Background
About one in five people treated for breast cancer develop lymphoedema later on. We reviewed the available evidence to determine whether some methods, such as manual lymph drainage (a massage therapy), compression, exercise or only education could help prevent lymphoedema.
Study characteristicsThe evidence is current to May 2013. Ten studies were included: four studies used manual lymph drainage with usual care, or combined with exercise or compression versus usual care or education alone (395 participants); three studies examined early versus late start of postoperative shoulder exercises (378 people); two studies used either progressive resistance exercise or restricted activity (358 people); and one study investigated a physiotherapy care plan versus no physiotherapy (65 people). The duration of patient follow-up ranged from two days to two years after the intervention.
Key results
No firm conclusion can be drawn about the effect of manual lymph drainage in addition to exercise and education on preventing the incidence of lymphoedema. This is because the two included studies found contradicting results. In addition, no firm conclusion can be drawn about manual lymph drainage in combination with other interventions, because only two studies were found that each tested different combinations. One of these studies found that manual lymph drainage combined with exercise lowered the risk of lymphoedema. The other study combined manual lymph drainage with compression, but this study was too small to draw conclusions.
Arm mobility (i.e. reaching upwards over the head) was better after manual lymph drainage than without it, but this improvement lasted only for the first few weeks after breast cancer surgery.
When assessing whether early or late shoulder exercises reduced the likelihood of developing lymphoedema, the studies did not provide a clear result. The likely incidence of lymphoedema ranged from 5% to 27% (early start) compared to 4% to 20% (for delayed start) during the first 6 to 12 months after surgery. Starting shoulder exercises immediately after surgery may improve shoulder mobility in the first month, compared to starting after the first week but no firm conclusions can be drawn and mobility is comparable later on.
Progressive resistance training did not increase the risk of developing lymphoedema compared to restricted activity, on the basis that symptoms were monitored and treated immediately if they occurred.
For all investigated interventions, no firm conclusion can be drawn about their effectiveness in reducing pain or improving quality of life.
Quality of the evidence
The evidence was considered to be low quality, except for the evidence on resistance training, which was of moderate quality. This was because many studies had shortcomings in how they were conducted; there were only a small number of studies for each intervention; the results differed between comparable studies; and the groups studied were relatively small.
Authors' conclusions:
Based on the current available evidence, we cannot draw firm conclusions about the effectiveness of interventions containing MLD. The evidence does not indicate a higher risk of lymphoedema
when starting shoulder-mobilising exercises early after surgery
compared to a delayed start (i.e. seven days after surgery). Shoulder mobility
(that is, lateral arm movements and forward flexion) is better in the
short term when starting shoulder exercises earlier compared to later.
The evidence suggests that progressive resistance exercise therapy does not increase the risk of developing lymphoedema, provided that symptoms are closely monitored and adequately treated if they occur.
Given the degree of heterogeneity encountered, limited precision, and the risk of bias across the included studies, the results of this review should be interpreted with caution.
Given the degree of heterogeneity encountered, limited precision, and the risk of bias across the included studies, the results of this review should be interpreted with caution.