Manual Lymphatic Drainage

The clinical syndrome that we chose was lymphedema following breast cancer.  Breast cancer is the most common cancer in women and will typically affect one out of eight women over the course of their lifetime (Breast Cancer, 2010). If the breast cancer is diagnosed and treatment is started quickly there is a very positive prognosis for these patients.  However, there are side effects of the treatment and one of the side effects is lymphedema.   One technique that a physical therapist can use is called manual lymphedema drainage.  This is a technique that has shown positive effects when combined with other modalities.  The technique involves using your hands to pump the arm and push the lymph into uninvolved lymph nodes. The purpose of this blog entry is to review six articles, three pro manual lymph drainage and three against it.   

Articles Supporting MLD

The first article we found was taken from the British Medical Journal and was published January 2010 issue (Torres Lacomba et al., 2010).  This study was a randomized, single blinded, clinical trial. Their objective was to study the effects that early physical therapy would have on women, who had surgical treatment for breast cancer, and the likelihood of secondary lymphedema developing. According to the authors, seventy one percent of women develop secondary lymphedema after surgery for breast cancer, which could be attributed to multiple factors.  The factors include lymph node removal, obesity, wound infection, lack of range of motion, and drainage.  The study involved patients at a hospital over at three-year span.   Women were included if they had unilateral surgery and axillary lymph node dissection.  The patients were randomly assigned into two groups, a control group and an intervention group.  The interventions group received manual lymph drainage from an experienced physiotherapist, performed exercises for the muscle group affected by the surgery, and were educated on the lymphatic system.  The control group received the same educational information that the interventions group received, but they did not have the other two interventions.  The statistical comparisons were binary outcome analysis to view the likelihood of lymphedema developing and continuous outcome analysis to view how the circumference changed, as well as the difference in arm circumference of two adjacent locations. 

The first article found that physiotherapy, manual lymph drainage, and patient education had a significant effect.  The interventions group developed secondary lymphedema in seven percent, while twenty-five percent of the control group developed lymphedema.  The authors stated that oedemas are caused by an imbalance of filtration and reabsorption.  The theory of the manual lymph drainage is that it helps to move lymph out of the affected tissue and improves the reabsorption.  The author’s of the study hypothesized that the manual lymph drainage post surgery had the possibility to increase positive outcomes.  According to the authors’ their limitations included the time frame of their follow up and that they chose one criteria for diagnosing lymphedema.  However, the authors’ believed that their intervention had a positive effect on the women who have unilateral surgery with axillary node dissection.  They believed their intervention helped to prevent secondary lymphedema, which in turn improves the quality of patient life. 

The second article analyzed 138 women of whom 55% had a combination of four types of treatments: manual lymph drainage (addressed in our video), compression, arm exercises, and deep breathing (also addressed in our video). 32% of the women received manual lymph drainage alone and 13% had very mild lymphedema which was treated by the patient themselves with instructions from a therapist.

The results showed that there was a 55.7% improvement in the women that had all four therapies concurrently and 41.2% improvement in the women that had manual lymph drainage alone.  Due to the embarrassing, and possibly debilitating, nature of a severely swollen limb due to lymphedema, this article provides important evidence in support of the manual lymphatic drainage intervention.

The final article supporting MLD consisted of two groups: the first group received MLD followed by simple lymphatic drainage (SLD), and SLD followed by MLD.  Thirty-one subjects that had unilateral lymphedema of greater than 10% for at least 3 months one year after breast cancer treatment participated in this study. The first group received 3 weeks of MLD (15 treatments), followed by 6 weeks of nothing, and then 3 weeks of SLD.  The second group had 3 weeks of SLD, followed by 6 weeks of nothing, and then 3 weeks of MLD (15 treatments).  This study showed that MLD in the early phases of lymphedema produced a statistically significant reduction in excess limb edema (9.65%), compared to SLD, which had a non-significant reduction in limb volume (3.85%).

Articles Refuting MLD

The first article that was against manual lymph drainage (MLD) was a randomized, single blind, control study (Devoogdt et al., 2011).  This study objective was to view how patients with breast cancer and axillary node dissection would respond to an intervention of MLD, exercise, and education.  The patients were selected over at two and half year time period based on their surgery and lymph node dissection.  From this they narrowed their patients down to one hundred sixty patients who agreed.  The patients were randomly selected for the interventions or control group.  The difference between the two groups was that the interventions group would receive MLD for 20 weeks beginning with the first week after the drainage tube was removed.  The MLD treatment began with the neck and axillary nodes, followed by the back and breast tissue, and finally the arm and hand.  This was done using a proximal to distal drainage technique.  Four different therapists performed this method of MLD, these for therapists also instructed the patients through exercise and education.

            The primary results of this study were that patients in the interventions group had almost the same likelihood of developing lymphedema after surgery.  According to the study, twenty four percent of patients in the interventions group developed lymphedema, as opposed to only nineteen percent in the control group.  The secondary outcomes were that each group had similar changes in arm volume.  According to the authors, after the six months of treatment the interventions group had no statistically significant changes.  This led the authors to conclude that MLD does not affect the prevention of lymphedema over a short time period.  This study did provide limitations and strengths.  The limitations of the study were half of the therapists performing the treatments were inexperienced (trained before the study) while the other half had more experience.  The strengths of the study were pre and post surgery measurements, stratification of patients, and randomized grouping. 

            The second article that was against MLD was a prospective, randomized control study that compared the use of MLD with compression versus only compression (McNeely et al., 2004).  The purpose was to look at how effective the combination of MLD and compression would be at decreasing volume of lymphedema. The patients were females with unilateral breast cancer and axillary node dissection.  As another exclusionary criteria the patients were required to be diagnosed with lymphedema.  The patients were randomly placed into either the control group (receiving only compression bandage) or the intervention group (compression and MLD).  The patients in each group received 4 weeks of treatment.  For the group receiving MLD the Vodder method was used.  The compression bandaging was layered and short stretch bandages were applied in a figure eight pattern. 

            The primary outcome of this study was that there was not a significant difference between the control group and the intervention group.  This was determined by the difference in the unaffected arm compared to the affected arm.  The authors’ point out that their study is in agreement with previous studies regarding compression and MLD.  However, the authors’ do mention that the patients who had mild lymphedema had better results from the MLD and the compression.  The authors’ hypothesize that because they have mild lymphedema there is still a functioning lymphatic system, which allows the lymph to be moved effectively.  They also hypothesize that the compression affects the filtration rate from artery to tissue and because the pressure is changed there is an increase in venous return.  Based on these two ideas they believe that compression is more effective in severe lymphedema due to lymphatic system damage.  The limitations for this study included the time period, upper extremity range of motion was not measured, and they did not assess pain, function, or quality of life. 

            The final article aimed to find out if MLD, added to standard therapy, improved the outcome for patients with stage 1 or 2 lymphedema after breast cancer treatment. Andersen et al. said that the most important reduction of edema happens in the first two weeks.  Forty-two patients at least 4 months post breast cancer treatment who had one or more symptoms of unilateral lymphedema, a difference in limb volume of at least 200 ml, and/or a difference of circumference of at least 2 cm participated in this study.  They were randomly assigned to receive standard therapy or standard therapy plus MLD.  Standard therapy included a custom made compression sleeve, education, and exercises.  The experimental group received standard therapy plus MLD 8 times in 2 weeks and was instructed on simple lymphatic drainage for home.  The results concluded that both groups had significant reduction in lymphedema, especially in the first month, and then continued to slightly decline in the next 11 months.  The standard therapy group saw a 60% reduction of edema after 3 months, compared to 48% in the MLD group.  Both groups reported a significant reduction of limb volume, discomfort, and an increase in joint mobility.

            Collectively, these articles suggest that compression, especially in the early stages of lymphedema, is the most important aspect of treatment. However, including MLD in treatment may help clear edema in some patients.  Because MLD is a massage technique there also could be psychological benefits for the patients that were not quantified in any of the studies we viewed.  In conclusion, the articles were somewhat inconclusive, but showed that MLD does have positive benefits when combined with other treatments.  

References 

Andersen, L., Højris, I., Erlandsen, M., & Andersen, J. (2000). Treatment of breast-cancer-related lymphedema with or without manual lymphatic drainage--a randomized study. Acta oncologica (Stockholm, Sweden), 39(3), 399-405. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20218087 

Breast Cancer." PubMed - Health. 28 Dec. 2010. Web. 03 Feb. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001911/>.

Devoogdt, N., Christiaens, M.-R., Geraerts, I., Truijen, S., Smeets, a., Leunen, K., Neven, P., et al. (2011). Effect of manual lymph drainage in addition to guidelines and exercise therapy on arm lymphoedema related to breast cancer: randomised controlled trial. Bmj, 343(sep01 1), d5326-d5326. doi:10.1136/bmj.d5326

McNeely, M. L., Magee, D. J., Lees, A. W., Bagnall, K. M., Haykowsky, M., & Hanson, J. (2004). The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial. Breast cancer research and treatment, 86(2), 95-106. doi:10.1023/B:BREA.0000032978.67677.9f

Rashmi Koul, M.D., Tarek Dufan, M.D., Catherine Russell, B.P.T., Wanda Guenther, R.M.T.,Zoan Nugent, Ph.D., Xuyan Sun, M.Sc., Andrew L. Cooke, F.R.C.P.C. "Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer." International Journal of Radiation Oncology*Biology*Physics (2007): 841-846.

Torres Lacomba, M., Yuste Sanchez, M. J., Zapico Goni, A., Prieto Merino, D., Mayoral del Moral, O., Cerezo Tellez, E., & Minayo Mogollon, E. (2010). Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ, 340(jan12 1), b5396-b5396. doi:10.1136/bmj.b5396

Williams, a F., Vadgama, a, Franks, P. J., & Mortimer, P. S. (2002). A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema. European journal of cancer care, 11(4), 254-61. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12492462