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An Executive Summary of the APTA Academy for Oncologic Physical Therapy Clinical Practice Guideline: Interventions for Breast Cancer–Related Lymphedema

Davies, Claire C. PT, PhD1; Levenhagen, Kimberly PT, DPT2; Ryans, Kathryn PT, DPT3; Perdomo, Marisa PT, DPT, MS4; Gilchrist, Laura PT, PhD5

Author Information
doi: 10.1097/01.REO.0000000000000223
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Breast cancer–related lymphedema (BCRL), a sequela of cancer treatments, results in increased limb volume, which is associated with activity and participation restrictions.1 Incidence of BCRL varies depending on lymphedema definitions, assessments, and criteria. Significant factors associated with BCRL include high body mass index, axillary lymph node dissection (ALND), and regional lymph node radiation.2–5 McDuff et al2 reported the 5-year rate of lymphedema was highest in individuals receiving ALND and radiation therapy (31.2%). In this same study, early-onset BCRL (<12 months) was associated with ALND (Hazard Ratio [HR] = 3.86; P = .0001), whereas radiation therapy was associated with lymphedema occurring at greater than 12 months.2 Although onset of lymphedema varies with differences in breast cancer treatments, the overall risk of lymphedema peaked between 12 and 30 months.2

Interventions are necessary at various time points throughout the cancer trajectory, beginning at diagnosis and continuing through survivorship. Evidence-based recommendations can guide clinical decision-making for selecting appropriate interventions based on an individual's clinical presentation. A lymphedema staging model6 (Table 1) was adapted from the International Society of Lymphology (ISL) criteria,7 using patient presentation8 across trajectory of treatment and survivorship. This model6 was used as a framework to develop recommendations based on clinical implementation. Initially, this clinical practice guideline (CPG) was intended to address all secondary upper-quadrant lymphedemas. Unfortunately, because of lack of high-quality evidence in populations other than breast cancer, an evidence-based guideline could only be developed for BCRL.

TABLE 1 - Lymphedema Staging Modela
Patient Presentation8 Stages From the International Society of Lymphology7 Description of Stages
At risk Not applicable Individuals with insult to the lymphatic system but without symptoms or signs of lymphatic transport impairment.
Subclinical Stage 0 Subclinical state where swelling is not visible, but lymphatic transport is impaired by clinical measures. Symptoms and subtle tissue changes may be noted.
Early lymphedema Stage I Early onset of swelling that is visible and subsides with elevation. Pitting may be present.
Moderate lymphedema Stage II Consistent volume change with pitting present. Elevation rarely reduces the swelling and progressive tissue fibrosis occurs.
Late lymphedema Stage III Skin changes such as thickening, hyperpigmentation, increased skinfolds, fat deposits, and warty overgrowths occur. Tissue is very fibrotic and pitting is absent.
aReprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association from the full-text guideline published in Physical Therapy at

The Academy of Oncologic Physical Therapy of the APTA supported a CPG development in appropriate interventions for BCRL as a continuation of previous work on diagnosis. As stated in the full CPG,

The aim of this CPG was to identify interventions targeting the core impairments of increased interstitial fluid and volume of the upper extremity as a direct impact of BCRL. Although many other impairments, activity limitations, and participation restrictions can occur in individuals impacted by BCRL, this CPG was constructed to identify interventions that target these core impairments. Clinicians should consider the evidence presented in this guideline along with the clinical presentation of an individual, their goals, and patient preferences when establishing an appropriate plan of care.6

The purpose of this paper is to provide an executive summary of the full CPG for interventions for those with BCRL; the full CPG can be accessed here (


Relevant research on the topic was amassed from multiple electronic databases, including PubMed and CINHAL, from January 2000 through March 2019. The APTA's Critical Appraisal Tool for Experimental Intervention Studies (CAT-EI) review tool was used to assess the quality of studies and assign a quality rating (Table 2).9

TABLE 2 - Quality Rating Scale for Individual Articlesa
Level Criteria
I High-quality RCTs: Met all 8 essential scoring items on Critical Appraisal Tool for Experimental Intervention Studies (CAT-EI), including randomized controlled trial of appropriate patient population and sample size, blinding of assessment, reliable and valid outcome measure, adequate follow-up, and appropriate statistical analysis.
II Acceptable quality: Evidence obtained from lesser quality clinical trials and met 6 of 8 quality indicators (eg, no blinding, short follow-up), high-quality prospective cohort studies or outcomes research.
III Low quality: Case-controlled studies, retrospective cohort studies, or other low-quality trials; met between 2 and 5 of essential scoring items on CAT-EI.
Unacceptable: Met 0 or 1 of the essential scoring items on CAT-EI
aReprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association from the full-text guideline published in Physical Therapy at

The guideline development group assigned each intervention an evidence grade (Table 3) based on an overall appraisal of the quality of evidence available. High- and acceptable quality evidence, when available, was synthesized to produce recommendations.

TABLE 3 - Evidence Grades Based on the Quality of Evidencea
Grade Recommendation Criteria and Strength of Recommendation
A Strong High-quality studies (level I) with moderate to substantial benefit/harm—“must/should” or “must not/should not”
B Moderate High-quality studies (level I) with slight benefit/harm OR acceptable quality studies (level II) for moderate-level benefit/harm—“should” or “should not”
C Weak Acceptable quality studies (level II) for slight benefit/harm OR low-quality studies (level III) for substantial benefit/harm—“may” or “may not”
Best practice Best practice Based on current clinical norms or expert opinion
aReprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association from the full-text guideline published in Physical Therapy at


For the evidence that supports each recommendation, see the full CPG.6 The included information in the italics below is reprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association© from the full text guideline published in Physical Therapy at


Prior to the initiation of an intervention, the therapist should perform a thorough examination to identify impairments, activity, and participation restrictions. Due to of the complexity of each person's medical history and oncologic treatment plan, it is imperative that the therapist constructs the plan of care in collaboration with the interprofessional team. Therapists should perform a systems review due to the multisystem side effects from cancer-related treatments and variations in surgical approaches, comorbid conditions, and oncologic management. These side effects may require variances from the recommendations due to their effect on exercise tolerance. The therapist is a critical member of the interprofessional care team and should monitor the initiation and progression of an exercise program.

  • Postoperative exercise and resumption of activity should be coordinated with the interprofessional team and an individualized exercise program should be gradually increased while monitoring for adverse events. (Best practice)
  • Individually tailored exercises should be included postoperatively and gradually progressed. (Grade B)
  • In individuals who have undergone ALND:
    • The addition of therapist-provided manual lymphatic drainage (MLD) to the postoperative care plan may not reduce the risk of developing BCRL. (Grade C)
    • Provision of a fitted compression garment to patients at high risk of developing lymphedema, when paired with upper extremity exercise and diaphragmatic breathing, may reduce development of lymphedema. (Grade B)


  • Early identification of subclinical lymphedema in high-risk groups through prospective surveillance may improve outcomes. (Grade C)
    • Monitoring with bioimpedance spectroscopy or volume measures may begin with a preoperative assessment, repeated every 3 months for the first year postoperatively and then biannually for up to 5 years. (Grade C)
  • Intervention for subclinical lymphedema may include education, self-massage, and use of compression garments. (Grade C)
  • If early subclinical lymphedema persists or progresses after initial conservative intervention, individuals may benefit from more intensive interventions, such as complete decongestive therapy (CDT). (Grade C)


  • Progressive resistance training is safe when an individualized program is supervised beginning at least 1 month postsurgery. (Grade A)
  • Individualized aerobic exercise programs should be provided. (Grade A)
  • Monitoring for exercise tolerance and adverse effects should initially occur at least weekly and then taper according to clinical presentation. (Grade A)


Early Lymphedema (ISL Stage I)

  • If early signs and/or symptoms of lymphedema are noted, the patient should be individually fitted with a compression garment, instructed in an exercise program, and provided education as first-line treatment. (Grade A)
    • If first-line treatment is not successful for early lymphedema, then CDT may be recommended. (Grade B)
    • Compression (garment or bandaging) should be tailored for the individual's lymphedema stage and impairments in consultation with the patient. (Grade A)

Moderate and Late Lymphedema (ISL Stages II and III)

  • CDT should be used to reduce limb volume in those diagnosed with moderate and late BCRL. (Grade B)
    • Compression bandaging and exercise are key components of CDT and should be used. (Grade A)
    • Modifying CDT, specifically shortening or omitting the MLD component, may yield similar results on long-term volume reduction. (Grade B)
    • In all treatment phases, compression interventions should be tailored to the individual's lymphedema stage, impairments, and preferences. (Grade A)
    • Kinesio tape may reduce volume but cannot be recommended to replace short-stretch compression bandaging in stage II and III BCRL. (Grade B)
      • If Kinesio tape is used in BCRL, clinicians should closely monitor for adverse events. (Grade B)
    • Once a stable volume reduction is achieved with phase I clinical treatment, a program of home care including self-MLD, individually fitted compression garment, appropriate nightly compression if indicated, and exercise should be recommended. (Grade B)
    • Use of a standard or advanced intermittent pneumatic compression device may be considered in phase II home care treatment. (Grade C)
    • Monitoring for volume changes with follow-up care may be an important component for optimal long-term volume reduction. (Grade C)
  • Low-level laser therapy may be considered in combination with either compression or CDT in patients with established lymphedema of the upper extremity. (Grade B)

For All Stages (ISL Stages 0-III) in Relation to Exercise29,32,67–78

  • Individualized programs of aerobic and resistance exercise should be provided for those who have BCRL (stages 0-III). (Grade A)
    • Resistance exercise should be initiated at low-level intensity and progressed slowly. (Best practice)
    • Individuals with comorbidities or complications due to cancer-related treatments should be referred to a specialist for evaluation and exercise prescription. (Best practice)
  • Sequential proximal to distal exercises incorporating diaphragmatic breathing should be used to improve volume reduction. (Grade B)
  • Compression use with exercise may have benefits. (Grade B)
  • Yoga may be a safe form of exercise but does not show evidence of effectiveness for lymphedema volume reduction. (Grade C)

For All Stages (ISL Stages 0-III) in Relation to Other Therapeutic Modalities79–82

  • The addition of myofascial therapy to stretching, exercise, and scar massage may be safe in patients greater than 3 months post–radiation therapy who are at risk for BCRL. (Grade C)
  • Acupuncture has insufficient evidence to support use for volume reduction. (Grade C)


The recommendations in this Executive Summary are intended to guide the clinician in selecting the most appropriate and effective interventions based on BCRL stage. Since the aim of this Executive Summary was to identify interventions that reduce excess interstitial fluid and overall limb volume, other intervention studies that investigated quality of life, function, and pain were not included. Therefore, use of additional interventions to target these impairments, activity limitations, and participation restrictions is likely warranted on the basis of an individual's needs. It is important to consider that literature published after the evidence review was completed could change these recommendations. Readers are encouraged to refer to the full CPG and original articles for specific information regarding the interventions and their related research studies. As cancer treatments and the patients' response to these treatments are heterogeneous in nature, it is important to consider the individual's presentation, impairments, activities and participation restrictions, goals, as well as clinical expertise, when incorporating the recommendations into practice.

The limitations of this Executive Summary are that patients were not included in the development of the recommendations, there was limited input by clinicians other than physical therapists, and high-level evidence for interventions was scarce. High-quality research is needed that stratifies the outcomes of interventions by well-defined lymphedema stages and investigates other forms of cancer-related lymphedema.


The following people were involved in quality reviews of the literature; Kathy Bartley, PT, DPT, MHA, CLT; Chris Beuthin, PT, DPT, GCS, CLT; Linda Boyle, PT, CLT-LANA; Jennifer Brooks, PT, DPT, CLT-LANA; Barbara Feltman, PT, DHS, CLT-LANA; Amy Flinn, PT, CLT-LANA; Brandi Johnson, PT, DPT, CLT-LANA; Megan Kaley, PT, DPT, WCS, CLT-LANA; Jean Kastner, PT, DPT, CLT-LANA; Kiersten Kilczewski, PT, DPT, CLT-LANA; Linda Koehler, PT, PhD, CLT-LANA; Vince Lepak, PT, DPT, MPH, CWS; Anne Lehman, PT, CLT-LANA, CMTPT; Vicki Naugler, PT, CLT-LANA; Lisa O'Block, PT, DPT; Nancy Potter, PT; Kristin Ryan, PT, DPT, CLT; and Christina Wright, PT, DPT, CLT.

The following people provided feedback on initial drafts of the CPG: Connie Brenna, BSN, RN; Cheryl Brunelle, PT, MS, CCS, CLT; Carmela Claypool, PT, CLT-LANA; Diane Galvin, PT; Nancy Hutchison, MD; Leslen Keith, OTD, CLT-LANA; Guenter Klose, CLT-LANA; Linda Koehler, PT, PhD, CLT-LANA; Jenette Lee, PT, PhD, CLT, CSCS; Patricia O'Brien, PT, MD; Lucinda Pfalzer, PT, PhD; Antionette Sanders, PT, DPT; Betty Smoot, PT, DPTSc; Bryan Spinelli, PT, PhD; Nicole Stout, PT, DPT, CLT-LANA; Linda Tripp, PT, DPT; Nadia Van Diepen, PT, DPT, CLT-LANA, WCC; Megan Webster, PT; Jan Weiss, PT, CLT-LANA; and Jodi Winicour, PT, CLT-LANA


1. Ahmed RL, Schmitz KH, Prizment AE, Folson AR. Risk factors for lymphedema in breast cancer survivors. The IOWA Women's Health Study. Breast Cancer Res Treat. 2011;130(3):981–991.
2. McDuff SGR, Mina AI, Brunelle CL, et al. Timing of lymphedema after treatment for breast cancer: when are patients most at risk?. Int J Radiat Oncol Biol Phys. 2019:103(1):62–70.
3. Warren LEG, Miller CL, Horick N, et al. The impact of radiation therapy on the risk of lymphedema after treatment from breast cancer: a prospective cohort study. Int J Radiat Oncol Biol Phys. 2014;88(3):565–571.
4. Mclaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol. 2008;26(32):5213–5219.
5. Chandra RA, Miller CL, Skolny MN, et al. Radiation therapy risk factors for development of lymphedema in patients treated with regional lymph node irradiation for breast cancer. Int J Radiat Oncol Biol Phys. 2015;91(4):760–764.
6. Davies CC, Levenhagen K, Ryans K, Perdomo M, Gilchrist L. Interventions for breast cancer-related lymphedema: a clinical practice guideline from the Academy of Oncologic Physical Therapy of the APTA. Phys Ther. 2020.
7. Lymphology International Society. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016;49(4):170–184.
8. Levenhagen K, Davies C, Perdomo M, Ryans K, Gilchrist L. Diagnosis of upper quadrant lymphedema secondary to cancer: clinical practice guideline from the Oncology Section of the American Physical Therapy Association. Phys Ther. 2017;97(7):729–745.
9. APTA. APTA Clinical Practice Guideline Process Manual. Alexandria, VA: APTA; 2018.
10. APTA. Guide to Physical Therapy Practice 3.0. Published 2014. Accessed February 2, 2019.
11. Bendz I, Fagevik Olsen MF. Evaluation of immediate versus delayed shoulder exercises after breast cancer surgery including lymph node dissection—a randomised controlled trial. Breast. 2002;11(3):241–248.
12. Sagen A, Karesen R, Risberg MA. Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up. Acta Oncol. 2009;48(8):1102–1110.
13. Todd J, Scally AJ, Dodwell D, Horgan K, Topping A. A randomised controlled trial of two programmes of shoulder exercise following axillary node dissection for invasive breast cancer. Physiotherapy. 2008;94(4):265–273.
14. de Oliveira MMF, Gurgel MSC, Amorim BJ, et al. Long term effects of manual lymphatic drainage and active exercises on physical morbidities, lymphoscintigraphy parameters and lymphedema formation in patients operated due to breast cancer: a clinical trial. PLoS One. 2018;13(1):e0189176.
15. Torres Lacomba M, Yuste Sánchez MJ, Zapico Goñi A, et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ. 2010;340:b5396.
16. Devoogdt N, Geraerts I, Van Kampen M, et al. Manual lymph drainage may not have a preventive effect on the development of breast cancer-related lymphoedema in the long term: a randomised trial. J Physiother. 2018;64(4):245–254.
17. Ochalek K, Gradalski T, Partsch H. Preventing early postoperative arm swelling and lymphedema manifestation by compression sleeves after axillary lymph node interventions in breast cancer patients: a randomized controlled trial. J Pain Symptom Manage. 2017;54(3):346–354.
18. Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM. Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema. Breast Cancer Res Treat. 2002;75(1):51–64.
19. Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112(12):2809–2819.
20. Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12(4):289–294.
21. Yang EJ, Ahn S, Kim EK, et al. Use of a prospective surveillance model to prevent breast cancer treatment-related lymphedema: a single-center experience. Breast Cancer Res Treat. 2016;160(2):269–276.
22. Kaufman DI, Shah C, Vicini FA, Rizzi M. Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer-related lymphedema. Breast Cancer Res Treat. 2017;166(3):809–815.
23. Kilgore LJ, Korentager SS, Hangge AN, et al. Reducing breast cancer-related lymphedema (BCRL) through prospective surveillance monitoring using bioimpedance spectroscopy (BIS) and patient directed self-interventions. Ann Surg Oncol. 2018;25(10):2948–2952.
24. Koelmeyer LA, Borotkanics RJ, Alcorso J, et al. Early surveillance is associated with less incidence and severity of breast cancer-related lymphedema compared with a traditional referral model of care. Cancer. 2019;125(6):854–862.
25. Whitworth PW, Cooper A. Reducing chronic breast cancer-related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy. Breast J. 2018;24(1):62–65.
26. Stout NL, Pfalzer LA, Springer B, et al. Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care. Phys Ther. 2012;92(1):152–163.
27. Kilbreath S, Refshauge K, Beith J, Lee UM. Resistance and stretching shoulder exercises early following axillary surgery for breast cancer. Rehabil Oncol. 2006;24(2):9–14.
28. Hayes SC, Rye S, Disipio T, et al. Exercise for health: a randomized, controlled trial evaluating the impact of a pragmatic, translational exercise intervention on the quality of life, function and treatment-related side effects following breast cancer. Breast Cancer Res Treat. 2013;137(1):175–186.
29. Schmitz KH, Ahmed RL, Troxel AB, et al. Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA. 2010;304(24):2699–2705.
30. Ammitzbøll G, Johansen C, Lanng C, et al. Progressive resistance training to prevent arm lymphedema in the first year after breast cancer surgery: results of a randomized controlled trial. Cancer. 2019;125(10):1683–1692.
31. Courneya KS, Segal RJ, Mackey JR, et al. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol. 2007;25(28):4396–4404.
32. Campbell KL, Winters-Stone KM, Wiskermann J, et al. Exercise guidelines for cancer survivors: consensus statement from the international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375–2390.
33. Földi MFE, Strößenreuther C, Kubik S. Földi's Textbook of Lymphology for Physicians and Lymphedema Therapists. 3rd ed. Munich, Germany: Urban & Fischer; 2012.
34. Sezgin Ozcan D, Dalyan M, Unsal Delialioglu S, Duzlu U, Polat CS, Koseoglu BF. Complex decongestive therapy enhances upper limb functions in patients with breast cancer-related lymphedema. Lymphat Res Biol. 2018;16(5):446–452.
35. Mobarakeh ZS, Mokhtari-Hesari P, Lotfi-Tokaldany M, Montazeri A, Heidari M, Zekri F. Combined decongestive therapy and reduction of pain and heaviness in patients with breast cancer-related lymphedema. Support Care Cancer. 2019;27(10):3805–3811.
36. Dayes IS, Whelan TJ, Julian JA, et al. Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer. J Clin Oncol. 2013;31(30):3758–3763.
37. Gradalski T, Ochalek K, Kurpiewska J. complex decongestive lymphatic therapy with or without Vodder II manual lymph drainage in more severe chronic postmastectomy upper limb lymphedema: a randomized noninferiority prospective study. J Pain Symptom Manage. 2015;50(6):750–757.
38. Tambour M, Holt M, Speyer A, Christensen R, Gram B. Manual lymphatic drainage adds no further volume reduction to complete decongestive therapy on breast cancer-related lymphoedema: a multicentre, randomised, single-blind trial. Br J Cancer. 2018;119(10):1215–1222.
39. Pujol-Blaya V, Salinas-Huertas S, Catasus ML, Pascual T, Belmonte R. Effectiveness of a precast adjustable compression system compared to multilayered compression bandages in the treatment of breast cancer-related lymphoedema: a randomized, single-blind clinical trial. Clin Rehabil. 2019;33(4):631–641.
40. Ligabue MB, Campanini I, Veroni P, Cepelli A, Lusuardi M, Merlo A. Efficacy of self-administered complex decongestive therapy on breast cancer-related lymphedema: a single-blind randomized controlled trial. Breast Cancer Res Treat. 2019;175(1):191–201.
41. Ochalek K, Gradalski T, Szygula Z. Five-year assessment of maintenance combined physical therapy in postmastectomy lymphedema. Lymphat Res Biol. 2015;13(1):54–58.
42. Vignes S, Porcher R, Arrault M, Dupuy A. Long-term management of breast cancer-related lymphedema after intensive decongestive physiotherapy. Breast Cancer Res Treat. 2007;101(3):285–290.
43. Uzkeser H, Karatay S, Erdemci B, Koc M, Senel K. Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: a randomized controlled trial. Breast Cancer. 2015;22(3):300–307.
44. Szuba A, Achalu R, Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer. 2002;95(11):2260–2267.
45. Haghighat S, Lotfi-Tokaldany M, Yunesian M, Akbari ME, Nazemi F, Weiss J. Comparing two treatment methods for post mastectomy lymphedema: complex decongestive therapy alone and in combination with intermittent pneumatic compression. Lymphology. 2010;43(1):25–33.
46. Szolnoky G, Lakatos B, Keskeny T, et al. Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex decongestive physiotherapy for breast cancer treatment-related lymphedema. Lymphology. 2009;42(4):188–194.
47. Fife CE, Davey S, Maus EA, Guilliod R, Mayrovitz HN. A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home. Support Care Cancer. 2012;20(12):3279–3286.
48. Ridner SH, Murphy B, Deng J, Kidd N, Galford E, Dietrich MS. Advanced pneumatic therapy in self-care of chronic lymphedema of the trunk. Lymphat Res Biol. 2010;8(4):209–215.
49. Wilburn O, Wilburn P, Rockson SG. A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema [ISRCTN76522412]. BMC Cancer. 2006;6:84.
50. Ridner SH, Murphy B, Deng J, et al. A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema. Breast Cancer Res Treat. 2012;131(1):147–158.
51. Tsai HJ, Hung HC, Yang JL, Huang CS, Tsauo JY. Could Kinesio tape replace the bandage in decongestive lymphatic therapy for breast-cancer-related lymphedema? A pilot study. Support Care Cancer. 2009;17(11):1353–1360.
52. Malicka I, Rosseger A, Hanuszkiewicz J, Woźniewski M. Kinesiology taping reduces lymphedema of the upper extremity in women after breast cancer treatment: a pilot study. Prz Menopauzalny. 2014;13(4):221–226.
53. Pop TB, Karczmarek-Borowska B, Tymczak M, Hałas I, Banaś J. The influence of Kinesiology taping on the reduction of lymphoedema among women after mastectomy—preliminary study. Contemp Oncol (Pozn). 2014;18(2):124–129.
54. Smykla A, Walewicz K, Trybulski R, et al. Effect of Kinesiology taping on breast cancer-related lymphedema: a randomized single-blind controlled pilot study. Biomed Res Int. 2013;2013:767106.
55. Melgaard D. What is the effect of treating secondary lymphedema after breast cancer with complete decongestive physiotherapy when the bandage is replaced with Kinesio Textape? A pilot study. Physiother Theory Pract. 2016;32(6):446–451.
56. Taradaj J, Halski T, Rosinczuk J, Dymarek R, Laurowski A, Smykla A. The influence of Kinesiology taping on the volume of lymphoedema and manual dexterity of the upper limb in women after breast cancer treatment. Eur J Cancer Care (Engl). 2016;25(4):647–660.
57. Collins S, Bradley N, Fitzgibbon S, McVeigh JG. Kinesiology taping for breast lymphoedema after breast cancer treatment: a feasibility randomised controlled trial. Phys Pract Res. 2018;39(2):107–116.
58. Assis L, Soares Moretti AI, Abrahão TB, de Souza HP, Hamblin MR, Parizotto NA. Low-level laser therapy (808 nm) contributes to muscle regeneration and prevents fibrosis in rat tibialis anterior muscle after cryolesion. Lasers Med Sci. 2013;28(3):947–955.
59. Storz MA, Gronwald B, Gottschling S, Schöpe J, Mavrova R, Baum S. Photobiomodulation therapy in breast cancer-related lymphedema: a randomized placebo-controlled trial. Photodermatol Photoimmunol Photomed. 2017;33(1):32–40.
60. Khalaf MM, Hassan MA, Ibrahim ZM. Helium neon laser therapy for post mastectomy lymphedema and shoulder mobility. Egyptian J Med Hum Gene. 2013;14(2):195–199.
61. Ridner SH, Poage-Hooper E, Kanar C, Doersam JK, Bond SM, Dietrich MS. A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema. Oncol Nurs Forum. 2013;40(4):383–393.
62. Ahmed Omar MT, Abd-El-Gayed Ebid A, El Morsy AM. Treatment of post-mastectomy lymphedema with laser therapy: double blind placebo control randomized study. J Surg Res. 2011;165(1):82–90.
63. Kozanoglu E, Basaran S, Paydas S, Sarpel T. Efficacy of pneumatic compression and low-level laser therapy in the treatment of postmastectomy lymphoedema: a randomized controlled trial. Clin Rehabil. 2009;23(2):117–124.
64. Lau RWL, Cheing GLY. Managing postmastectomy lymphedema with low-level laser therapy. Photomed Laser Surg. 2009;27(5):763–769.
65. Carati CJ, Anderson SN, Gannon BJ, Piller NB. Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind, placebo-controlled trial. Cancer. 2003;98(6):1114–1122.
66. Kaviani A, Fateh M, Yousefi Nooraie R, Alinagi-zadeh MR, Ataie-Fashtami L. Low-level laser therapy in management of postmastectomy lymphedema. Lasers Med Sci. 2006;21(2):90–94.
67. Zhang X, Brown JC, Paskett ED, Zemel BS, Cheville AL, Schmitz KH. Changes in arm tissue composition with slowly progressive weight-lifting among women with breast cancer-related lymphedema. Breast Cancer Res Treat. 2017;164(1):79–88.
68. Cormie P, Galvão DA, Spry N, Newton RU. Neither heavy nor light load resistance exercise acutely exacerbates lymphedema in breast cancer survivor. Integr Cancer Ther. 2013;12(5):423–432.
69. Hayes SC, Reul-Hirche H, Turner J. Exercise and secondary lymphedema: safety, potential benefits, and research issues. Med Sci Sports Exerc. 2009;41(3):483–489.
70. Buchan J, Janda M, Box R, Schmitz K, Hayes S. A randomized trial on the effect of exercise mode on breast cancer-related lymphedema. Med Sci Sports Exerc. 2016;48(10):1866–1874.
71. Bracha J, Katz-Leurer M. The immediate effect of upper arm exercise compared with lower or combined upper and lower arms exercise on arm volume reduction in women with breasts cancer related lymphedema: a randomized preliminary study. Rehabil Oncol. 2012;30(3):3–8.
72. Jönsson C, Johansson K. Pole walking for patients with breast cancer-related arm lymphedema. Physiother Theory Pract. 2009;25(3):165–173.
73. Tidhar D, Katz-Leurer M. Aqua lymphatic therapy in women who suffer from breast cancer treatment-related lymphedema: a randomized controlled study. Support Care Cancer. 2010;18(3):383–392.
74. Singh B, Buchan J, Box R, et al. Compression use during an exercise intervention and associated changes in breast cancer–related lymphedema. Asia-Pac J Clin Oncol. 2016;12(3):216–224.
75. Mazor M, Lee JQ, Peled A, et al. The effect of yoga on arm volume, strength, and range of motion in women at risk for breast cancer-related lymphedema. J Altern Complement Med. 2018;24(2):154–160.
76. Lai YT, Hsieh CC, Huang LS, et al. The effects of upper limb exercise through yoga on limb swelling in Chinese breast cancer survivors—a pilot study. Rehabil Nurs. 2017;42(1):46–54.
77. Douglass J, Immink MA, Piller N, Ullah S. Yoga for women with breast cancer-related lymphoedema: a preliminary 6-month study. J Lymphoedema. 2012;7(2):30–38.
78. Loudon A, Barnett T, Piller N, Immink MA, Williams AD. Yoga management of breast cancer-related lymphoedema: a randomised controlled pilot-trial. BMC Complement Altern Med. 2014;14:214.
79. De Groef A, Van Kampen M, Verlvoesem N, et al. Effect of myofascial techniques for treatment of upper limb dysfunctions in breast cancer survivors: randomized controlled trial. Support Care Cancer. 2017;25(7):2119–2127.
80. Bao T, Iris Zhi W, Vertosick EA, et al. Acupuncture for breast cancer-related lymphedema: a randomized controlled trial. Breast Cancer Res Treat. 2018;170(1):77–87.
81. Cassileth BR, Van Zee KJ, Chan Y, et al. A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. Acupunct Med. 2011;29(3):170–172.
82. Smith CA, Pirotta M, Kilbreath S. A feasibility study to examine the role of acupuncture to reduce symptoms of lymphoedema after breast cancer: a randomised controlled trial. Acupunct Med. 2014;32(5):387–393.

breast neoplasm; evidence-based practice; secondary lymphedema; treatment

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