Conservative treatment of lymphedema: the state of the art.

This article aims to discuss the possibilities of conservative and non-pharmacological treatments for lymphedema. A non-systematic review of the literature was carried out, including studies involving human subjects with different types of lymphedema. Several approaches to lymphedema treatment have been reported and Complex Decongestive Therapy (CDT) has been considered the most effective treatment for limb lymphedema. Other conservative treatments have been proposed such as Taping, Extracorporeal Shock Wave Therapy, Acupuncture, Photobiomodulation Therapy, Endermologie, Intermittent Pneumatic Compression, and Low-frequency, Low-intensity Electrotherapy. The choice of the therapeutic approach to be employed should consider lymphedema characteristics, the therapist's experience, and the patient's wishes. In addition, since this is a chronic condition, the patient must adhere to the treatment. To this end, the therapeutic proposal may be the key to better control of limb volume.

Este artigo tem como objetivo discutir as possibilidades de tratamentos conservadores e não medicamentosos para o linfedema. Foi realizada uma revisão não sistemática da literatura, com a inclusão de estudos realizados em humanos com diferentes tipos de linfedema. Várias abordagens de tratamento foram relatadas, sendo a terapia descongestiva complexa considerada o tratamento mais eficaz para o linfedema de membros. Outros tratamentos conservadores foram propostos, como taping, terapia por ondas de choque extracorpórea, acupuntura, fotobiomodulação, endermologia, compressão pneumática intermitente e eletroterapia de baixa intensidade e baixa frequência. A escolha da abordagem terapêutica a ser empregada deve considerar as características do linfedema, a experiência do terapeuta e os desejos do paciente. Além disso, como é uma condição crônica, o paciente deve aderir ao tratamento. Para isso, a proposta terapêutica pode ser a chave para um melhor controle do volume do membro.

Agreement Between Optoelectronic Volumetry and Circumferential Girth Measurements to Diagnose Lymphedema in Patients Submitted to Axillary Radical Lymphadenectomy for Treatment of Cutaneous Melanoma.

Background: To assess the agreement between indirect and optoelectronic volumetries to diagnose lymphedema based on arm volume difference in patients with axillary lymph node dissection (ALND) for cutaneous melanoma. Methods and Results: Patients were assessed by circumferential girth measurements (truncated cone formula) to determine the upper limb volumes (indirect volumetry) and by optoelectronic volumetry (Perometer®) of affected and control limbs. A diagnosis of lymphedema on each measuring method was defined as an absolute volume difference >200 mL or a relative volume >10%. Forty-six patients with ALND were included. There were no significant differences between the volume means or the mean absolute or relative differences measured by each method. Good correlation was observed between the volume of upper limbs for both the left (r = 0.998) and right (r = 0.985) arms. As for the diagnosis of lymphedema, an absolute volume difference >200 mL determined a prevalence of 28% (13/46) of lymphedema by indirect volumetry and 35% (16/46) by optoelectronics volumetry. The crude diagnostic agreement was 93% with a kappa = 85% (agreement adjusted by chance) between methods. If a 10% increase in the relative volume difference between the arms was used as the diagnostic criterion, prevalence was 20% (9/46) and 22% (10/46), respectively. Conclusion: There is good agreement between perometry and circumferential girth measurements when classifying patients as having a difference between arm volumes >200 mL or 10%, the most frequently used cutoffs to diagnose lymphedema.

Conservative treatment of lymphedema: the state of the art / Tratamento conservador do linfedema: estado da arte

Abstract This article aims to discuss the possibilities of conservative and non-pharmacological treatments for lymphedema. A non-systematic review of the literature was carried out, including studies involving human subjects with different types of lymphedema. Several approaches to lymphedema treatment have been reported and Complex Decongestive Therapy (CDT) has been considered the most effective treatment for limb lymphedema. Other conservative treatments have been proposed such as Taping, Extracorporeal Shock Wave Therapy, Acupuncture, Photobiomodulation Therapy, Endermologie, Intermittent Pneumatic Compression, and Low-frequency, Low-intensity Electrotherapy. The choice of the therapeutic approach to be employed should consider lymphedema characteristics, the therapist's experience, and the patient's wishes. In addition, since this is a chronic condition, the patient must adhere to the treatment. To this end, the therapeutic proposal may be the key to better control of limb volume.

Resumo Este artigo tem como objetivo discutir as possibilidades de tratamentos conservadores e não medicamentosos para o linfedema. Foi realizada uma revisão não sistemática da literatura, com a inclusão de estudos realizados em humanos com diferentes tipos de linfedema. Várias abordagens de tratamento foram relatadas, sendo a terapia descongestiva complexa considerada o tratamento mais eficaz para o linfedema de membros. Outros tratamentos conservadores foram propostos, como taping, terapia por ondas de choque extracorpórea, acupuntura, fotobiomodulação, endermologia, compressão pneumática intermitente e eletroterapia de baixa intensidade e baixa frequência. A escolha da abordagem terapêutica a ser empregada deve considerar as características do linfedema, a experiência do terapeuta e os desejos do paciente. Além disso, como é uma condição crônica, o paciente deve aderir ao tratamento. Para isso, a proposta terapêutica pode ser a chave para um melhor controle do volume do membro.

Efficacy of exercise therapy during radiotherapy to prevent reduction in mouth opening in patients with head and neck cancer: A randomized controlled trial.

OBJECTIVE: The aim of this study was to compare the efficacy of 2 protocols of exercise therapy to avoid reduction in mouth opening (MO) in patients undergoing radiotherapy for head and neck cancer. STUDY DESIGN: This was a randomized, controlled, double-blind, 3-arm, parallel-group, prevention clinical trial. Ninety patients were randomized into 3 groups to perform exercises during radiotherapy treatment: intervention group 1 (G1); intervention group 2 (G2); and control group (CG). Maximum MO was measured before (T0), immediately after (T1), and at 12 months (T2) after completion of radiotherapy treatment. Generalized estimating equations model complemented by the least significant difference test was applied to group comparisons. RESULTS: There was no significant difference in MO measure between the groups at the 3 assessment time points (P = .264). The difference in MO measure from baseline to 12 months after having completed radiotherapy was -1 mm in CG (95% confidence interval [CI] -4.0 to 2.0); 1.3 mm in G1 (95% CI -1.7 to 4.3); and 0.5 mm in G2 (95% CI -3.4 to 4.4). CONCLUSIONS: It was not possible to conclude that the exercise protocols performed in this study are more effective than the usual guidance to prevent reduction in MO in patients undergoing radiotherapy for head and neck cancer.

USE OF COMPRESSION GARMENT IN THE TREATMENT OF MALIGNANT LYMPHEDEMA IN A PATIENT WITH RECURRENT BREAST CANCER: CASE REPORT / Utilização de vestimenta compressiva no tratamento do linfedema maligno em paciente com câncer de mama recidivado: relato de caso

Introduction: Malignant lymphedema is a rapidly progressive condition, and its treatment is a major challenge. Objective: To demonstrate the benefit of using compression garments in reducing limb volume and improving the symptoms of a patient with malignant lymphedema with recurrent breast cancer. Case report: A 67-year-old woman, diagnosed with a 2.3 cm, triple negative, invasive ductal carcinoma in the left breast, submitted to quadrantectomy with axillary dissection (T2aN1bM0). The patient developed benign lymphedema after eight years of surgery, but only started complex decongestive physiotherapy three years after the diagnosis, presenting an important improvement. The following year, the patient returned with complaints of worsening lymphedema. At the examination, there was an expressive volume increase and areas of vascular alteration in the left upper limb (LUL) and in the anterior quadrant of the thorax. The exams confirmed axillary vein thrombosis due to tumor obstruction. Lymphoscintigraphy showed unsatisfactory lymphatic drainage. As a last treatment option, the use of LUL low elastic compression garment was adopted, after poor success after the use of multi-layered compression bandages. LUL volume was 6,158.1 mL prior to using the garment. After ten days of continuous use, the volume decreased to 5,174.2 mL. In the last evaluation, the volume was 4,510.8 mL, presenting a reduction of 1,647.3 mL (26.7%). The patient developed acute respiratory failure caused by pleural metastasis, and died. Conclusion: The compression garment provided benefits such as significant improvement in the feeling of heaviness in the limb due to the reduction of volume and in the ease of putting on and taking off the garment in or make the hygiene, when compared to the multilayer compression bandages. Other advantages were the reduction of costs and the promotion of well-being.

Introdução: O linfedema maligno é uma condição com rápida progressão, e seu tratamento é um grande desafio. Objetivo: Demonstrar o benefício do uso de vestimenta compressiva na redução do volume do membro e na melhora dos sintomas de uma paciente com linfedema maligno após câncer de mama recidivado. Relato de caso: Colocar paciente de 67 anos, sexo feminino, com diagnóstico de carcinoma ductal invasor em mama esquerda com 2,3 cm e triplo negativo, submetida a quadrantectomia com esvaziamento axilar (T2aN1bM0). A paciente desenvolveu linfedema benigno após oito anos de cirurgia, porém só iniciou tratamento fisioterapêutico com terapia física complexa descongestiva três anos após o diagnóstico, apresentando melhora importante. No ano seguinte, retornou ao consultório com queixa de piora do linfedema. Ao exame, apresentava aumento de volume expressivo e áreas de alteração vascular no membro superior esquerdo (MSE) e no quadrante anterior do tórax. Os exames confirmaram trombose de veia axilar por obstrução tumoral. A linfocintilografia demonstrou ausência de drenagem linfática satisfatória. Adotou-se, como última opção de tratamento, o uso da vestimenta compressiva de baixa elasticidade de MSE, após baixa resposta do enfaixamento compressivo multicamadas. O volume do MSE era de 6.158,1 mL antes do uso da vestimenta. Após dez dias contínuos de uso, o volume diminuiu para 5.174,2 mL. Na última avaliação, o volume era de 4.510,8 mL, apresentando redução de 1.647,3 mL (26,7%). A paciente evoluiu com insuficiência respiratória aguda ocasionada por metástase pleural à direita, vindo a falecer. Conclusão: A vestimenta proporcionou benefícios como melhora importante da sensação de peso no membro devido à redução de volume e facilidade em colocar e retirar a vestimenta para fazer a higiene, quando comparada ao enfaixamento compressivo multicamadas. Outras vantagens foram a redução de custos e a promoção do bem-estar.

Validação do instrumento "questionário de funcionalidade, incapacidade e saúde do linfedema de membros inferiores" e avaliação com volumetria opto-eletrônica em pacientes com linfedema secundário ao tratamento oncológico / Lymphoedema functioning, disability and health questionnaire portuguese version: validation in oncologic lymphedema population

Introdução: O linfedema de membros inferiores é um dos efeitos adversos mais incapacitantes do tratamento do câncer e pode afetar a qualidade de vida (QV). A volumetria optoeletrônica (VOPE) é um método não invasivo moderno para detectar o linfedema. Este artigo descreve a validação do Questionário de Funcionalidade, Incapacidade e Saúde do Linfedema para Linfedema de Membro Inferior (Lymph-ICF-LL) em pacientes com linfedema secundário ao câncer e avaliação com VOPE. Objetivo: O primeiro objetivo deste estudo foi determinar a validade do Questionário de Funcionalidade, Incapacidade e Saúde do Linfedema de Membro Inferior (Lymph-ICF-LL) como uma escala de sintomas para linfedema de membros inferiores em pacientes oncológicos após 6 meses de cirurgia linfonodal. O segundo objetivo foi comparar métodos de avaliação de volume de membros utilizando métodos objetivos, medidas de circunferência e avaliação clínica. Métodos: 84 pacientes com câncer ginecológico ou melanoma cutâneo com e sem presença de linfedema de membros inferiores completaram a avaliação clínica, questionário de QV e volumetria da perna com perimetria com fita métrica e 55 destes pacientes foram também avaliados com volumetria optoeletrônica. Resultados: A mediana do score total do questionário entre foi de 15 e a média foi 22.A média do score para pacientes portadores de linfedema foi significamente maior que para os não portadores, 31,54 (IC 25,84 e 37,22) e 2,55 (IC 1.04 e 4.06) respectivamente (p< 0,0001). Quanto pior o grau de linfedema, pior a qualidade de vida (p<0,0001). O volume do MID na PM apresentou média de 7743 ml e mediana de 7318 ml e na VOPE média de 8134 ml e mediana de 8307 ml. A concordância observada entre os dois métodos, pelo coeficiente de correlação de Pearson, foi de 0,79 (moderada). A média e o desvio padrão da diferença entre as medidas da VOPE e perimetria para perna esquerda e direita foi de 77 ml (dp +-1793 ml) e 54 ml (dp+- 1331 ml) e seus limites de concordância -7664 ml a 3193ml e -2928 ml a 2958 ml respectivamente. A diferença absoluta média foi de 42 ml (dp +- 1211 ml) com limites de concordância entre -1211 ml a 2747ml e a diferença relativa foi de 1,08 (dp 6,26) e seus limites de concordância -22,03 e 9,17. A volumetria indireta pela perimetria teve forte correlação (k=0.5823) com a avaliação clínica subjetiva do especialista em linfedema Conclusão: O Questionário de Funcionalidade, Incapacidade e Saúde do Linfedema para Linfedema de Membro Inferior (Lymph-ICF-LL) é uma válida ferramenta específica de QV em portadores de linfedema que pode ser usada em pacientes com linfedema secundário oncológico. Existe considerável viés de medição entre a perimetria e a volumetria optoeletrônica; seus resultados devem ser comparados com cautela, uma vez que não são intercambiáveis

Background: Lower-limb lymphedema (LLL) is one of the most disabling adverse effects of cancer treatment and can impact Quality of life (QoL). Optoelectronic volumetry (OPVO) is a modern non-invasive method to detect lymphedema. This paper describes the validation of Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) in patients with LLL secondary to cancer and OPVO evaluation. Objective: The first aim of this study was to determine the validity of Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) as a symptom scale for lower limb lymphedema in oncologic patients after 6 months of lymph node surgery.The second aim was to compare leg volume assessment using objective methods, circumference measurements and clinical evaluation. Methods: 84 gynecologic cancer and cutaneous melanoma survivors with and without lymphedema completed the clinical evaluation, Lymph-ICF-LL and lower limb volume evaluation with perimetry and 55 patients were also evaluated with optoelectronic volumetry. Results: The median total score of the questionnaire was 15 and the average was 22. The mean score for lymphedema patients was significantly higher than for non-lymphedema patients, 31.54 (CI 25.84 and 37.22) and 2.55 (CI 1.04 and 4.06) respectively (p <0.0001). The worse the degree of lymphedema, the worse the quality of life (p <0.0001). The average PM volume was 7743 ml and a median of 7318 ml, and the average VOPE of 8134 ml and a median of 8307 ml. The agreement observed between the two methods by Pearson's correlation coefficient was 0.79 (moderate). The mean and standard deviation of the difference between left and right leg VOPE and perimeter measurements were 77 ml (dp + -1793 ml) and 54 ml (dp + - 1331 ml) and their limits of agreement -7664 ml to 3193ml and -2928 ml to 2958 ml respectively. The mean absolute difference was 42 ml (dp + - 1211 ml) with agreement limits between -1211 ml and 2747 ml and the relative difference was 1.08 (dp 6.26) and their agreement limits -22.03 and 9.17. Indirect volume perimetry was strongly correlated (k = 0.5823) with the subjective clinical assessment of the lymphedema specialist. Conclusion: Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) is as validated condition-specific tool of QoL, which can be used for oncology secondary lymphedema. There is a considerable measurement bias between perimetry and optoelectronic volumetry, its results should be compared with caution since they are not interchangeable

Agreement between Perometry and Sequential Arm Circumference Measurements in Objective Determination of Arm Volume.

BACKGROUND: Limb circumference measurements (CM) and perometry are the preferred methods for objectively measuring arm volume in lymphedema surgery research. Understanding the measurement bias involved in these measuring systems is important to properly interpret and compare studies and their results. METHODS: Arm volumes from 91 patients were measured using sequential girths and the truncated cone formula (CM) and with the use of an automated perometer (perometry). The absolute volume of the largest arm (V), the volume difference between the arms (VD), and the relative difference between them (percentage of excess volume [PEV]) were calculated with both methods. The agreement between methods was assessed by the Pearson's correlation test and the Bland-Altman's method. RESULTS: Correlations were strong for V (r = 0.99), VD (r = 88), and PEV (r = 0.86). Volumes measured by perometry were, on average, 10.6 mL smaller than volumes calculated from CM, while their limits of agreement (LOA) ranged from -202 to 181 mL. The LOA represents the range we could expect the arm volumes measured with the two methods to differ by chance alone, 95% of the times. For VD, LOA was -101 to 141 mL, with a mean difference of 19.9 mL, while PEV had a mean difference of 0.9%, with LOA ranging from -5 to 6.8%. CONCLUSION: There is considerable measurement error between arm volume estimated by perometry and by CM. Volumes calculated with these methods should be compared with caution. Furthermore, we observed an increasingly relevant measurement bias in outcomes that are mathematically derived from arm volumes.

THE VALIDITY OF AN ADJUSTABLE COMPRESSION VELCRO WRAP FOR THE TREATMENT OF PATIENTS WITH UPPER LIMB LYMPHEDEMA SECONDARY TO BREAST CANCER: A PILOT STUDY / Validação de uma vestimenta de contenção para tratamento de linfedema de membro superior secundário ao câncer de mama: estudo piloto

Objective: To analyze the efficacy of an adjustable compression Velcro wraps used to reduce limb volume as a form of treatment for upper limb lymphedema secondary to breast cancer. Methods: Women with lymphedema who had already undergone conventional treatment with compression bandaging were included. These patients were recruited through an evaluation in which the manual perimetry was applied using the truncated cone formula, and in which lymphedema were considered as a difference greater than 10% and/or 200 mL between the limbs. Patients wore their compression devices daily, taking them off only for a shower. In a period of one month of use, manual lymphatic drainage was not applied. Performing exercises was allowed 3 times a day. Patients returned after one month to have their limb volume reassessed and also to respond to a questionnaire. Results: A total of 9 patients were evaluated, and the median volume difference between the affected limb and the control during the first evaluation was 564.4 (SD=443.2) mL. At the reevaluation, the median difference was 390.6 (SD=306.8) mL. There was a significant difference when comparing the volumes at the evaluation and reevaluation (p=0.008). The degree of satisfaction was 9 (SD=1.3). Conclusion: The adjustable compression Velcro wrap was effective in the reduction of limb volume in with lymphedema. In addition, the patients reported that the device was more practical and more comfortable compared to the compression

Objetivo: A nalisar a eficácia de uma vestimenta de contenção em velcro para redução do volume do membro como forma de tratamento de linfedema de membro superior secundário ao esvaziamento axilar por câncer de mama. Métodos: Foram incluídas mulheres com linfedema que já tivessem realizado o tratamento convencional com enfaixamento compressivo. O recrutamento dessas pacientes foi através da avaliação com a perimetria manual aplicada na fórmula do cone truncado, considerando linfedema uma diferença maior que 10% e/ou 200 mL entre os membros. As pacientes deveriam utilizar diariamente a vestimenta, só retirando para tomar banho. Nesse período de um mês de uso, não deveriam fazer drenagem linfática manual, e sim apenas exercícios linfomiocinéticos três vezes ao dia. A s pacientes retornaram após um mês para a reavaliação do volume do membro e também responderam a um questionário. Resultados: Foram avaliadas 9 pacientes, sendo que a mediana de diferença de volume entre o membro afetado e o controle na primeira avaliação foi de 564,4 (DP=443,2) mL. Na reavaliação, a mediana da diferença foi de 390,6 (DP=306,8) mL. Houve diferença significativa quando comparados os volumes na avaliação e na reavaliação (p=0,008). O grau de satisfação da vestimenta foi de 9 (DP=1,3). Conclusão: A vestimenta mostrou-se eficaz como alternativa na redução do volume do membro com linfedema, e os pacientes relataram ser mais prática e proporcionar maior comodidade quanto comparada ao enfaixamento compressivo. Pacientes que moram em outras cidades ou que não têm disponibilidade para realizar tratamento diariamente podem se beneficiar do uso da vestimenta.