Eficacia del tratamiento conservador no farmacológico del linfedema postmastectomía

doi:10.1016/S0048-7120(07)75500-7

Rehabilitación

Volume 41, Issue 3, February 2007, Pages 126-134

https://doi.org/10.1016/S0048-7120(07)75500-7 Get rights and content

Resumen

Objetivo

Analizar la eficacia de las intervenciones no farmacológicas en el linfedema postmastectomía.

Estrategia de búsqueda

Se revisaron las bases de datos Medline, Physiotherapy Evidence Database y la Biblioteca Cochrane hasta mayo de 2006. Se completó con una búsqueda en la web a través de Google.

Selección de artículos

Se localizaron 15 ensayos clínicos aleatorizados, 4 revisiones sistemáticas, 3 guías de práctica clínica, 3 informes de evaluación tecnológica y 3 documentos de la Colaboración Cochrane (una revisión y dos protocolos).

Síntesis de resultados y Conclusiones

No se localizaron evidencias científicas de alta calidad. La información más fiable de la que disponemos se basa en ensayos clínicos aleatorizados con muestras pequeñas. Sólo en unos pocos estudios el seguimiento es a largo plazo (igual o superior a un año). En ningún trabajo se utilizó el enmascaramiento y sólo en unos pocos ensayos clínicos se realizó un análisis de las pérdidas. Las terapias físicas han demostrado un efecto moderado sobre la reducción del edema. Las prendas de compresión son, probablemente, el tratamiento principal. Con ellas puede esperarse una estabilización y, habitualmente, una modesta mejoría. Hay evidencia débil y contradictoria de la utilidad a corto plazo del drenaje linfático manual y la compresión neumática externa. La terapia física compleja no ha demostrado su utilidad sobre alternativas más simples. La elevación del brazo y los ejercicios pueden producir una pequeña mejoría combinados con otras técnicas. Los resultados positivos observados con el láser son aún demasiado preliminares.

Summary

Objectives

To analyze effectiveness of the non-pharmacological interventions in the management of lymphedema postmastectomy.

Search strategy

We reviewed the following databases: Medline, Physiotherapy Evidence Database and the Cochrane Library up to May 2006. We also made a used a complete web in Google.

Articles selection

We found 15 randomized clinical trials, 4 systematic reviews, 3 clinical guidelines, 3 technological evaluations reports and 3 Cochrane Collaboration documents (1 review and 2 protocols).

Results and conclusions

We did not find any high quality scientific evidence. The most reliable information available is based on randomized clinical trials with small samples. Follow- up was long term in only a few studies (equal or higher to one year). None of the studies used the blinded method, and only a few clinical trials used a patients loss to follow-up analysis. Physical therapy had a moderate effect on edema reduction. Compression garments are probably the main treatment. Using those garments we could expect stabilization and usually modest recovery. There is a weak and contradictory evidence of the short term utility of manual lymph drainage and external pneumatic compression. Complete decongestive therapy has shown no special utility versus the simpler alternatives. Arm elevation and exercises may produce a small improvement in combination with other techniques. The positive results observed with laser therapy are still very preliminary.

Bibliografía (63)

D. Dini et al.
The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study
Ann Oncol
(1998)
G. Bertelli et al.
Conservative treatment of postmastectomy lymphedema: a controlled, randomized trial
Ann Oncol
(1991)
J. Sitzia et al.
Manual lymphatic drainage compared with simple lymphatic drainage in the treatment of post-mastectomy lymphoedema. A pilot randomised trial
Physiotherapy
(2002)
J. Barclay et al.
Reducing the symptoms of lymphedema: is there a role for aromatherapy?
Eur J Oncol Nurs
(2006)
M.J. Brennan
Lymphedema following the surgical treatment of breast cancer: a review of pathofisiology and treatment
J Pain Symptom Manag
(1992)
C.D. Collins et al.
Computed tomography in the assessment of response to limb compression for lymphedema: a controlled study
Clin Radiol
(1995)
S.M. Ramos et al.
Edema volume, not timing, is the key to success in lymphedema treatment
Am J Sur
(1999)
M. Wozniewski et al.
Complex physical therapy for lymphedema of the limbs
Physiotherapy
(2001)
S.R. Harris et al.
Clinical practice guidelines of the care and treatment of breast cancer. Cancer: 11. Lymphedema
CAMJ
(2001)
B. Clark et al.
Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow up study
QJM
(2005)

M.B. Tobin et al.

The psychological morbidity of breast cancer related arm swelling

Cancer

(1993)

E. Maunsell et al.

Arm problems and psychological distress after surgery for breast cancer

Can J Surg

(1993)

J.A. Petrek et al.

Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis

Cancer

(2001)

J. Engel et al.

Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients

Breast Cancer Res Treat

(2003)

A. Herd-Smith et al.

Prognostic factors for lymphedema after primary treatment of breast cancinoma

Cancer

(2001)

M.W. Kissin et al.

Risk of lymphoedema following the treatment of breast cancer

Br J Surg

(1986)

L. Kligman et al.

The treatment of lymphedema related to breast cancer. A systematic review and evidence summary

Support Care Cancer

(2004)

C. Badger et al.

Benzo-pyrones for reducing and controlling lymphoedema of the limbs

Cochrane Database Syst Rev

(2004)

A.M. Calderón et al.

Linfofármacos en el linfedema postmastectomía: revisión sistemática

Rehabilitación (Madr)

(2006)

C. Badger et al.

A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery in the treatment of patients with lymphedema of the limb

Cancer

(2000)

B. Le Vu et al.

Efficacy of massage and mobilization of the upper limb after surgical treatment of breast cancer

Bull Cancer

(1997)

L. Andersen et al.

Treatment of breast-cancer-related lymphedema with or without lymphatic drainage

Acta Oncol

(2000)

K. Johansson et al.

A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema

Lymphology

(1998)

A. Szuba et al.

A randomized, prospective study of a role for adjuntive intermittent pneumatic compression

Cancer

(2002)

A.F. Williams et al.

A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema

Eur J Cancer Care

(2002)

D. McKenzie et al.

Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study

J Clin Oncol

(2003)

M. McNeely et al.

The adition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial

Breast Cancer Res Treat

(2004)

K. Didem et al.

The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery

Breast Cancer Res Treat

(2005)

C. Carati et al.

Treatment of postmastectomy lymphedema with low-level laser therapy

Cancer

(2003)

A. Kaviani et al.

Low level laser therapy in management of postmastectomy lymphedema

Lasers Med Sci

(2006)

R.J. Damstra et al.

CBO-Richflïng ‘lymphedema’ [Dutch Institute for Health Care Improvement (CBO) Guideline ‘Lymphedema’]

Ned Tijdschr Geneeskd

(2003)

Cited by (11)

Effectiveness of the use of unstable shoes in improving quality of life in lower limb lymphedema. A pilot study
2017, Rehabilitacion
El linfedema se produce por una alteración en la circulación linfática. La bomba muscular y articular juegan un papel importante en dicha circulación, constituyendo mecanismos extrínsecos para favorecer el retorno, tanto venoso como linfático. El uso del calzado con suela inestable puede activar y fortalecer la musculatura de los miembros inferiores potenciando ambos mecanismos. El objetivo es evaluar la eficacia del uso del calzado con suela inestable en la calidad de vida en pacientes con linfedema de miembro inferior.
Se diseñó un ensayo clínico, controlado y aleatorizado, a doble ciego. Al tratamiento habitual del linfedema se añadió el uso de los zapatos con suela inestable (MBT^®) al grupo experimental, para realizar las actividades diarias. Al grupo control se añadió el uso de zapatillas deportivas normales. Se reclutaron 21 sujetos. Se utilizó la encuesta EQ-5D de calidad de vida. Para el análisis comparativo se utilizó la t de Student.
Diecisiete sujetos completaron el estudio, de los cuales 10 usaron MBT^® y 7 calzado deportivo convencional. Después de la intervención, ambos grupos mostraron un aumento de la puntuación media del cuestionario. Sin embargo, en el grupo que utilizó el calzado con suela inestable, el incremento fue de 18 puntos (p = 0,003), frente a 11,4 (p = 0,18) del grupo control.
Se puede considerar que el uso del calzado con suela inestable puede contribuir a mejorar la calidad de vida del paciente con linfedema del miembro inferior.
Lymphoedema is due to a lymph circulation disorder. Muscle and joint pumps are important extrinsic mechanisms of both lymphatic and venous return. The use of unstable shoes can activate and strengthen the muscles in the lower limbs, thus activating both mechanisms. The aim of this study was to evaluate the effectiveness of unstable shoes in improving quality of life in patients with lower limb lymphoedema.
A double blind, randomised controlled trial was designed. In addition to their usual lymphoedema treatment, persons in the experimental group wore unstable shoes (MBT^®) during their activities of daily living. The control group was given regular trainers. A total of 21 participants were recruited. Quality of life was measured using the EQ-5D questionnaire. Student's t- test was used for comparisons between groups.
Seventeen participants completed the study, of whom 10 used unstable shoes and 7 used another type of trainers. After the intervention, both groups showed an increase in mean quality of life scores. However, the mean score increased by 18 points in the group wearing MBT shoes (p = .003) and by 11.4 points in the control group (p = .18).
The results of this study show that this kind of footwear may help to enhance quality of life in people with lower limb lymphoedema.
How to assess a lymphedema
2013, FMC Formacion Medica Continuada en Atencion Primaria
The role of the school of lymphedema and kinesitherapy in the prevention and treatment of lymphedema
2010, Rehabilitacion
La elevada prevalencia de linfedema con su impacto en la calidad de vida y la eficacia incompleta de las terapias actuales hace aconsejable la instauración de programas de prevención que hagan posible una detección y un tratamiento precoz. La escuela de linfedema tiene como objetivo el de instruir a los pacientes de riesgo y a pacientes afectados en las medidas de prevención, autocuidado y en la identificación precoz del linfedema o sus complicaciones.
Los ejercicios activos forman parte de los programas de prevención del linfedema y del tratamiento del mismo en la denominada terapia física compleja.
Estudios recientes muestran que además de los ejercicios habituales recomendados la elaboración personalizada de protocolos que engloben actividad aeróbica, de resistencia y de flexibilización están indicados ya que ni desencadenan ni exacerban el linfedema, pero contribuyen a aumentar la calidad de vida de estos pacientes.
The high prevalence of lymphedema along with its impact on quality of life and incomplete efficacy of current therapies makes the establishment of prevention programs that enable detection and early treatment recommendable. The School of Lymphedema aims to educate the at-risk and affected patients regarding preventive measures, self-care and early identification of lymphedema and its complications.
Active exercises are part of lymphedema prevention programs and its treatment in the so-called complex physical therapy.
Recent studies show that in addition to the recommended regular exercises, development of personalized protocols including aerobic, resistance and flexibility exercises is indicated since they neither trigger nor exacerbate lymphedema but contribute to improving the quality of life of these patients.
Diagnostic and therapeutic protocol of lymphedema: Informed consent
2010, Rehabilitacion
Revisión bibliográfica de la literatura científica en relación al diagnóstico y tratamiento del linfedema. Exposición de diversos protocolos de actuación en el manejo de estos pacientes.
Se realizaron búsquedas bibliográficas en las bases de datos MEDLINE, CANCERLIT, EMBASE, Cochrane Database, Triptabase,CRD (DARE, HTA,NHS-CED), PEDro, National Guideline Clearinghouse, SIGN, Fisterra y SUMSearch. Se consultaron trabajos de la Sociedad Internacional de Linfología.
Se han revisado los estudios publicados sobre linfedema hasta 2009. Se incluyeron:
8 revisiones sistemáticas, 4 guías de práctica clínica , un consenso internacional, un informe de la Agencia de Evaluación de Tecnología Sanitarias y artículos independientes. Se han excluido los casos clínicos.
El tratamiento del linfedema es básicamente conservador. Está basado en la terapia física descongestiva que se fundamenta en una larga experiencia y en el consenso internacional. No obstante aun hay falta de evidencia científica para su manejo óptimo.
El éxito de los resultados está basado en un diagnóstico precoz y un tratamiento adecuado planificado «a largo plazo», intentando que el paciente forme parte activa del programa sin lo cual es difícil conseguir resultados positivos.
To review the medical literature regarding the diagnosis and treatment of lymphedema and to present some management action protocols regarding these patients.
The study was based on a search of the literature retrieved from MEDLINE, CANCERLIT, EMBASE, Cochrane Database, Triptabase, CRD (DARE, HTA,NHS-CED), PEDro, National Guideline Clearinghouse, SIGN, Fisterra and SUMSearch. A non-systematic review of articles from the International Lymphology Society was also carried out.
Articles on lymphedema found up to December 2009 were reviewed. Eight systematic reviews, 4 clinical practice guidelines, 1 International Consensus, 1 Health Care Technology Evaluation Report and independent articles were included. Medical Reports were excluded.
Treatment of lymphedema is basically conservative. It is based on decongestive physical therapy, which is based on longstanding experience and international consensus. However, scientific evidence is still lacking for its effective management.
Successful outcome is based on early diagnosis and a long-term treatment plan. The patient should be involved actively in the treatment plan, positive outcomes being difficult to achieve without this participation.
Complex decongestive therapy in the early stages of breast cancer-related lymphoedema
2019, Fisioterapia
Analizar los resultados del tratamiento con terapia descongestiva compleja (TDC) aplicada por primera vez en sujetos con linfedema secundario a cáncer de mama (LSCM) grados 0-I.
Estudio descriptivo retrospectivo con sujetos diagnosticados de LSCM de grado 0 y I en una Unidad de Linfedema, a los que se les realiza TDC por primera vez entre los años 2013 y 2016. Se compara el porcentaje de exceso de volumen (PEV) del linfedema en 3 intervalos (inicial, postratamiento y en la revisión médica) y se calcula la reducción del mismo (RPEV) después del tratamiento. Se registran datos demográficos, clínicos y las características del linfedema.
Fueron incluidas 27 mujeres, con una media de edad de 55 años (49-62). El 88,90% de ellas (n = 24) intervenidas de linfadenectomía y el 85,20% (n = 23) con radioterapia coadyuvante. Se realizaron de media de 23 sesiones. Previo a la TDC 7 participantes tenían LSCM de grado 0 y 20 de grado I; después del tratamiento 16 participantes tenían linfedema de grado 0 y 11 de grado I. La media inicial de PEV fue de 11,76%, 8,77% después del tratamiento y 7,57% en la revisión médica. El PEV se redujo en 22 participantes después del tratamiento (81,50%). Exceptuando un caso, la reducción de volumen se mantuvo estable en la revisión médica. La RPEV después del tratamiento fue 28,15% y 44,79% en la revisión médica.
Este estudio muestra unos resultados favorables al empleo de TDC para el tratamiento de linfedema secundario a cáncer de mama de grado 0 y/o I.
To analyse the outcomes of Complex Decongestive Therapy (CDT) applied for the first time in patients with Breast Cancer-Related Lymphoedema (BCRL) stages 0-I.
A descriptive and retrospective study performed on subjects with BCRL severity stages 0 and I recruited in the Lymphology Unit, and who had CDT for the first time between 2013 and 2016. A comparison was made of the percent excess volume (PEV) of lymphoedema at 3 intervals (initial, post-treatment, and medical check-up) and we calculated the percent excess volume reduction (PEVR) after treatment. Demographic data, clinical and lymphoedema characteristics were recorded.
The study included a total of 27 women, with mean age of 55 years (49-62). A lymphadenectomy had been performed on 88.90% (n = 24), and 85.20% (n = 23) had radiation therapy. There was a mean of 23 sessions. Before CDT, 7 participants had stage 0 BCRL and 20 had stage I. After treatment, 16 participants had lymphoedema stage 0 and 11 had stage I. The mean initial PEV was 11.76%, 8.77% after treatment and 7.57% in the medical check-up. PEV was reduced in 22 participants after treatment (81.50%). There was only one case where the reduction of volume remained stable in the medical check-up. The mean PEVR after treatment was 28.15% and 44.79% in the medical check-up.
This study shows favourable results of Complex Decongestive Therapy in Breast Cancer-Related Lymphoedema stages 0 and I.
Management of breast cancer-related lymphoedema utilizing complex decongestive therapy and intermittent multi-chamber pneumatic compression. Experiences of a lymphoedema unit
2018, Rehabilitacion
El protocolo de tratamiento para los pacientes con linfedema sigue siendo controvertido. El objetivo de este trabajo es analizar el resultado de la Terapia Descongestiva Compleja con presoterapia multicompartimental secuencial aplicada por primera vez a pacientes con linfedema secundario a cáncer de mama en una Unidad de Linfedema.
Este estudio observacional con seguimiento retrospectivo está basado en la revisión de historias clínicas durante el periodo 2013-2016. 48 pacientes reunieron los criterios de inclusión de: diagnóstico de linfedema secundario a cáncer de mama, realizar por primera vez sesiones completas de Terapia Descongestiva Compleja (con drenaje linfático manual, presoterapia multicompartimental secuencial y vendaje multicapas) haber realizado la toma de medidas y firmar el consentimiento informado. La valoración se realizó comparando las medidas en centímetros del perímetro del miembro tratado y el contralateral en 7 niveles en 3 momentos (inicial, postratamiento y en la revisión) usando la fórmula de Kuhnke para obtener los volúmenes aproximados.
La diferencia entre los volúmenes de ambos miembros bajó desde el 21,61% de media inicial, al 15,98% a corto plazo y al 15,64% a medio plazo, consiguiéndose bajada de volumen en 39 de los pacientes y bajada del grado de linfedema en 21 de ellos.
Los resultados avalan la elección de la Terapia Descongestiva Compleja con presoterapia multicompartimental secuencial como tratamiento estándar en el linfedema secundario a cáncer de mama. Es necesaria más investigación con estudios objetivables y reproducibles que incluyan resultados a largo plazo.
The optimal treatment protocol for lymphoedema patients is still controversial. Therefore, the aim of this study was to analyse the results of Complex Decongestive Therapy with intermittent multi-chamber pneumatic compression applied for the first time in patients with breast cancer-related lymphoedema in a Lymphoedema Unit.
This retrospective observational study was based on a review of medical records from 2013-2016. A total of 48 patients met the inclusion criteria, ie, those who had received a diagnosis of breast cancer-related lymphoedema, had undergone complete sessions of Complex Decongestive Therapy (with manual lymphatic drainage, intermittent multi-chamber pneumatic compression and multi-layer bandaging) for the first time, had available recorded measurements and had signed an informed consent form. The assessment was conducted by comparing the measurement in centimetres of the circumference of the affected limb with the contralateral measurements at 7 levels in 3 time intervals (initial, post-treatment and at the medical follow-up). The Kuhnke method was used to obtain the approximate volumes.
The difference between the volumes of the two limbs decreased from an initial mean of 21.61%, to 15.98% in the short-term and 15.64% in the medium-term, so there was a volume reduction in 39 patients. Moreover, the stage of lymphoedema decreased in 21 of them.
The results support the choice of Complex Decongestive Therapy with intermittent multi-chamber pneumatic compression as a standard treatment in breast cancer-related lymphoedema. Further research is required on this issue with measurable and reproducible studies that include long-term-results.

View all citing articles on Scopus

View full text

RevisiónEficacia del tratamiento conservador no farmacológico del linfedema postmastectomíaEffectiveness of nonpharmacological interventions in the management of lymphedema postmastectomy

Resumen

Objetivo

Estrategia de búsqueda

Selección de artículos

Síntesis de resultados y Conclusiones

Summary

Objectives

Search strategy

Articles selection

Results and conclusions

Ann Oncol

Ann Oncol

Physiotherapy

Eur J Oncol Nurs

J Pain Symptom Manag

Clin Radiol

Am J Sur

Physiotherapy

Clinical practice guidelines of the care and treatment of breast cancer. Cancer: 11. Lymphedema

CAMJ

Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow up study

QJM

The psychological morbidity of breast cancer related arm swelling

Cancer

Arm problems and psychological distress after surgery for breast cancer

Can J Surg

Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis

Cancer

Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients

Breast Cancer Res Treat

Prognostic factors for lymphedema after primary treatment of breast cancinoma

Cancer

Risk of lymphoedema following the treatment of breast cancer

Br J Surg

The treatment of lymphedema related to breast cancer. A systematic review and evidence summary

Support Care Cancer

Benzo-pyrones for reducing and controlling lymphoedema of the limbs

Cochrane Database Syst Rev

Linfofármacos en el linfedema postmastectomía: revisión sistemática

Rehabilitación (Madr)

A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery in the treatment of patients with lymphedema of the limb

Cancer

Efficacy of massage and mobilization of the upper limb after surgical treatment of breast cancer

Bull Cancer

Treatment of breast-cancer-related lymphedema with or without lymphatic drainage

Acta Oncol

A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema

Lymphology

A randomized, prospective study of a role for adjuntive intermittent pneumatic compression

Cancer

A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema

Eur J Cancer Care

Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study

J Clin Oncol

The adition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial

Breast Cancer Res Treat

The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery

Breast Cancer Res Treat

Treatment of postmastectomy lymphedema with low-level laser therapy

Cancer

Low level laser therapy in management of postmastectomy lymphedema

Lasers Med Sci

CBO-Richflïng ‘lymphedema’ [Dutch Institute for Health Care Improvement (CBO) Guideline ‘Lymphedema’]

Ned Tijdschr Geneeskd

Revisión
Eficacia del tratamiento conservador no farmacológico del linfedema postmastectomíaEffectiveness of nonpharmacological interventions in the management of lymphedema postmastectomy