Circumferential Measurements to Calculate Lower Limb Volume in Persons with Lymphedema: What Segment Length Is to Be Recommended?

Background: Circumferential measurements (CMs) every 4th cm are commonly used to assess lower limb volume (LLV), but fewer measurements would be less time-consuming. The aim of this study was therefore to establish the agreement between LLV measurements derived from CM every 4th cm (V4), 8th cm (V8), and 12th cm (V12), and to evaluate the intrarater test-retest reliability for each of the three measurement methods in persons with lower limb lymphedema (LLL). Methods and Results: Forty-two persons with unilateral or bilateral LLL were measured twice, 2 weeks apart. Volume measurements for the V4, V8, and V12 methods were derived using CM. The agreement was evaluated using intraclass correlation coefficient (ICC3.1) and Bland-Altman graphs including 95% limits of agreement (LOA). The reliability was evaluated using ICC2.1 and standard error of measurement (SEM%) and smallest real difference (SRD%). The agreement was high for the V4 and V8 methods (ICC 0.999), and for the V4 and V12 methods (ICC 0.998). The graphs revealed slightly higher agreement between the V4 and V8 than between the V4 and V12 methods visualized by the 95% LOA (-117 to 62 and -236 to 132 mL, respectively). For all three measurement methods, the test-retest reliability was high (ICC 0.993-0.995) and the measurement error low (SEM%: 1.2%-1.4% and SRD%: 3.4%-3.8%). Conclusions: The higher agreement between the V4 and V8 methods than between V4 and V12, and the high test-retest reliability in LLV measurements support the V8 method to replace the V4 method in persons with LLL.

Impedance of Extracellular Fluid, Volume, and Local Tissue Water Can Be Reliably Measured in People With Lower Limb Lymphedema.

OBJECTIVE: Lower limb lymphedema (LLL) is a chronic condition. To be able to evaluate changes of LLL over time and effects of interventions, reliable measurement methods are important. Currently, there is limited knowledge of the reliability of commonly used measurement methods in LLL. The study objective was to evaluate the test-retest (intrarater) reliability of impedance of extracellular fluid, volume, and local tissue water measurements in people with unilateral or bilateral LLL and measurement errors both for a group of people and for a single individual. METHODS: Forty-two people with mild to moderate unilateral or bilateral, primary or secondary LLL were measured twice, 2 weeks apart. Impedance of extracellular fluid was measured by bioimpedance spectroscopy and calculated as arm-to-leg ratio, volume with circumference measurements every 4 cm, and local tissue water with tissue dielectric constant at 14 points. Test-retest reliability was evaluated using the intraclass correlation coefficient [ICC(2,1)], changes in the mean, SE of measurement in relative terms (SEM%), and the smallest real difference in relative terms (SRD%). RESULTS: For the impedance ratio, the reliability was high [ICC(2,1) = 0.79-0.90] and the measurement errors were acceptable (SEM% = 5.0%-5.2%; SRD% = 14.0%-14.4%). For volume, the reliability was high (ICC = 0.99) and the measurement errors were low (SEM% = 1.1%-1.7%; SRD% = 3.1%-4.6%). For the tissue dielectric constant, the reliability was fair to excellent [ICC(2,1) = 0.68-0.96] and the measurement errors were acceptable (SEM% = 4.2%-9.7%; SRD% = 11.7%-26.8%). CONCLUSIONS: Measurements of impedance of extracellular fluid, volume, and local tissue water are reliable in people with mild to moderate LLL. The measurement errors were acceptable in all 3 methods indicating that real, clinical changes in lymphedema can be measured both for a group of people and a single individual. IMPACT: The results from this test-retest reliability study can help clinicians and researchers to interpret if real clinical changes in lymphedema occur over time or after an intervention in people with mild to moderate LLL.

The Effect of Exercise for the Prevention and Treatment of Cancer-Related Lymphedema: A Systematic Review with Meta-analysis.

INTRODUCTION: The purpose of this systematic review and meta-analysis was to evaluate the effects of exercise on (i) the prevention of cancer-related lymphedema (CRL) and (ii) the treatment of CRL, lymphedema-associated symptoms, and other health outcomes among individuals with CRL. METHODS: An electronic search was undertaken for exercise studies measuring lymphedema and involving individuals at risk of developing or with CRL. The Effective Public Health Practice Project Quality scale was used to assess study quality, and overall quality of evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach. Meta-analyses were performed to evaluate effects of exercise on CRL incidence, existing CRL status, lymphedema-associated symptoms, and health outcomes. RESULTS: Twelve studies ( n = 1955; 75% moderate-high quality) and 36 studies ( n = 1741; 58% moderate-high quality) were included in the prevention and treatment aim, respectively. Relative risk of developing CRL for those in the exercise group compared with the nonexercise group was 0.90 (95% confidence interval (CI), 0.72 to 1.13) overall and 0.49 (95% CI, 0.28 to 0.85) for those with five or more lymph nodes removed. For those with CRL in the exercise group, the standardized mean difference (SMD) before to after exercise of CRL was -0.11 (95% CI, -0.22 to 0.01), and compared with usual care postintervention, the SMD was -0.10 (95% CI, -0.24 to 0.04). Improvements after intervention were observed for pain, upper-body function and strength, lower-body strength, fatigue, and quality of life for those in the exercise group (SMD, 0.3-0.8; P < 0.05). CONCLUSIONS: Findings support the application of exercise guidelines for the wider cancer population to those with or at risk of CRL. This includes promotion of aerobic and resistance exercise, and not just resistance exercise alone, as well as unsupervised exercise guided by symptom response.

Test-Retest Reliability of Volume and Local Tissue Water Measurements in Lower Limbs of Healthy Women and Men.

Background: Measurements of lower limb (LL) volume and local tissue water by tissue dielectric constant (TDC) are common in lymphedema management. Knowledge of normal variability in health subjects is important and can serve as a base for early lymphedema diagnosis but is currently lacking. The aim of this study was to evaluate test-retest reliability of LL volume and TDC values in healthy women and men. Methods and Results: Thirty-three women and 28 men were measured twice, 2 weeks apart. Volume was calculated from circumferential measurements every 4 cm and TDC in 14 points. Test-retest reliability was evaluated using intraclass correlation coefficient (ICC), changes in the mean, standard error of measurement in percentage (SEM%), and smallest real difference in percentage (SRD%). For volume, reliability was high (ICC 0.99) and measurement errors were low in both women and men (SEM%: 1.1%-1.3%; SRD%: 3.1%-3.6%). For TDC, reliability was fair to excellent in women (ICC 0.63-0.93) and poor to excellent in men (ICC 0.21-0.89). Measurement errors were acceptable in all points in women (SEM%: 3.9%-10.2%; SRD% 10.8%-28.2%), but only in 11 points in men (SEM%: 3.9%-14.5%; SRD%: 10.9%-40.1%). The points close to bone and tendons in men had lower reliability and higher measurement errors. Conclusion: Measurements of LL volume and TDC are reliable in healthy women and men; both methods can be recommended. However, TDC points close to bone and tendons in men should be used with caution.

Compression Treatment of Breast Edema: A Randomized Controlled Pilot Study.

Background: Patients treated for breast cancer with breast conserving surgery and radiotherapy (RT) often complain about swelling, heaviness, and pain in the treated breast. This pilot study was undertaken to examine if compression therapy was effective as an early treatment to reduce breast edema and symptoms assessed by Visual Analogue Scale (VAS). Methods and Results: Fifty-six breast cancer-treated women with breast edema, diagnosed by the measurement of tissue water content by tissue dielectric constant (TDC) technique 3 months post-RT, were randomized to either an intervention group, wearing a sports bra of compression type, or a control group, wearing a standard bra daily for 9 months when tissue water content in breast, upper arm, and lateral thorax of the operated side, and symptoms assessed by VAS were evaluated. No differences were found between the groups at start or end of study concerning tissue water content or VAS. However, within both groups, a significant reduction in tissue water content and experience of heaviness was found. Conclusion: Breast edema as well as experience of heaviness in the affected breast found at 3 months post-RT decreased after 9 months independent of whether a sports bra of compression type or a standard bra was used.

The effects of pole walking on arm lymphedema and cardiovascular fitness in women treated for breast cancer: a pilot and feasibility study.

The benefit of exercise for breast cancer-treated women is well documented. However, studies of cardiovascular fitness training for women with breast cancer-related arm lymphedema are rare. The purpose of this study was to investigate the effects of intensive pole walking on arm lymphedema in women treated for breast cancer. Thirty-five women with unilateral lymphedema were included and twenty-three completed an eight-week exercise intervention consisting of pole walking 3-5 times per week, for 30-60 min, at 70%-80% of their maximum heart rate, preceded by a two-week control period. Measurements of arm lymphedema (water displacement method), body weight, cardiovascular fitness (sub-maximal bicycle ergometer test) and subjective assessments (disability of the arm, shoulder and hand (DASH) questionnaire; heaviness and tightness using a visual analogue scale (VAS); and well-being) were performed before the control period and before and after the exercise intervention. The results indicated a significant reduction in total arm volume of the lymphedema arm (p = 0.001), in lymphedema absolute volume (p = 0.014) and lymphedema relative volume (p = 0.015). Significant decreases of heart rate (p = 0.004), DASH score (p = 0.053) and rating of tightness in the arm (p = 0.043) were found. Positive and negative influences on well-being were reported. The conclusion of this study is that pole walking is feasible for breast cancer-treated women with arm lymphedema.

Low rate of lymphedema after extended pelvic lymphadenectomy followed by pelvic irradiation of node-positive prostate cancer.

BACKGROUND: The aim of the present study was to evaluate the prevalence and severity of lower limb lymphedema after pelvic lymphadenectomy and radiotherapy to the pelvic lymph nodes in patients with prostate cancer. METHODS: Twenty-six patients underwent combined treatment for high-risk node-positive prostate cancer at Skåne University Hospital between April 2008 and March 2011. The treatment consisted of extended pelvic lymphadenectomy followed by androgen deprivation therapy and radiotherapy. The pelvic lymphnodes, prostate and seminal vesicles were treated with external beam radiotherapy (EBRT) to an absorbed dose of 50 Gy followed by a brachytherapy (BT) boost of 2x10 Gy to the prostate only. Twenty-two patients accepted an invitation to a clinical examination with focus on lower limb swelling. The median time between the end of radiotherapy and examination was 2.2 years (range 1.2-4.1). RESULTS: Six patients (27%) experienced grade 1 lymphedema and two patients (9%) grade 2 while none had grade 3 or 4 according to the CTC Common Toxicity Criteria scale 4.0. Three patients required treatment with compression stockings. CONCLUSION: Brachytherapy and pelvic EBRT have a low incidence of lymphedema (at median 2.2 y after treatment) in patients with high-risk node-positive prostate cancer that have undergone pelvic lymph node dissection.

Pole walking for patients with breast cancer-related arm lymphedema.

Arm lymphedema is a well-known side effect of breast cancer treatment. Studies of the effect of physical exercise on arm lymphedema are very rare. The purpose of this study was to investigate the influence of pole walking on breast cancer-related arm lymphedema when using a compression sleeve. Twenty-six women with unilateral arm lymphedema took part in a clinical study of pole walking on one occasion, 4 kilometers for 1 hour. Measurements were made before, immediately after, and 24 hours later. Results revealed no changes in total arm volume of the swollen arm, measured with water displacement method, or in subjective assessments of heaviness and tightness in the affected arm using visual analogue scale. Immediately after pole walking, a temporary increase in total arm volume of the healthy arm (P=0.037) was found. Twenty-four hours later, no differences were found compared to the measurements before walking. The median for perceived exertion immediately after pole walking, measured with Borg scale, was 11 ("fairly light"). The results suggest that a controlled, short-duration pole-walking program can be performed by patients with arm lymphedema, using a compression sleeve, without deterioration of the arm lymphedema.

Pentoxifylline and vitamin E treatment for prevention of radiation-induced side-effects in women with breast cancer: a phase two, double-blind, placebo-controlled randomised clinical trial (Ptx-5).

BACKGROUND: A previous study has shown that pentoxifylline in combination with vitamin E can reverse radiation-induced fibrosis. The aim of the present study is to investigate if the same drugs could prevent radiation-induced side-effects in women with breast cancer. PATIENTS AND METHODS: A randomised, placebo-controlled, double-blind, parallel group trial was performed. Women with breast cancer were treated for 12 months with 400 mg pentoxifylline t.i.d. or placebo, in combination with 100 mg vitamin E t.i.d., starting 1-3 months after the completion of radiotherapy. The primary end-point was passive abduction of the shoulder, and the secondary end-point was difference in arm volumes. The trial is registered on the ISRCTN.org website, number ISRCTN39143623. RESULTS: 83 patients were included in the study; 42 in the pentoxifylline+vitamin E group and 41 in the placebo+vitamin E group. Both treatments were generally well tolerated. Seven patients were withdrawn from the treatment due to disease progression; four in the pentoxifylline group and three in the placebo group. At inclusion, patients had impaired passive abduction of the shoulder. During treatment, both the groups improved significantly. Median improvement from baseline was 3.7 degrees (p=0.0035) on pentoxifylline and was 9.4 degrees (p=0.0041) in the placebo group, but no difference between the groups was detected (p=0.20). Arm volumes increased over time in the placebo group (1.04%), but not on pentoxifylline (0.50%), and differed significantly between the groups (p=0.0172). CONCLUSIONS: The combination of pentoxifylline and vitamin E was safe and may be used for the prevention of some radiation-induced side-effects.