Effect of Manual Lymphatic Drainage on Breast Cancer–Related Postmastectomy Lymphedema

A Meta-analysis of Randomized Controlled Trials

Abstract

Background 

Manual lymphatic drainage (MLD) is widely used in the treatment of breast cancer–related postmastectomy lymphedema (BCRL). However, the therapeutic benefit of MLD on BCRL remains controversial.

Objective 

The aim of this study was to analyze the efficacy of MLD for BCRL.

Method 

Four electronic databases were systematically searched for trials comparing MLD and no MLD treatment as options for BCRL. Comparative treatment results included reduction of upper extremity limb volume with subgroup analysis by the number and duration of treatments.

Results 

A total of 457 patients were included in the analysis. There was no significant difference in the amount of upper extremity edema between the MLD treatment and control or no MLD groups (P = .11). However, when the treatment course was ≥20 sessions, there was a significant reduction in the upper extremity volume (P = .03). There was also a significant reduction in the upper extremity volume when treatment duration was >2 weeks (P = .03).

Conclusion 

Manual lymphatic drainage treatment statistically did not reduce the upper extremity limb volume of BCRL, but upper extremity volume was reduced at statistically significant levels when treatment number were ≥20 sessions or the duration of treatment was >2 weeks.

Implication for Practice 

Reduction in upper limb volume is dependent on the number and duration of treatments. When treatment number were ≥20 sessions, or the duration of treatment was >2 weeks, reduction of upper limb volume was statistically achieved. Manual lymphatic drainage treatment can be clinically recommended to treat BCRL according to these parameters.

Breast cancer–related postmastectomy lymphedema (BCRL) is the most common chronic condition following mastectomy, with an incidence ranging from 8% to 52% in the first 2 postoperative years.¹ A study conducted by Armer et al² reported that approximately 75% of lymphedema cases occur in the first year after breast cancer surgery. As reported in the literature, BCRL is defined as an increase in arm volume by at least 150 mL compared with preoperatively, an increase in arm circumference by at least 2 cm, or an increase in arm volume of the affected arm by at least 10% compared with the unaffected arm.³ Breast cancer–related postmastectomy lymphedema can lead to many serious consequences, such as pain with arm exercise necessitating movement restrictions, emotional disorders; increased the risk of infection in the affected arm; and in severe cases may progress to upper limb disability.¹ Clearly, it can seriously impair a patient’s life. To avoid more serious and chronic irreversible sequelae, various interventions have been developed over the past few decades to treat BCRL, including complete decongestive therapy, intermittent pneumatic compression therapy, exercise, and education.² Complete decongestive therapy is a widely used combination management for lymphedema encompassing several elements that is considered effective in treating BCRL.² The components includes intensive lymphedema therapy, continued meticulous skin and nail care, range-of-motion exercises, manual lymphatic drainage (MLD), and application of compression garments and/or bandages.^2,4 Manual lymphatic drainage is a key component of complete decongestive therapy; the specific massage technique instructions are summarized as follows: draw 5 diaphragmatic breaths and massage from under the ipsilateral ear auricle to the bottom of the neck, from inferior to the lateral aspect of the clavicle to its medial extent, from the operated side to the opposite arm’s armpit, and the operated side armpit itself.¹

Manual lymphatic drainage has been shown to have multiple physiological effects including increasing the rate of lymphatic contraction, increasing protein reabsorption in the lymphatic vessels, reducing microlymphatic hypertension, and improving regional collateral skin lymphatic drainage.^5,6 Despite the aforementioned apparent beneficial effects, the actual measured therapeutic effect of MLD on BCRL still remains unclear. Some studies have reported that MLD may be ineffective in the reduction of upper lymphedema of BCRL.^7,8 In contrast, 2 systematic analyses in 2011⁹ and 2016¹⁰ reported that MLD successfully reduced upper limb volume. Hence, we conducted this meta-analysis to evaluate the efficacy of MLD on postmastectomy BCRL, including the reduction of upper limb lymphedema and improvement of arm symptoms and functions. If the intervention proved effective, which particular format of MLD was most effective?

Materials and Methods

Search Strategies

PubMed, EMBASE, Web of science, and the Cochrane Library were systematically searched from the time of their establishment to January 2020 using the following search terms: “breast cancer,” “breast neoplasm,” “breast tumor,” “breast adenocarcinoma,” “breast sarcoma,” “breast carcinoma,” “mastectomy,” “axillary dissection,” “sentinel node dissection,” “lymph node excision,” “lymph node dissection,” “axillary node dissection,” “lymphadenectomy,” “manual lymphatic drainage” and “weight training,” “physiotherapy,” “rehabilitation,” “shoulder immobilization,” “stretching,” “psychosocial therapy,” “movement program,” “mobilization,” “physical therapy,” “exertion,” “musculoskeletal manipulations,” “strength training,” “physical activity” or “exercise.” The language was limited to English, and retrieval was based on the subject terms, key words, or title. References of studies with potential relevance and review articles were manually checked.

Inclusion Criteria

Inclusion criteria included the following: 1) randomized controlled trials (RCTs), including cross-over and cluster RCTs; 2) patients with BCRL (diagnostic criteria: an increase in arm volume by at least 150 mL compared with preoperatively, an increase in arm circumference by at least 2 cm, or an increase in arm volume of the affected arm by at least 10% compared with the unaffected arm); 3) patients ≥18 years old enrolled in studies; 4) the treatment of the experimental group was MLD; 5) presence of a control group managed with compression bandaging or other standard treatment; 6) outcome measures that included changes in upper limb volume or circumference; and 7) a minimum of 20 patients in the trial.

Exclusion Criteria

Publications not meeting the inclusion criteria or patients with serious complications (vital signs unstable) were excluded.

Outcome Measures

The primary efficacy outcome was lymphedema change of the operated-side upper limb from baseline to postintervention, as measured by the volume change or arm circumference change. We analyzed the data reported to determine the efficacy of MLD to treat BCRL. The symptoms and functions were evaluated by heaviness, pain, anxiety, mobility, and quality of life. We evaluated the variation of symptoms and functions by the mean change score from baseline to postintervention according to validated scales (eg, numeric rating scale, the EuroQol 5D questionnaire, visual analog scale).¹¹

Data Extraction and Quality Assessment

Data extraction was performed by 2 authors, independently reviewing primary texts, supplementary appendices, and protocols, carefully evaluating study characteristics (publication year, first author, journal, and country of origin), patient characteristics (diagnostic criteria, age range, mean age, and sample size), intervention details (number of intervention sessions, duration and format of intervention, management method of control group), and outcome measures (as outlined above). The methodological quality of RCTs was assessed in accordance with the risk-of-bias tool described in the Cochrane Handbook for Systematic Reviews of Interventions (Cochrane Handbook 5.2).¹² Random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective reporting, and other potential risks of bias were assessed. Trials with high risk of bias of ≥1 key domain were considered to be at high risk of bias. Trials with low risk of bias for all key domains were judged as being at low risk of bias; otherwise, they were considered to be at an unclear risk of bias.

Statistical Analysis

The principal emphasis of this meta-analysis was to analyze the efficacy of MLD for BCRL. The measurements were expressed as standardized mean difference (SMD) with 95% confidence intervals (CIs) for continuous outcomes, and significance was set at P < .05. We used funnel plots to detect possible publication bias. We conducted subgroup analyses to examine whether outcomes were influenced by the number of treatment sessions and duration of intervention. We also performed sensitivity analyses for primary efficacy outcomes (eg, excluding those studies that were low-quality). Analyses were performed using Review Manager 5.3 (Cochrane Collaboration, London, UK).

Results

Study Selection and Study Characteristics

Our initial search identified 2091 studies from the 4 databases, of which 28 full-text articles were carefully screened by the authors. The PRISMA statement flowchart shows the process of literature screening, study selection, and reasons for exclusion (Figure 1). Only 8 high-quality articles met our stringent criteria to be included in our meta-analysis. Our final study group comprised 457 patients, 236 in the treatment group and 221 in the control group. All patients were female, the ages ranged from 25 to 84 years of age, and the treatment duration extended from 1 to 4 weeks. Two articles included the change of heaviness, 2 articles included the change of pain, and 2 articles included the change of mobility.

Figure 1: Summary of trial identification and selection.

Volume Reduction

Comparing the MLD treatment group with the no-MLD treatment control group, there was no significant reduction in upper limb volume for BCRL (SMD, 0.43; 95% CI, −0.10 to 0.96; P = .11; I² = 86%; Figure 2).

Figure 2: Primary efficacy outcome of manual lymphatic drainage. Forest plot of the standardized mean difference for upper volume change of breast cancer–related postmastectomy lymphedema patients after manual lymphatic drainage.

Improvement of Symptoms and Arm Function

Perceived heaviness in the arm was reduced by 18% in the study by Andersen et al,¹³ whereas Tambour et al⁷ reported the reduction of heaviness at the end of treatment in the experimental group had an average of 0.4 points, and the control group had an average of 1.5 points, P = .50; there was no significant reduction in heaviness according to Andersen et al¹³ and Tambour et al.⁷ Andersen et al¹³ reported that limitation of arm mobility was reduced by 22% in their treatment group. Arm mobility scores reduced to 0.5 and 0.6 in the treatment and control groups, respectively, P = .80, as reported by Tambour et al.⁷ There was no significant reduction in mobility in the 2 groups.^7,13

Manual lymphatic drainage may not have a positive effect on reducing pain in the upper limbs. There was no significant reduction in pain according to Tambour et al⁷ and Bergmann et al¹⁴ (SMD, −0.09; 95% CI, −0.43 to 0.25; P = .61; Figure 3).

Figure 3: Forest plot of comparison: the reduction of pain score.

Subgroup Analyses

We conducted multiple subgroup analyses to examine the relative efficacy of MLD treatment compared with the no-MLD treatment group, for example, the treatment session (<20 or ≥20 sessions) and the duration of intervention (≤2 or >2 weeks). In the group with <20 MLD sessions,^4,7,13–15 there was no significant difference between the MLD group and the no-MLD treatment group (SMD, 0.82; 95% CI, −0.17 to 1.82; P = .11; Figure 4A). In contrast, for patients in the group with ≥20 sessions,^16–18 there was a significant difference compared with the no-MLD treatment group (SMD, 0.31; 95% CI, 0.03 to 0.58; P = .03; Figure 4A). In the ≤2 weeks’ duration of the MLD group,^3,11,13 there was no significant difference between the MLD group and the no-MLD treatment group (SMD, 2.03; 95% CI, −0.39 to 4.44; P = .10; I² = 96%; Figure 4B). In the >2 weeks’ duration of MLD group,^7,14,16–18 there was a significant difference between the 2 groups (SMD, 0.23; 95% CI, −0.02 to 0.44; P = .03; I² = 0%; Figure 4B).

Figure 4: Subgroup analysis of primary efficacy outcome. A, Forest plot of the standardized mean difference (SMD) in upper volume change for the number of manual lymphatic drainage treatment sessions subgroup. B, Forest plot of the SMD in upper volume change for the duration of manual lymphatic drainage treatment subgroup.

Sensitivity Analyses

We carried out sensitivity analyses for volume reduction of BCRL. We performed a sensitivity analysis by excluding those studies that were of low quality.⁴ The effect size was much lower with low heterogeneity (SMD, 0.16; 95% CI, −0.06 to 0.39; P = .15; I² = 26%; Figure 5).

Figure 5: Sensitive analysis. Forest plot of odds ratios (with 95% confidence intervals) of discontinuance for any reason.

Risk of Bias for Independent Studies

From the risk-of-bias graph, the overall quality of the literature was found to be below average (Figure 6). Five of the studies described the methods of random sequence generation (selection bias) in detail and were classified as low risk. There were studies that did not describe the methods of random sequence generation (selection bias). The funnel plot would indicate that there may be publication bias (Figure 7), but the results must be viewed with caution because of the small number of publications.

Figure 6: Risk-of-bias analysis and quality assessment of included trials. A, Percentages of the assessments of each risk-of-bias item across all included studies. B, Individual assessments of each risk-of-bias item for each included study.

Figure 7: Funnel plot for primary efficacy outcomes.

Discussion

Our final analysis determined that there is no statistical benefit of MLD in reducing the upper limb volume of BCRL compared with the no-MLD treatment control group managed with standard care (SMD, 0.43; P = .11). Our conclusion does not agree with some previous studies. For example, McNeely et al¹⁷ found a statistically significant benefit from the addition of MLD massage for reducing upper extremity lymphedema volume. Similarly, Shao and Zhong¹⁰ found a statistical benefit in volume reduction between adding MLD to routine treatment and routine treatment only. Despite our exhaustive literature review, we were limited to only 8 reports that met our study criteria, and the resultant limited number of patients for analysis may be one of the reasons for the lack of demonstrating treatment benefit.

In addition, the difference of inclusion and exclusion criteria may also be the reason for the different conclusions of 2 previous systematic reviews and meta-analyses.^10,17 First, McNeely et al¹⁷ included all cancer-related edema and all intervention methods; we included only BCRL and MLD. Second, there were 7 studies on MLD treatment of lymphedema after breast cancer–related mastectomy. Among them, 3 studies^19–21 that did not meet the inclusion criteria were excluded in our meta-analysis. Turning to Shao and Zhong,¹⁰ their study design was quite different from ours as they compared the efficacy of standard treatment alone with standard treatment combined with MLD for BCRL. Shao and Zhong¹⁰ limited their statistical analysis to only 3 studies,^13,17,18 which may further account for the differences between theirs and our conclusions.

Subgroup analysis demonstrated statistical reduction of upper limb volume in BCRL patients who underwent ≥20 MLD treatment sessions or a treatment duration >2 weeks. It appears that the clinical use of MLD to treat BCRL requires multiple treatment sessions or a prolonged duration to achieve the therapeutic effect. However, because of our strict study criteria, the sample size was limited, and additional high-quality randomized trials are needed.

Recently, some studies have attested to the efficacy of adding MLD to bandage treatment^15,17 and MLD to standard therapy.^7,13,14 Perhaps comprehensive treatment may be more effective than MLD alone, but it is more complicated and time-consuming. Therefore, we intend to explore additional methods to enhance the effectiveness of MLD and further investigate whether there are other benefits of MLD to the heaviness, pain, and mobility of the upper extremity. In conducting this meta-analysis, some of the included studies suggested that MLD may not reduce the upper limb tightness, mobility, and arm pain compared with no MLD. However, the data of tightness and mobility were insufficient for secondary analysis. The question of whether MLD truly and demonstrably improves symptoms and function for the treatment of postmastectomy BCRL will require more randomized trials to be finally resolved.

This report has certain limitations. First, the publications included in this meta-analysis are limited in number, are relatively low-quality, and have apparent publication bias (Figure 6, Figure 7); additional high-quality RCTs are needed. Second, we used upper limb volume to evaluate upper limb lymphedema only; unfortunately, insufficient data were available to conduct secondary analysis of improvement in upper limb symptoms and function. Again, larger comprehensive clinical studies will be required to resolve these issues. Third, upper extremity volume of BCRL can increase or decrease over time, so variations in the time points at which the upper limb volume was measured could have influenced the results. Finally, even a precise definition of BCRL varies among published reports (Table); a consensus standard for this complication needs to be established to facilitate future comparative research.

Table - Characteristics of Included Trials

Study	No. of Patients	Intervention Program (Experimental Group; Control Group)	Definition of BCRL	Initial Arm Volume, Mean SD), mL (Experimental Group; Control Group)	Age Range, Mean (SD), y	BMI Range, Mean (SD), kg/m2	Treatment Duration, wk	No. of Sessions	No. of Chemotherapy Sessions	No. of Radiotherapy Sessions	Follow-up, mo	LR
Johansson et al, 1999 15	38	CB + MLD (n = 20); CB (n = 18)	Volume >10%	NA (2841); NA (2882)	47.5-69.5 (57.5)	NA NA	1	<20	15; 18	NA	>0.75	NA
Andersen et al, 2000 13	44	ST + MLD (n = 23); ST (n = 21)	Volume >30%	340 (1323); 361 (1296)	25-77 (53)	NA NA	2	8	9; 6	12; 11	12	4
Sitzia et al, 2002 4	28	MLD (n = 15); SLD (n = 13)	PCEV ≥20%	NA (3395); NA (3473)	48-85 (68)	NA NA	2	10	NA	NA	>1	4
Williams et al, 2002 16	60	MLD (n = 29); SLD (n = 31)	Volume >10%	NA; NA	NA 57.9; 59.3	NA NA	3	21	7; 3	22; 25	>3	2
McNeely et al, 2004 17	50	CB + MLD (n = 25); CB (n = 25)	D-volume >150 mL	535 (NA); 630 (NA)	NA (13)	NA NA	4	28	14; 6	21; 18	>1	5
Dayes et al, 2013 18	103	CB + MLD (n = 57); CB (n = 46)	Volume >10%	3422 (838); 3266 (781)	61; 59 NA	(32; 30) NA	4	20	38; 28	50; 36	>6	NA
Bergmann et al, 2014 14	57	ST + MLD (n = 28); ST (n = 29)	D-circumference >3 cm	NA; NA	62.16; 63.55 (9.06;10.98)	30.44; 29.08 5.14;5.97)	3.4	10	14; NA	14; NA	1	9
Tambour et al, 2018 7	77	ST + MLD (n = 39); ST (n = 38)	D-circumference >3 cm	2942.9 (593.9); 2889.7(491.3)	62.0; 60.9 (11.5;10.8)	29.6; 29.4 (5.5;5.3)	4	8	NA	NA	7	NA

Abbreviations: BCRL, breast cancer–related postmastectomy lymphedema; CB, compression bandaging; D-circumference, circumference difference; D-volume, volume difference; LR, the number of patients lost to follow-up; MLD, manual lymphatic drainage; PCEV, percentage change in excess limb volume; SLD, simple lymphatic drainage; ST, standard treatment.

In summary, when the number of MLD treatment sessions is ≥20 or the duration is >2 weeks, there is an effective reduction of upper limb volume; therefore, it is necessary to have sufficient number of sessions and duration of interventions for the treatment of BCRL in clinical. But the current evidence is not sufficient to evaluate the most effective format of clinical intervention in BCRL patients. More high-quality randomized clinical trials are needed to analyze the efficacy of MLD.