [PubMed]
Table 1. Statistical indicators – metacarpophalangeal joints’ perimetry.
Table 1. Statistical indicators – metacarpophalangeal joints’ perimetry.
Evaluation Statistical indicators T-test for dependent means
Mean ± standard deviation Minimum Maximum Amplitude Variation coefficient t df P Effect size
Initial 19.0 ± 1.1 17.0 21.0 4.0 5.6% 7.86 24 <0.001 1.57
Final 18.3 ± 1.0 16.5 20.0 3.5 5.6%
Table 2. Statistical indicators – distal radio-ulnar joint perimetry.
Table 2. Statistical indicators – distal radio-ulnar joint perimetry.
Evaluation Statistical indicators T-test for dependent means
Mean ± standard deviation Minimum Maximum Amplitude Variation coefficient t df P Effect size
Initial 18.5 ± 2.0 15.0 24.0 9.0 11.1% 5.19 24 <0.001 1.04
Final 17.0 ± 1.4 14.0 19.5 5.5 8.2%
Table 3. Statistical indicators – 10 cm distal to the lateral elbow joint.
Table 3. Statistical indicators – 10 cm distal to the lateral elbow joint.
Evaluation Statistical indicators T-test for dependent means
Mean ± standard deviation Minimum Maximum Amplitude Variation coefficient t df P Effect size
Initial 25.8 ± 3.0 21.0 32.5 11.5 11.6% 6.55 24 <0.001 1.31
Final 23.2 ± 2.3 19.0 28.0 9.0 9.7%
Table 4. Statistical indicators – 5 cm proximal to the elbow joint.
Table 4. Statistical indicators – 5 cm proximal to the elbow joint.
Evaluation Statistical indicators T-test for dependent means
Mean ± standard deviation Minimum Maximum Amplitude Variation coefficient t df P Effect size
Initial 31.5 ± 3.6 27.0 41.0 14.0 11.5% 7.04 24 <0.001 1.41
Final 29.0 ± 2.9 24.0 35.5 11.5 10.1%
Table 5. Statistical indicators of arm perimetry - 10 cm proximal to elbow joint.
Table 5. Statistical indicators of arm perimetry - 10 cm proximal to elbow joint.
Evaluation Statistical indicators T-test for dependent means
Mean ± standard deviation Minimum Maximum Amplitude Variation coefficient t df P Effect size
Initial 34.5 ± 4.2 27.0 46.0 19.0 12.0% 6.61 24 <0.001 1.32
Final 32.7 ± 4.5 25.5 46.0 20.5 13.7%
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.

Downloads

302

Views

238

Comments

0

Subscription

Notify me about updates to this article or when a peer-reviewed version is published.

Email

Prerpints.org logo

Preprints.org is a free preprint server supported by MDPI in Basel, Switzerland.

facebook logotwitter logolinkedin logo
MDPI Initiatives
Important Links
Subscribe

Disclaimer

Terms of Use

Privacy Policy

© 2025 MDPI (Basel, Switzerland) unless otherwise stated