Early Physiotherapy May Help Prevent Lymphedema After Breast Cancer Surgery

Laurie Barclay, MD

January 22, 2010

January 22, 2010 — Early physiotherapy may help prevent and reduce lymphedema after breast cancer surgery, according to the results of a randomized, single blinded, controlled trial reported in the January 12 issue of the BMJ.

"Acquired interruption or damage to the axillary lymphatic system after surgery or radiotherapy for breast cancer can lead to regional or generalised accumulation of lymph fluid in the interstitial space, known as secondary lymphoedema," write María Torres Lacomba, from Alcalá de Henares University in Madrid, Spain, and colleagues. "Efforts have been made to reduce the risk of secondary lymphoedema by preoperative and postoperative counselling and education and by early detection."

The goal of this study was to assess the efficacy of early physiotherapy in reducing the risk for secondary lymphedema after surgery for breast cancer. At a university hospital in Madrid, Spain, 120 women who had breast surgery involving dissection of axillary lymph nodes between May 2005 and June 2007 were randomly assigned to an early physiotherapy group or to a control group.

Patients in the early physiotherapy group were treated by a physiotherapist with a program involving manual lymph drainage, massage of scar tissue, and progressive active and action-assisted shoulder exercises, as well as an educational strategy, whereas the control group received only the educational strategy. The primary study endpoint was the incidence of clinically significant secondary lymphedema, defined as more than a 2-cm increase vs the nonaffected side in arm circumference measured at 2 adjacent points.

Of 116 women who completed 1-year follow-up, 18 (16%) developed secondary lymphedema, including 14 in the control group (25%) and 4 in the physiotherapy group (7%; = .01; risk ratio, 0.28; 95% confidence interval [CI], 0.10 - 0.79). Survival analysis showed that secondary lymphedema was diagnosed 4 times earlier in the control group vs the physiotherapy group (intervention/control, hazard ratio, 0.26; 95% CI, 0.09 - 0.79).

"Early physiotherapy could be an effective intervention in the prevention of secondary lymphoedema in women for at least one year after surgery for breast cancer involving dissection of axillary lymph nodes," the study authors write. "This result emphasises the role of physiotherapy in the awareness, prevention, early diagnosis, and treatment of secondary lymphoedema."

Limitations of this study include physiotherapy provided by trained physiotherapists, limiting generalizability; use of a particular criterion for diagnosing lymphedema; and possible measurement errors.

In an accompanying editorial, Dr. Andrea Cheville, from Mayo Clinic in Rochester, Minnesota, suggests that physiotherapy shows promise in a selected group of women.

"Limited but compelling evidence supports the usefulness of physiotherapy after surgical clearance of the axillary lymph nodes to control pain, enhance shoulder functionality and range of motion, and reduce a woman's risk of developing lymphoedema," Dr. Cheville writes. "Clinicians should therefore consider referring patients to physiotherapists who are trained in treating lymphoedema. Future research is needed to assess the efficacy of specific treatment modalities such as education and manual lymphatic draining."

The Health Institute Carlos III of the Spanish Health Ministry supported this study. The study authors and Dr. Cheville have disclosed no relevant financial relationships.

BMJ. 2010;340:b5396. Abstract


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