European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review

Different physical treatment modalities for lymphoedema developing after

axillary lymph node dissection for breast cancer: A review
Nele Devoogdt a,b,c,*, Marijke Van Kampen a,b, Inge Geraerts a,b, Tina Coremans c, Marie-Rose Christiaens d
a
Department Physiotherapy, University Hospitals Leuven, Belgium
b
Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgium
c
Department of Health Care Sciences, University College of Antwerp, Belgium
d
Multidisciplinary Breast Center, University Hospitals Leuven, Belgium

A R T I C L E I N F O A B S T R A C T

Article history: The purpose of this article is to provide a systematic review of Combined Physical Therapy, Intermittent
Received 8 February 2009 Pneumatic Compression and arm elevation for the treatment of lymphoedema secondary to an axillary
Received in revised form 18 November 2009 dissection for breast cancer. Combined Physical Therapy starts with an intensive phase consisting of skin
Accepted 19 November 2009
care, Manual Lymphatic Drainage, exercises and bandaging and continues with a maintenance phase
consisting of skin care, exercises, wearing a compression sleeve and Manual Lymphatic Drainage if
Keywords: needed.
Breast cancer
We have searched the following databases: PubMed/MEDLINE, CINAHL, EMBASE, PEDro and
Lymphoedema
Combined Physical Therapy
Cochrane. Only (pseudo-) randomised controlled trials and non-randomised experimental trials
Intermittent Pneumatic Compression investigating the effectiveness of Combined Physical Therapy and its different parts, of Intermittent
Elevation Pneumatic Compression and of arm elevation were included. These physical treatments had to be
applied to patients with arm lymphoedema which developed after axillary dissection for breast cancer.
Ten randomised controlled trials, one pseudo-randomised controlled trial and four non-randomised
experimental trials were found and analysed. Combined Physical Therapy can be considered as an
effective treatment modality for lymphoedema. Bandaging the arm is effective, whether its effectiveness
is investigated on a heterogeneous group consisting of patients with upper and lower limb
lymphoedema from different causes. There is no consensus on the effectiveness of Manual Lymphatic
Drainage. The effectiveness of skin care, exercises, wearing a compression sleeve and arm elevation is not
investigated by a controlled trial. Intermittent Pneumatic Compression is effective, but once the
treatment is interrupted, the lymphoedema volume increases.
In conclusion, Combined Physical Therapy is an effective therapy for lymphoedema. However, the
effectiveness of its different components remains uncertain. Furthermore, high-quality studies are
warranted. The long-term effect of Intermittent Pneumatic Compression and the effect of elevation on
lymphoedema are not yet proven.
ß 2009 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.1. Combined Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.1.1. Skin care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.1.2. Manual Lymphatic Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.1.3. Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.1.4. Multi-layer bandaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.1.5. Compression sleeve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.2. Intermittent Pneumatic Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

* Corresponding author at: University Hospitals Leuven, Department Physiotherapy, Herestraat 49, 3000 Leuven, Belgium. Tel.: +32 16 348577; fax: +32 16 342186.
E-mail address: nele.devoogdt@artesis.be (N. Devoogdt).

0301-2115/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2009.11.016
4 N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9

3.3. Elevation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1. Introduction Randomised and pseudo-randomised controlled trials (RCTs)

and non-randomised experimental trials were included. The study
Lymphoedema is an oedema caused by a reduced transport population was patients with arm lymphoedema, and this, for the
capacity of the lymphatic system [1]. Patients with lymphoedema majority of the patients, developed after axillary dissection for
experience physical problems as well as psychosocial problems. It breast cancer. Only studies investigating the effectiveness of
is a phenomenon feared by many breast cancer patients [2,3]. The Combined Physical Therapy and its different parts, of Intermittent
incidence of lymphoedema after breast surgery is 26% on average Pneumatic Compression and of arm elevation were included.
[2]. Because of the reduced quality of life and the high incidence of Outcome parameters were arm volume, shoulder mobility, muscle
lymphoedema after axillary dissection for breast cancer, an strength, subjective symptoms, tissue elasticity, skinfold thickness
effective, evidence-based treatment is necessary. and quality of life.
According to the International Society of Lymphology [3], In Table 1 each study is described in detail, with an overview of
lymphoedema has to be treated with Combined Physical Therapy. the level of evidence and the Pedro score, the sample character-
This is a two-stage treatment program. During the first or istics, a description of the treatment of lymphoedema, the
intensive phase, the lymphoedema has to be maximally reduced. measurements and the results. The level of evidence is based on
This phase consists of skin care, Manual Lymphatic Drainage, the method outlined by the National Health and Medical Research
exercises and multi-layer bandaging. The second or maintenance Council. The Pedro score (see Table 2) is a score out of 10 and is
phase aims to conserve and optimize the result obtained in the determined by the staff of ‘the Physiotherapy Evidence Database’
first phase. It consists of skin care, exercises, compression by a (or PEDro) and can be found on the website: http://www.pe-
low-stretch elastic sleeve and Manual Lymphatic Drainage when dro.fhs.usyd.edu.au. Only RCTs and pseudo-RCTs are analysed and
needed. scored.
The aim of skin care in lymphoedema management is to
improve or maintain the condition and integrity of the skin, and to 3. Results
prevent skin injury, trauma and infection [4]. Manual Lymphatic
Drainage is a gentle massage technique and stimulates the The search of the databases resulted in 317 articles, of which 15
lymphatic flow and the formation of lympholymphatic and articles were included (see Fig. 1).
axilloaxillary anastomoses [5]. Long-term exercises can lead to
improved lymph flow by increased sympathetic outflow, increased 3.1. Combined Physical Therapy
muscular contractions and increased ventilation [6]. A multi-layer
bandage counterbalances the elastic insufficiency of the connec- No RCTs were found about the effectiveness of Combined
tive tissue of the subcutis and increases the tissue pressure to Physical Therapy using a control group who did not receive
enhance lymph flow. A compression sleeve protects the arm Combined Physical Therapy because, for ethical reasons, it is not
against wounds and bites and helps to maintain the lymphoedema possible to refuse treatment to patients with lymphoedema.
reduction reached during the intensive phase [1]. Didem et al. [8] have investigated the effectiveness by comparing
Intermittent Pneumatic Compression is a multi-chamber device Combined Physical Therapy performed by an experienced physical
that inflates sequentially from distal to proximal, pushing the
liquid ahead by its inflation [7].
The purpose of this manuscript is to review the available
literature on different physical treatment modalities for lymphoe-
dema, more specifically Combined Physical Therapy and its
different parts, Intermittent Pneumatic Compression and arm
elevation, after axillary dissection for breast cancer and to offer
recommendations based on this literature.

2. Materials and methods

The literature search was limited to peer-reviewed articles in

English, French and Dutch, with the following databases searched:
PubMed/MEDLINE, CINAHL, EMBASE, PEDro and Cochrane. Studies
of all dates were included and review articles were excluded.
General keywords used for this search were ‘lymphoedema’,
‘lymphedema’ or ‘lymphoedematous’. These keywords were
combined with: therapy/treatment/physiotherapy; skin care;
drainage/massage; exercise; bandage/bandaging; stockings/gar-
ment/sleeve/hosiery; pneumatic/compression/pressotherapy/
pump; elevation.
The selection of articles was performed in three phases (see
Fig. 1). In the first phase the selection was performed by analysing
the titles of the articles. In the second phase the abstracts and in the
third phase the articles were analysed. Fig. 1. Overview of the systematic literature search.
Table 1
Overview of randomised controlled trials (RCTs or level II), pseudo-RCTs (level III-1) and non-randomised experimental trials (level III-2) with sample characteristics, description of treatment, measurement and result.

Author and evidence Sample characteristics Treatment Measurement Result

Combined Physical Therapy (CPT)

Didem et al. [8] N = 53 All patients: home program with bandage, Before and after 4 weeks: Oedema volume: 56% group CPT
Level II Inclusion: unilateral oedema exercises, skin care, self-massage and walking Arm volume: volumeter versus 36% group standard
Pedro: 6 after breast cancer, <5 cm difference, Group CPT Shoulder mobility physiotherapy (p < 0.050)
duration >1 year (N = 27): skin care, MLD, exercises, Shoulder mobility: shoulder flexion,
bandage, 3/week, 4 weeks abduction and external rotation increased
Group standard physiotherapy (N = 26): elevation, in both groups equally (p > 0.050)
head, neck and shoulder exercise, bandage

N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9
Swedborg [9] N = 39 Group A: massage (manual and vibrator, 15 min, Before and after 4 weeks: Oedema volume: 21% group A versus
Level III-2 Inclusion: unilateral oedema after 5/week), grip exercises (20 min; 5/week), Arm volume: volumeter 28% group B versus 30% group C
Pedro: / breast cancer, >150 ml difference elastic sleeve (during day)
Group B: idem group A + warmth (20 min)
Group C: idem group A + elastic sleeve
(during day and night) 4 weeks

Skin care (no RTC or pseudo-RCT)

Manual Lymphatic Drainage (MLD)
Andersen et al. [11] N = 42 All patients: standard therapy with sleeve Before and after 3 months: Oedema volume: 60% group standard
Level II Inclusion: unilateral oedema after (class II: 32–40 mmHg), information, exercises Arm volume: circumferences therapy versus 48%
Pedro: 6 breast cancer, >200 ml difference Group standard therapy (N = 22): / Shoulder mobility group standard therapy/MLD (p > 0.050)
or >2 cm difference Group standard therapy/MLD (N = 20): MLD: Symptoms: Symptoms and compliance: difference (p > 0.050)
Exclusion: >30% difference 8 sessions in 2 weeks, 1 h/session, questionnaire
education daily self-massage Compliance therapy

Johansson et al. [13] N = 35 All patients: bandage, 3 weeks, day and night Before and after 2 and 3 weeks: Oedema volume: first 2 weeks: 27% group
Level III-1 Inclusion: unilateral oedema after Group B (N = 18): / Arm volume: volumeter B versus 20%
Pedro: 4 breast cancer, >10% difference Group B/MLD (N = 17): MLD, 45 min/day, 5 days, Symptoms: pain, heaviness, group B/MLD (p > 0.050); third week: 4%
Exclusion: <6 months oedema start after 2 weeks of bandage tension group B versus 11% group B/MLD (p = 0.040)
treatment Symptoms: no difference (p > 0.050)

McNeely et al. [10] N = 45 All patients: skin care, bandage, 5/week, 4 weeks Before and after 4 weeks: Oedema volume: 46% group MLD/B
Level II Inclusion: unilateral oedema after Group MLD/B (N = 24): MLD during 45 min Arm volume: volumeter versus 39% group B (p = 0.217)
Pedro: 7 breast cancer, >150 ml oedema group B (N = 21): /
Exclusion: <6 months oedema treatment

Williams et al. [12] N = 31 All patients: skin care, compression Before and after 3 weeks: Oedema volume: 10% group MLD
Level II Inclusion: unilateral oedema after sleeve, 5/week, 3 weeks Arm volume: arm circumferences versus 4% group
Pedro: 3 breast cancer, >3 months, >10% oedema, Group MLD (N = 15): MLD by specialist, 45 min Trunk oedema: calliper SLD (p = 0.053)
clinically detectable trunk swelling (neck, anterior and posterior trunk, swollen arm) Quality of Life: QLQ-C30 Trunk oedema and quality of life: no
Group SLD (N = 16): Simple Lymphatic Drainage Symptoms difference (p > 0.050)
(SLD) by patient self, 20 min (neck, unaffected Symptoms: group
axilla, anterior chest wall) MLD less pain (p = 0.010), discomfort (p = 0.002),
heaviness (p = 0.003), fullness (p < 0.001), bursting
(p = 0.008) and hardness (p < 0.001) than group SLD

Exercises
Moseley et al. [15] N = 52 Experimental group (N = 24): exercise (inspire while Before and after 1 month: Oedema volume: 101 ml experimental
Level III-2 Inclusion: unilateral oedema after breast opening arms and expire while closing arms in Arm volume: perometer group versus 7 ml control
Pedro: / cancer, duration >0.5 year, >200 ml difference horizontal plane), 10 min, 2/day, 1 month Trunk oedema: BIA group (p > 0.050);
Exclusion: <1 month oedema treatment Tissue resistance: tonometer Trunk oedema: no difference
Control group (N = 28): / Symptoms: pain, heaviness, Tissue resistance: anterior thorax: +1.0 mm
tightness, pins and needles, experimental group versus 0.4 mm control group
burning sensations (p = 0.005); forearm and upper arm: no difference
and perceived arm size Symptoms: experimental group less heaviness (p = 0.044)
and perceived size (p = 0.016) than control group

5
 6
Table 1 (Continued )

Author and evidence Sample characteristics Treatment Measurement Result

McKenzie and Kalda [14] N = 14 All patients: compression sleeve (day) Before and after 8 weeks: Oedema volume: 0% exercise group versus
Level II Inclusion: unilateral oedema after Exercise group (N = 7): arm exercises Arm volume: volumeter +6% control group (p > 0.050)
Pedro: 2 breast cancer, 2–8 cm difference with elastic sleeve: 8 weeks, 3/week Quality of life: SF-36 Quality of life: no difference (p > 0.050)
Control group (N = 7): /

Bandage
Badger et al. [16] N = 78 All patients: elevation, exercises, skin Before and after 18 days and Oedema volume: after 19 days: 34%
Level II Inclusion: unilateral upper care, self-massage 24 weeks: group B/H versus 10% group H (p < 0.050);
Pedro: 6 (N = 54) or lower (N = 29) Group B/H (N = 32): bandage Arm volume: perometer after 24 weeks: 33% group
limb oedema, >20% difference during 18 days, 24 h/day, B/H versus 20% group H (p < 0.050)

N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9
replaced each day, hosiery after 18 days
Group H (N = 46): immediately hosiery

Compression sleeve
Hornsby et al. [17] N = 25 All patients: exercise, information about Before and after 4 weeks: Oedema volume: 23% experimental
Level II Inclusion: oedema skin care, self-massage,4 weeks Arm volume: volumeter group versus +1% control group (p = 0.150)
Pedro: 3 after breast cancer Experimental group (N = 14):
compression sleeve day and night
Control group (N = 11): /

Intermittent Pneumatic Compression (IPC)

Berlin et al. [20] N = 55 All patients: elastic sleeve, 25–50 mmHg, 4 weeks Before and after 4 weeks: Oedema volume: no difference
Level III-2 Inclusion: unilateral or bilateral oedema Group A (N = 28): / Arm volume: volumeter
Pedro: / after breast cancer, >100 ml increase of Group B (N = 8): IPC with Flowtron, one chamber,
preoperative arm volume 20 min, daily, 80 mmHg
Group C (N = 19): IPC with Lympha Press,
different overlapping chambers, 20–30 min,
twice daily, 90–120 mmHg

Dini et al. [18] N = 80 All patients: guidelines about skin care Before and after 9 weeks: Oedema circumference: 12%
Level II Inclusion: unilateral Experimental group (N = 40): IPC 2 weeks, Arm circumference experimental group versus 3%
Pedro: 5 oedema, >10 cm difference 5 weeks rest, IPC 2 weeks, 2 h/day, 60 mmHg control group (p = 0.084)
Exclusion: prior oedema treatment Control group (N = 40): /

Johansson et al. [19] N = 24 All patients: elastic sleeve for 4 weeks Before, after 2 and 4 weeks: Oedema volume after 2 weeks:
Level II Inclusion: unilateral oedema after After 2 weeks: Group MLD (N = 12): Arm volume: volumeter 7%; after 4 weeks: 15% group MLD
Pedro: 4 breast cancer, >10% difference MLD, 45 min/session, 2 weeks, 5/week Shoulder mobility: goniometer versus 7% group IPC (p = 0.360)
Group IPC (N = 12): IPC, 40–60 mmHg, Muscle strength: Shoulder mobility, muscle strength,
2 h/session, 2 weeks, 5/week gripping force Symptoms subjective symptoms: no difference

Szuba et al. [7] N = 23 All patients: 10 days CPT and 30 days Before and after 10 and 40 days: Oedema volume: after 10 days: 45%
Level II Inclusion: unilateral oedema after compression sleeve and self-MLD Arm volume: volumeter group CPT/IPC versus 26% group CPT
Pedro: 5 breast cancer, >20% difference Group Tissue elasticity: tonometer (p < 0.05); after 40 days: 30% group
CPT/IPC: Joint mobility: goniometer CPT/IPC versus 27% group CPT
10 days IPC, 30 min, 40–50 mmHg Group CPT: / (p > 0.05) Tissue elasticity and joint mobility:
no significant difference

Zanolla et al. [21] N = 60 All patients: elastic sleeve (during day) Before and after 3 months: Oedema volume 21% group 1 versus 5%
Level III-2 Inclusion: oedema after breast cancer and benzopyrones Arm circumference group 2 versus 25% group 3 (p > 0.050)
Pedro: / Group 1 (N = 20): IPC with uniform Mood: VAS Mood: no significant difference
pressure, 90 mmHg, 6 h/day, 1 week
Group 2 (N = 20): IPC with different
pressure, 160 mmHg, 6 h/day, 1 week
Group 3 (N = 20): MLD, 1h, 3/week, 4 weeks
 N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9 7

Table 2
Overview of PEDro score of the level II and III-1 studies.

Author Eligibility Allocation Baseline Blind Blind Blind Follow- Intention- Between-group Point estimates Total
criteriaa comparability subject therapist assessor up to-treat comparison and variability score
Random Concealed

Andersen et al. [11] + + + + + + + 6

Badger et al. [16] + + + + + + + 6
Didem et al. [8] + + + + + + + 6
Dini et al. [18] + + + + + 5
Hornsby [17] + + + 3
Johansson et al. [13] + + + + + 4
Johansson et al. [19] + + + + + 4
McKenzie and Kalda [14] + + 2
McNeely et al. [10] + + + + + + + + 7
Szuba et al. [7] + + + + + + 5
Williams et al. [12] + + + + 3
a
Eligibility criteria does not contribute to the total score on 10.

therapist, to a standard physiotherapy program consisting of
elevation, exercises and bandaging, performed by the patient
herself at home (PEDro score of 6, see Tables 1 and 2). The patients
who received Combined Physical Therapy had a significantly
higher arm oedema reduction in comparison to the other patients
( 56% versus 36%, p < 0.05).
Another study (non-randomised experimental trial) examined
the effect of a combined physical treatment, but not applied as the
classic form of Combined Physical Therapy [9]. They compared
three groups and the treatment was applied for 4 weeks. The first
group received a manual massage and a massage with a vibrator 5
times a week for 15 min, performed grip exercises 5 times a week
for 20 min and wore an elastic sleeve every day during day-time.
The second group had the same treatment but also received
warmth on the arm (55 8C) 5 times a week for 20 min. The third
group had, in addition to the treatment of the first group, also
worn an elastic sleeve day and night. The oedema reduction was
21%, 28% and 30% respectively after 4 weeks of treatment. In the
weekend the oedema often increased. In the first week, the
treatment was most effective, in the second week it was half as
effective and in the last 2 weeks the effect was the lowest.
3.1.1. Skin care
The effectiveness of skin care is not investigated by a
randomised controlled trial.
3.1.2. Manual Lymphatic Drainage
Three level II studies and one level III-1 study have investigated
the effectiveness of Manual Lymphatic Drainage (see Table 1). The
two studies of the highest quality could not show an additional
effect of Manual Lymphatic Drainage, additional to bandaging and
skin care [10] or to wearing a compression sleeve and to receiving
information [11]. McNeely et al. [10] made subgroups of patients
with mild, moderate and severe lymphoedema and compared the
effect of Manual Lymphatic Drainage, bandaging and skin care to
bandaging and skin care alone. They found that the reduction was
significantly higher in the group with mild lymphoedema who
received Manual Lymphatic Drainage, skin care and bandaging
than in the group with mild lymphoedema who only received skin
care and bandaging. This significant difference was not noticed in
the group with moderate or severe lymphoedema. Williams et al.
[12] (PEDro score of 3) compared Manual Lymphatic Drainage
performed by a Vodder specialist to a simplified form of lymphatic
drainage performed by the patient herself. The Manual Lymphatic
Drainage group had a borderline significant higher reduction of
arm oedema than the group who had the simplified form ( 10%
versus 4%, p = 0.053). Patients with Manual Lymphatic Drainage
had also a significant improvement of emotional functioning,
dyspnoea and sleep disturbances and had a significant improve-
ment of all arm symptoms (pain, discomfort, heaviness, fullness,
bursting and hardness). In the study of Johansson et al. [13] (PEDro
score of 4) all patients wore a multi-layer bandage for 3 weeks and
one of two groups received also Manual Lymphatic Drainage in the
third week. After 2 weeks, lymphoedema reduction was equal for
both groups. After the third week, the group with Manual
Lymphatic Drainage had a significant higher reduction of
lymphoedema ( 11%) than the group without Manual Lymphatic
Drainage ( 4%) (p = 0.040). The reduction of subjective symptoms,
such as pain, heaviness and tension was equal for both groups. In
all studies, Manual Lymphatic Drainage was performed by a
specialist and the duration of one session was between 45 min and
1 h. In the four studies, the number of sessions varied from 5 [13] to
8 [11] to 15 [12] and to 20 [10].
3.1.3. Exercises
One randomised controlled pilot study of low quality (PEDro
score 2) has examined the effectiveness of exercises for the
treatment of lymphoedema (see Table 1) [14]. Lymphoedema
volume did not change, neither in the exercises group, who wore
an elastic sleeve and performed resistance exercises 3 times a week
for 8 weeks, nor in the control group, who only wore an elastic
sleeve. In contrast, in the study of Moseley et al. [15], which is a
controlled but non-randomised study, the patients had after 1
month performing exercises twice a day for 10 min (N = 24) more
(non-significant) reduction of lymphoedema volume compared to
the patients who did not perform the exercises (N = 28) (9% versus
0%, p = 0.211). They had significantly more impression of the
anterior thorax with the tonometer (+1.0 versus 0.4; p = 0.005)
and had less subjective symptoms as heaviness (p = 0.044) and
perceived size (p = 0.016).
3.1.4. Multi-layer bandaging
One RCT exists about the effectiveness of multi-layer bandaging
in comparison to hosiery (see Table 1) [16]. All patients received
limb elevation, exercises, skin care and self-massage. The first
group wore a bandage for 18 days. After 18 days they started to
wear a compression sleeve (upper limb) or garment (lower limb).
The second group wore a compression sleeve or garment from the
start. Patients with bandages had a higher lymphoedema reduction
immediately after the treatment and at long-term follow-up. This
study is of good quality (6 on PEDro scale) but the patient group is
heterogeneous. Patients with lymphoedema of the upper and
lower limb of different causes were included.
3.1.5. Compression sleeve
An RCT of Hornsby [17] investigated the effect of wearing a
compression sleeve during the intensive phase (see Table 1, PEDro
score 3). All patients received information about lymphoedema
8 N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9
and performed exercises, self-massage and skin care during 4
weeks. One group also wore a compression sleeve. Lymphoedema
reduction was (not significantly) higher in the patient group who
wore a compression sleeve compared with the other group ( 23%
versus +1%, p = 0.150).
No RCT exists about the effectiveness of wearing a compression
sleeve during the maintenance phase.
3.2. Intermittent Pneumatic Compression
Three level II studies exist about the effectiveness of Intermit-
tent Pneumatic Compression (see Table 1). In the study of Szuba
et al. [7] (PEDro score of 5) all patients received Combined Physical
Therapy for 10 days. One group also received Intermittent
Pneumatic Compression for 30 min a day. For the next 30 days,
the reduction of lymphoedema was maintained by wearing a
compression sleeve and self-drainage for both groups. After 10
days, patients with Combined Physical Therapy and Intermittent
Pneumatic Compression had a significantly higher reduction of
lymphoedema volume ( 45%) compared to patients who had only
Combined Physical Therapy ( 26%) (p < 0.050). In the mainte-
nance phase, the additional effect of Intermittent Pneumatic
Compression disappeared and after 30 days both groups had equal
amount of lymphoedema reduction ( 30% versus 27%,
p > 0.050). Dini et al. [18] (PEDro score of 5) examined the
additional effect of 20 sessions Intermittent Pneumatic Compres-
sion for 2 h a day on skin care. After 9 weeks, patients who had
Intermittent Pneumatic Compression and skin care had a border-
line significantly higher lymphoedema reduction ( 12%) com-
pared to patients who only had skin care ( 3%) (p = 0.084). They
did not follow up their patients further. The third RCT (PEDro score
of 4) compared the effectiveness of Manual Lymphatic Drainage
and wearing a compression sleeve to Intermittent Pneumatic
Compression and wearing a compression sleeve [19]. After 2
weeks, patients with Manual Lymphatic Drainage had an
additional reduction of lymphoedema volume of 15% and patients
with Intermittent Pneumatic Compression had an additional
reduction of 7% (p = 0.360). Furthermore, Berlin et al. [20]
performed a non-randomised experimental trial. All patients
received a compression sleeve; one group received additionally
one-chamber Intermittent Pneumatic Compression, a second
group received multi-chamber Intermittent Pneumatic Compres-
sion and these two groups were compared to a third group who did
not receive Intermittent Pneumatic Compression. There was no
significant difference in lymphoedema reduction between the
three groups. Another non-randomised experimental trial was
performed by Zanolla et al. [21]. The oedema circumference was
significantly decreased by 21% in the group with uniform
compression therapy with lower pressure (90 mmHg) and non-
significantly decreased by 5% in the group with different
compression therapy with higher pressure (160 mmHg). The
therapy was applied during 1 week for 6 h a day. Pressure of
Intermittent Pneumatic Compression ranged between 40 mmHg
and 60 mmHg for the level II studies [7,18,19] and between
80 mmHg and 160 mmHg for the other studies [20,21].
3.3. Elevation
No controlled study exists about the effectiveness of arm
elevation for the treatment of lymphoedema.
4. Discussion
This review article gives an overview of the effectiveness of the
physical treatment, i.e. Combined Physical Therapy and its
different parts, Intermittent Pneumatic Compression and arm
elevation, of lymphoedema developing after axillary dissection for
breast cancer.
From 15 studies meeting the inclusion and exclusion criteria,
only 11 studies were (pseudo-) randomised controlled trials
(RCTs). Moreover, the quality of the major part of the (pseudo-)
RCTs was poor. Only 4 of 11 studies had a score of 6 or 7 on the
PEDro scale. In none of the studies was the subject or the therapist
blinded to the type of treatment. In only one study was the assessor
blinded. In addition, in only 3 of 11 studies was the allocation to the
treatment group concealed and in only 3 of 11 studies were
intention-to-treat analyses applied.
It can be supposed that Combined Physical Therapy is an
effective treatment modality for arm lymphoedema developing
after axillary dissection. Patients with Combined Physical Therapy
performed by a specialist had 20% higher reduction of lymphoe-
dema volume compared to a placebo Combined Physical Therapy
performed by the patient herself [8]. The quality of this study was
acceptable. According to Swedborg [9] Combined Physical Therapy
was most effective the first week and the oedema volume
decreased less towards the end of the fourth week of the intensive
treatment. They also concluded that the treatment sessions should
preferably be given daily and breaks at weekends should be
avoided. These are findings from only one older study and have to
be confirmed by other studies.
The effectiveness of the different parts of Combined Physical
Therapy will be successively discussed. The effectiveness of skin
care has not been examined by controlled studies. The effect of
exercise on the lymphoedema volume is not obvious. Firstly, a high
qualitative RCT is missing. Secondly, the results of two studies with
low quality are conflicting. The effectiveness of Manual Lymphatic
Drainage is well investigated but there is conflicting evidence. Two
RCTs [10,11] of moderate to high quality do not show an effect of
Manual Lymphatic Drainage, whereas results from one RCT [12]
and one pseudo-RCT [13], both of low quality, show an additional
beneficial effect from Manual Lymphatic Drainage on lymphoe-
dema volume reduction. McNeely et al. [10], although finding no
overall beneficial effect from Manual Lymphatic Drainage,
analysed subgroups of patients and found that patients with mild
lymphoedema in the group with Manual Lymphatic Drainage had a
larger reduction than patients with mild lymphoedema in the
group without Manual Lymphatic Drainage. So, based on the
conflicting findings among these studies, further study is
warranted to determine the relative benefit of Manual Lymphatic
Drainage. Hornsby [17] could not statistically prove the effective-
ness of a compression sleeve for the treatment of lymphoedema.
The study was of low quality and they included a limited number of
patients (N = 25). Badger et al. [16] have proven in a moderate
quality study the effectiveness of bandaging and this in compari-
son with hosiery. This study included patients with all different
causes of lymphoedema of both the lower and the upper limb. So,
the exact effect of bandaging on lymphoedema developing after
axillary dissection for breast cancer is not known. There exists no
scientific evidence to support or refute the use of a compression
sleeve during the maintenance phase of Combined Physical
Therapy.
The effectiveness of Intermittent Pneumatic Compression is
well investigated. Two RCTs, both of moderate quality, showed a
significant short-term effect of Intermittent Pneumatic Compres-
sion on lymphoedema reduction [7,18] but in the long term, the
effect could not be maintained [7]. Another study concluded that
Intermittent Pneumatic Compression is as effective as Manual
Lymphatic Drainage [19].
Due to a lack of high-quality studies it is difficult to make
conclusions and offer recommendations about the different
physical treatment modalities discussed in this review. One
placebo-controlled study of moderate quality has proven that
 N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9
Combined Physical Therapy is effective for the treatment of
lymphoedema after axillary dissection for breast cancer. This has
to be further confirmed by other high-quality studies. Scientific
evidence on bandaging exists, although the study was of moderate
quality and the study group consisted of patients with upper and
lower lymphoedema. The effect of bandaging has to be further
examined on only breast cancer patients with arm lymphoedema.
Further research on the effectiveness of skin care, exercises and
wearing an elastic sleeve is necessary. Two studies with acceptable
quality could not prove the effectiveness of Manual Lymphatic
Drainage, so this treatment modality also has to be further
investigated. Intermittent Pneumatic Compression is an effective
treatment modality for lymphoedema at short term. These studies
were of moderate quality. High-quality studies with long-term
application of Intermittent Pneumatic Compression at lower
pressures are needed.
Requirements for new studies are high-quality randomised
controlled trials in which enough patients are included, in which a
power analysis is performed, in which besides the lymphoedema
volume the arm symptoms and quality of life are also analysed and
in which subgroups of patients with lymphoedema are analysed.
Acknowledgements
None.
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