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ORIGINAL ARTICLE
Year : 2017  |  Volume : 17  |  Issue : 3  |  Page : 148-152

Effectiveness of compression therapy along with exercise to reduce upper limb lymphedema in breast cancer patients


1 Department of Physiotherapy, Mayo Hospital, KEMU, Lahore, Pakistan
2 Department of Physiotherapy, Sargodha Medical College, University of Sargodha, Sargodha, Pakistan

Date of Web Publication4-Oct-2017

Correspondence Address:
Muhammad Mustafa Qamar
Department of Physiotherapy, Sargodha Medical College, University of Sargodha, Sargodha
Pakistan
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DOI: 10.4103/sjsm.sjsm_23_17

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  Abstract 

Objectives: Lymphedema is a communal issue in breast cancer patients. This study was designed to evaluate the effectiveness of compression therapy and exercise in the treatment of lymphedema in breast cancer patients.
Materials and Methods: Thirty patients were randomly assessed in a randomized controlled study trial at the Department of Oncology, Mayo Hospital Lahore. Patients were divided into two groups. Fifteen patients were selected in Group 1 (compression therapy), and 15 patients were selected in Group 2 (compression therapy along with exercise). Both groups received eight sessions for 4 weeks followed by one session in each week. Limb circumferential measurements were used to assess the limb volume reduction and pain numeric rating scale for pain and shoulder pain and disability index scale for the pain and disability. Data were collected at baseline and after 4 weeks.
Results: Statistically significant improvement was found in both groups (P > 0.05). However, no group difference was insignificant. However, clinically, the compression bandage along with exercise and skin care is more effective in reducing lymphedema in breast cancer patients.
Conclusion: This study concluded that both the treatment techniques, compression bandage and compression bandage along with exercise are effective in reducing lymphedema and pain; but, clinically, compression bandage along with exercise is more effective.

Keywords: Breast cancer, compression therapy, exercise, limb volume reduction, lymphedema


How to cite this article:
Butt AJ, Ijaz Gondal M J, Qamar MM. Effectiveness of compression therapy along with exercise to reduce upper limb lymphedema in breast cancer patients. Saudi J Sports Med 2017;17:148-52

How to cite this URL:
Butt AJ, Ijaz Gondal M J, Qamar MM. Effectiveness of compression therapy along with exercise to reduce upper limb lymphedema in breast cancer patients. Saudi J Sports Med [serial online] 2017 [cited 2019 May 21];17:148-52. Available from: http://www.sjosm.org/text.asp?2017/17/3/148/215920




  Introduction Top


Breast cancer has the highest incidence rate, and the death rate is the second highest among women in all cancers.[1] The incidence of breast cancer-related lymphedema ranges from 6% to 83%.[2] 1.1 million cases of breast cancer were diagnosed, and 410,000 patients died in 2004 worldwide.[3] Lymphedema can occur in any cancer and has been found to occur ranges from within days to 30 years after breast cancer treatment.[4],[5] More than one women out of five experience lymphedema after breast cancer.[6]

Lymphedema leads to disability and disfiguration of the lymphatic system that arose with the management of breast carcinoma.[7] Lymphedema occurs due to the impaired lymphatic system which may be due to the removal of lymph nodes, mastectomy surgery, chemotherapy, and radiotherapy in breast cancer treatment.[8],[9],[10],[11],[12],[13] It normally arises as a consequence of mastectomy and radiations.[7] Women affected with breast cancer lymphedema experience pain with the swelling of the arm followed by tightness and heaviness in the involved arm and recurrent episodes of skin infections.[14],[15] Lymphedema if worsened could be serious and disable the patient with high complication after breast cancer treatment. Psychological distress is most common, and functional ability is also lost. It also leads to cosmetic deformity. There is no such treatment of lymphedema, so the aim is to reduce the swelling of an upper extremity, to increase the range of motion (ROM) and to decrease the discomfort.[10],[16],[17],[18]

There are certain nonpharmacological strategies including manual lymphatic drainage (MLD), complex decongestive therapy (CDT),[15],[19] massage,[14],[15],[20] compression therapy, manual therapy, and exercise [15],[19] have been suggested in lymphedema. MLD is one of massage techniques that helps in removal of the excess accumulation of interstitial fluid, which also augments the lymphatic transport.[20] MLD and CDT alone has been found inadequate.[16],[10],[21]

In clinical trial cases of 58 women, postmastectomy lymphedema was studied. To treat their lymphedema, standard therapy with and without MLD was used. Two groups were made to test the effectiveness of both. One group consisted of 29 patients with standard treatment and also MLD and other also consisted of 29 patients with just standard therapy. The duration of both therapies was 4 weeks and the assessment of patient's condition was monitored. After 3 months of treatment, a satisfactory response was not observed with the first group as the reduction volume was below the 20% that was achieved by the second group within same 3 months' time frame.[20]

Compression therapy which includes compression which may be in the form of bandaging or in the form of garment, a pneumatic compression pump, skin care, exercise, massage, and physical therapies have been used to treat lymphedema in the upper limb of patients treated breast cancer.[14],[16],[17],[18] Low stretch compression bandaging is an effective treatment for the reduction of volume from slight to moderate level of lymphedema for the treatment of breast cancer.[17]

Exercises are an essential part of the lymphedema rehabilitation program. Limb exercises can be used to improve venous return and combating lymphedema. These can be performed progressively and are advised to increase lymphatic drainage and for increasing the ROM range of movement and strength of upper limb.[19]

The aim of the study is to compare the effectiveness of pressure therapy with or without exercise to reduce lymphedema in breast cancer patients in the upper limb.


  Materials and Methods Top


This was an interventional study, completed at Oncology Unit, Mayo Hospital Lahore. All patients with secondary lymphedema evaluated objectively by an oncologist. After approval from Local Ethical Committee, 30 patients included in the study having mild to moderate degree of lymphedema and fulfill the inclusion criteria [Table 1] and randomly divided into two group by lottery method. Group A was treated by compression/pressure therapy alone, and Group 2 was treated by exercise along with pressure therapy. Both groups received eight sessions in 4 weeks. An informed written consent was taken according to Helsinki Declaration and study was approved by the Local Ethical Committee. All this information will be collected using a predesigned pro forma.
Table 1: Inclusion and exclusion criteria for participants

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The crepe bandage (compression) is applied in both groups for 4 weeks. Bandages are worn 20–22 h a day, 7 days a week throughout her treatment phase. Two sessions are given per week. The bandage provides the greatest compression at the distal end of the limb and provides least compression at the proximal end closest to the body. Continue the bandage with a turn to secure the start of bandage. Continue the bandage in this way which may cover the two-thirds of turn. Finish the bandage with a straight turn that may secure the bandage. At the wrist, the locking of bandage will be diagonal. Continue the bandage until the dressing is complete. The bandage will start from wrist to lower arm and then upper arm. At first, therapist apply the bandage, and then, the patient progressively learns to perform self-bandaging for herself. Two types of exercises are performed, one is breathing exercises and general arm exercises which include passive ROM exercises initially and then active ROM exercises (flexion, extension, adduction, abduction, circumduction, and pumping exercises) for 10 min three times a day. Exercise includes rolling of head, shoulder shrugging and is guided to inhale during rising and exhale during lowering. The patient is instructed to tighten the abdominals and press the lower region of back against chair; during tightening the muscles of abdomen, the patient is advised to exhale. The patient is asked to join both hands together at the level of shoulder and hold it for 5 s during exhaling. Patient is advised to hold a stick and act as she is pulling that stick (two foot) for 5 s at the level of chest and expire during pulling. Reach exercise of arms. Stretching of both arms and rotation of both wrists. Opening and closing of fingers. These exercises are performed for half an hour, thrice a day.

Recordings of limb volume will be measured by metric tape and both arm measurements will be compared and functional status will be assessed by numeric pain rating scale (NPRS) and shoulder pain and disability index (SPADI). The participants interviewed for pain and shoulder disability and swelling by the direct and indirect method.

Measurements and procedures

The measurement was taken on the circumference to evaluate the volume by a tape (metric) at different sites of the limb as it is a convenient procedure.[14] The measurement of both arms was assessed and compared to evaluate the lymphedema and hence excess volume reduction was analyzed after giving a combination of physical therapies.[15],[22] In this research, the equation to measure limb volume would be taken as a volume of the cylinder because limbs are considered as a series of cylindrical segments. The volume of each segment would be measured by C2/π.[22] The starting point was above 2 cm from the joint, and C, circumference, was measured at 4 cm above the starting point. In this study, proximal and distal volume of limb edema reduction was analyzed by volume of cylinder equation describe above.[22],[23],[24]

Functional performance

The progress of patient was measured by SPADI scale. The progress of all patients was measured on a unified scale describing disability including pain intensity, personal care, lifting weights, walking, sitting, standing, sleeping, social life, and traveling. Score in all disabilities was added as the final pretreatment SPADI score, and posttreatment SPADI score was added as variables. Functional status of the shoulder was assessed by NPRS and SPADI score.[25]

Statistical analysis

Data were demonstrated as mean and analyzed by SPSS version 16 (released 2007, SPSS for Windows, SPSS Inc., Chicago, IL, USA), and paired sample t-test was used for analysis to determine the effect of time and group.


  Results Top


Improvement in pain after study period

A significant reduction of pain was observed after study period in both groups [Graph 1]. About 20% reduction of pain was observed on NPRS in compression group and about 38% in combination group of exercise and compression therapy (P< 0.005). However, there was no statistically difference in both groups. As in combination group, there was more improvement; the compression therapy along with exercise can be considered clinically more superior to compression therapy alone.



Improvement in total limb volume after study period

A significant reduction in total limb volume was observed after study period in both groups [Graph 2]. About 26% reduction in total limb volume was observed in compression therapy group and about 32.5% in combination group of exercise and compression therapy (P< 0.005). However, there was no statistically difference in both groups. As in combination group, there was more improvement; the compression therapy along with exercise can be considered clinically more superior to compression therapy alone.



Improvement in shoulder pain and disability index score after study period

A significant reduction in SPADI score was observed after study period in both groups [Graph 3]. About 15% improvement SPADI score was observed in compression therapy group and about 31% in combination group of exercise and compression therapy (P< 0.005). However, there was no statistically difference in both groups. As in combination group, there was more improvement; the compression therapy along with exercise can be considered clinically more superior to compression therapy alone.




  Discussion Top


The aim of the current study is to compare the effectiveness of compression therapy alone and compression therapy along with exercise to reduce lymphedema in breast cancer patients in the upper limb. Within group, analysis revealed that there was significant volume reduction in both groups but compression therapy along with exercise is clinically more effective in reducing lymphedema, pain, discomfort, and disability in breast cancer patients when pre- and post-intervention scores were compared in both groups. However, the improvement in compression therapy along with exercise was more as compared to compression therapy alone.

Lymphedema normally occurs as a result of treatment of cancer such as mastectomy and radiations.[7] Lymphedema could be serious associated with stress and there is no such cure, but the aim is to increase the functional status and to decrease discomfort.[10],[16],[17],[18]

Complex/complete decongestive therapy is effective and more significant in reducing lymphedema volume as compared to MLD.[10],[16]

The study conducted in “Adelaide Lymphedema Clinic” included 78 patients and were studied for a month resulted in 64% reduction in lymphedema when was given CDT, a combination of skin care, MLD, and exercises with the use of crepe bandage.[15] Two studies previously conducted in Australia and the USA; it was proved that Cognitive processing therapy (CPT)/Complete decongestive therapy (CDT) are more significant in combination with benzopyrones in the reduction of lymphedema.[16]

Four studies were done previously, and results were evaluated to compare the effectiveness in reducing lymphedema in breast cancer patients. The results showed 7% reduction in lymphedema when the treatment was by compression bandage for 2 weeks. In another study, the reduction was 4% reduction when the treatment was with crepe bandage for 6 weeks. The reduction was 5% when the treatment was with compression garment for 2 weeks. In the fourth study, the reduction was 8% when compression garment was given with 6 weeks.[19],[26],[27]

Another study was conducted in which the effects of limb exercise with a combination of self-massage and crepe bandage were evaluated. It was found that limb exercise with crepe bandage is more effective than combination of self-massage and crepe bandage in reducing lymphedema.[19]

Another study was done in which the effects of compression bandage was examined for 2 weeks first separately and then compression bandage with MLD for 1 week in 38 female patients. Pain, heaviness, and arm volume were measured. The volume reduction was 47 ml in compression bandage (CB) plus Manual lymph drainage (MLD) group, and in CB group, the reduction was 20 ml. In both groups, the feeling of heaviness and tension in the arm was decreased, and in CB plus MLD, the pain was decreased.[17]

In another study, half of the patients were given standard treatment and half of them were given standard treatment plus MLD for eight times in 2 weeks. Standard treatment included skin care, exercises with crepe bandage. No significant changes were noted in both groups.[1] Another study conducted in which volume reduction was noted with crepe bandage, stockings, skin care, and elevation.[18] Exercises are an essential part of CPT. The study showed that exercise alone did not reduce volume.[1],[11],[12] In another study, the exercises showed 12–101 ml reduction.[2]

In our research, 30 patients had been enrolled in my study. Fifteen patients were in group A in which patients were given compression therapy (crepe bandage) alone, and 15 patients were given compression therapy (crepe bandage) along with exercise in Group 2. In my study, the excess total limb volume in both groups decreased. Pain score and SPADI score in both groups are reduced but the reduction in excess total limb volume, pain score, and SPADI score is more significant in Group 2 (compression therapy along with exercise). Hence, the compression therapy along with exercise is clinically more effective in treating for lymphedema in breast cancer patients.


  Conclusion Top


This study concluded that both the treatment techniques, compression bandage and compression bandage along with exercise are effective in reducing lymphedema and pain; but, clinically, compression bandage along with exercise is more effective in treating lymphedema in breast cancer patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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