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Annals of Oncology 18: 639646, 2007 doi:10.1093/annonc/mdl182 Published online 3 October 2006

A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment
A. L. Moseley1*, C. J. Carati2 & N. B. Piller3
1 School of Nursing & Midwifery, University of South Australia, Adelaide; 2Department of Anatomy, School of Medicine, Flinders University, Adelaide; 3Department of Surgery & Lymphoedema Assessment Clinic, Flinders University & Medical Centre, Adelaide, Australia

Received 10 April 2006; revised 13 June 2006; accepted 23 June 2006

Secondary arm lymphoedema is a chronic and distressing condition which affects a signicant number of women who undergo breast cancer treatment. A number of health professional and patient instigated conservative therapies have been developed to help with this condition, but their comparative benets are not clearly known. This systematic review undertook a broad investigation of commonly instigated conservative therapies for secondary arm lymphoedema including; complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral pharmaceuticals, low level laser therapy, compression bandaging and garments, limb exercises and limb elevation. It was found that the more intensive and health professional based therapies, such as complex physical therapy, manual lymphatic drainage, pneumatic pump and laser therapy generally yielded the greater volume reductions, whilst self instigated therapies such as compression garment wear, exercises and limb elevation yielded smaller reductions. All conservative therapies produced improvements in subjective arm symptoms and quality of life issues, where these were measured. Despite the identied benets, there is still the need for large scale, high level clinical trials in this area. Key words: breast cancer, conservative therapies, lymphoedema

introduction
Currently, secondary arm lymphoedema affects approximately 30% of those who undergo breast cancer treatment [1] and results in excess uid accumulation in the interstitial space, detrimental tissue changes, limb swelling and quality of life issues. As this condition will generally worsen over time [2], a number of health professionals based and patient instigated conservative therapies that aim to decrease the limb swelling and its associated problems have been developed. Two systematic reviews have investigated some of these therapies in upper and lower limb lymphoedema, including manual lymphatic drainage, compression bandaging and garments [3] and benzopyrones [4], with both studies nding it difcult to make denitive therapy recommendations. Due to the chronicity of secondary arm lymphoedema there is still a need to determine the comparative benets of the different conservative therapies for this condition. Therefore this review aimed to undertake a broad investigation of commonly instigated conservative therapies for this population, including; complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral

pharmaceuticals, low level laser therapy, compression bandaging and garments, limb exercises and limb elevation.

inclusion and exclusion criteria

All study participants had to have a formal diagnosis of secondary arm lymphoedema subsequent to breast cancer surgery (total or partial mastectomy) radiotherapy chemotherapy. Studies which included participants with recurrent cancer and/or primary lymphoedema were excluded.

conservative therapies
This systematic review focused on therapies that are commonly administered to or undertaken by secondary arm lymphoedema patients, and included the following: Complex physical therapy (CPT) involves 24 weeks of daily manual lymphatic drainage (described below) followed by compression bandaging (administered by a health professional) and skincare plus prescribed limb exercises undertaken by the patient [5]. The patient is then tted with a compression garment. Manual lymphatic drainage (MLD) uses various light massage techniques to encourage the removal of excess interstitial uid, increase lymphatic transport and soften brotic induration

*Correspondence to: Ms A. L. Moseley, Institute of Womens Health, Department of Gynaecological Oncology, University College London, London, UK; E-mail: amanda.moseley@yahoo.com.au

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[68]. All methods start by clearing the areas distance or adjacent to the affected limb before moving to the limb root then to its most distal section and then back to the limb root again. Self/partner massage: Health professionals often teach patients (or their signicant other) a simplied version of manual lymphatic drainage which includes clearing of the adjacent area and limb root followed by sweeping strokes over the limb itself [9]. Pneumatic pumps: These are single or multiple chambered pumps that envelop the limb and inate and deate at different cycles and pressures to encourage uid drainage from the distal to the proximal end of the limb [12]. Oral pharmaceuticals encompass the alpha (a) Benzopyrones such as the Coumarin derivatives and the gamma (c) Benzopyrones such as the avones and avonols [16]. Benzopyrones may help lymphoedema by reducing vascular permeability, protein and extracellular uid accumulation [16, 17], stimulating lymph contractility and ow [16, 18] and reducing protein concentration and brotic induration in the tissues by stimulating proteolysis [19]. Low level laser therapy uses low intensity wave lengths between 6501000 nm, either in a scanning or spot laser form. Research suggests that laser therapy increases the rate of lymph vessel pumping and promotes lymph vessel regeneration [13], reduces pain [14] and softens both brous tissue and surgical scarring [15]. Compression bandaging consists of a gauze sleeve which protects the skin, soft cotton wrap or high density foam and 23 layers of short-stretch bandaging. Compression helps to decrease the amount of interstitial uid formation, prevent lymph back ow and enhance the muscle pump by providing a relatively inelastic barrier for the muscle to work against [10]. Compression garments have a similar mode of action as compression bandaging and are designed to be graduated, with the greatest compression being at the distal end of the limb and the least amount being at the proximal end. Limb exercises can be progressive, resistive or sequential in nature and are recommended as a way of varying total tissue pressure to encourage lymphatic drainage and for improving limb range of movement and strength [11]. Limb elevation reduces capillary exudation in to the tissues and promotes lymphatic return. It is considered most useful in the earlier (uid) stage of lymphoedema [5].

Annals of Oncology

The general terms used for all these search engines were as follows: Secondary lymphoedema/lymphedema Arm swelling/oedema/edema

These were then combined with the following terms:

Complex/complete, physical/decongestive therapy Manual lymphatic drainage/lymphatic massage/lymphatic drainage Support hosiery Compression garment/sleeve Compression bandaging/bandage Pneumatic/compression/intermittent pump therapy Exercise/physical therapy Elevation Laser/low level laser/laser therapy

In addition, health institution websites and online lymphatic societies were also searched. The biennial congress proceedings of The International Society of Lymphology (19772004) and the Australian Lymphoedema Association (20002004) were searched by hand. Primary authors were contacted when publications were difcult to source. The reference section of each article was also checked for relevant articles.

data extraction and quality assessment

Endnote 7 was used as the data extraction tool. Once the data had been extracted and recorded, the quality of each study was assessed and given a rating. The Quality Scale Assessment tools used in this review were based upon a tool developed by Mulrow and Oxman (1996) [20], with one tool being developed and used for the review of randomised trials (scored out of 10) and the other for non-randomised trials (scored out of eight). The data extraction and rating was undertaken by A. Moseley, with the process checked by N. Piller and C. Carati. The quality rating and level of evidence [21] for each reviewed study is presented in Table 1.

analysis
This review included studies performed in the randomized controlled, parallel and cross-over format plus case control and cohort studies. Case studies and anecdotal evidence were not reviewed. Due to treatment and data heterogeneity, a metaanalysis could not be performed. Therefore, only a narrative of the different conservative therapies for secondary arm lymphedema is presented. For ease of comparison, an approximate oedema reduction (%) has been calculated in each case where the limb volume reduction is presented in milliliters (ml).

literature search
The literature search was limited to English, with the following databases searched; Cumulative Index to Nursing & Allied Health Literature (Cinahl), Medline, Academic Research Periodicals, PubMed Clinical Queries (including Complementary Medicine), CANCERLIT, EBM Reviews Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (CDSR), American College of Physicians (ACP) Journal Club, Database of Abstracts of Reviews of Effects (DARE), PREMEDLINE, Australian Medical Index, Physiotherapy Evidence Database (PEDro) and the National Guidelines Clearing House.

results
The average percentage volume change at end of trial achieved by each reviewed conservative therapy is displayed in Figure 1. This demonstrates the magnitude of the reduction (average) that can be achieved by the different conservative therapies.

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Quality rating 4 5 4 5 4 4 3 3 4 8 2 2 6 5 5 6 5 5 2 6 5 5 4 7 7 4 7 8 8 5 5 2 5 6 5 1 5 5 4 4 4 5 6 Level of evidence III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-2 III-2 III-3 III-3 III-3 III-3 III-3 III-3 III-3 III-3 II II II II II III-3 III-3 III-3 III-2 III-2 III-3 III-2 III-3 III-3 III-2 III-3 III-3 III-2 III-3

Table 1. Quality rating and level of evidence of the reviewed conservative therapy studies Treatment CPT Szolnoky et al. [26] Wozniewski et al. [27] Szuba et al. [22] Piller et al. [9] Boris et al. [23] Bunce et al. [28] Caroll & Rose [24] Casley-Smith & Casley-Smith [25] Swedborg [29] MLD McNeeley et al. [34] DuBois [33] Korpon et al. [30] Ang et al. [37] Williams et al. [32] Andersen et al. [33] Johansson et al. [35] Johansson et al. [36] Piller et al. [31] Pneumatic pumps DuBois [33] Szuba et al. [39] Johansson et al. [36] Swedborg [40] Zelikovski et al. [41] Oral pharmaceuticals Burgos et al. [43] Loprinzi et al. [44] Pecking et al. [45] Cluzan et al. [40] Casely-Smith et al. [47] Low level laser Carati et al. [48] Piller & Thelander [50] Piller & Thelander [49] Compression Korpon et al. [30] Andersen et al. [33] Johansson et al. [35] Johansson et al. [36] Hornsby [51] Swedborg [40] Exercise Moseley et al. [52] Box et al. [53] Buckley et al. [54] Johansson et al. [11] McKenzie & Kalda [55] Elevation Swedborg et al. [56]

Figure 1. The average percentage volume change at end of trial of each conservative therapy.

complex physical therapy (CPT)

Five studies reviewed investigated standard CPT over a varying treatment period of 8 days to 3 months [9, 2225]. Participant numbers ranged from 1678, with some studies having no stated exclusion criteria [22, 23] and others having a poorly stated criterion [24, 25]. The reductions achieved from the ve studies varied from 298652 ml (18.766%), with three studies demonstrating additional volume reductions over 612 months follow up [9, 22, 25]. Two studies measured subjective symptoms, with one showing a reduction in pain [24] and the other in tightness, heaviness, pins and needles, cramps and tension [9]. One study investigated standard CPT (n = 13) in comparison with CPT plus 30 min of intermittent pump (50 mmHg) therapy (n = 14) [26]. After 10 days CPT alone yielded a 3.1% mean volume reduction whilst the CPT + pneumatic group had a statistically greater reduction of 7.9%. Although a reduction in symptoms was reported, it was not stated what symptoms were actually measured. The follow-up measurements over one and two months demonstrated a continuing decrease in percentage volume in both treatment groups (3.6% and 9.6% at 2 months). Two studies investigated CPT in combination with intermittent pump therapy. The rst study [27] involved 1 hour of intermittent pump (4070 mmHg) therapy incorporated into the CPT regime (n = 188), with this regime yielding statistically signicant percentage reductions in all grades of lymphoedemas (grade IIII, 43.419.3 %) after 5 weeks of treatment. The second study involved a regime of CPT with a pump of <60 mmHg (n = 25) [28]. After 1 month there was a reduction of 40% in excess limb volume, with this reduction being maintained at 12 months follow up. The last study investigated a combination of

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treatments incorporated into the CPT regime, including mechanical plus manual massage, hand grip exercises, the wearing of a compression garment and the addition of hot compresses during one treatment phase [29]. All treatment combinations yielded similar actual oedema reductions in the range of 8.513%. All the reviewed studies demonstrated that a reduction in limb volume and/or percentage oedema can be achieved with standard CPT, CPT plus pump therapy and a combination of therapies, with ve studies [9, 22, 25, 26, 28] demonstrating a continued volume reduction at follow up (range 112 months). The three studies [9, 24, 26] which measured subjective symptoms demonstrated that these improved after the CPT regime, unfortunately none of these studies report whether these improvements were sustained at the follow up periods. The study by Piller et al. (1996) also demonstrated that volume and subjective symptom reductions could be achieved when patients and their partners were taught how to apply a regime of lymphatic massage and compression bandaging themselves [9]. The optimal treatment period for CPT appears to be 1 month, however, two studies [22, 29] achieved a volume reduction at the end of 78 days of treatment.

Annals of Oncology

manual lymphatic drainage (MLD)

Two studies investigated the effect of MLD alone. These two studies [30, 31] involved 1217 participants who received MLD and who experienced a volume reduction of 104156 ml (810%), with one study reporting that the volume reduction was maintained at 6-months follow up [31]. The other study reported reductions in heaviness and tension, but did not state the inclusion/exclusion criteria or the length and frequency of MLD [30]. Two studies investigated MLD in comparison to another treatment modality. The rst of these studies used a cross-over design to investigated a phase of MLD and self massage (n = 27), each over a 3-week period [32]. Results showed that MLD produced a statistically signicant reduction of 71 ml and improvements in subjective heaviness, fullness and bursting whilst the self massage resulted in a non signicant reduction of 30 mls. The second randomized study investigated MLD (n = 20) in comparison to a control group who undertook education, wearing a compression sleeve and limb exercises (n = 20) [33]. After 2 weeks the control group actually had a greater percentage reduction in absolute oedema (60%) in comparison to the MLD group (48%). Both groups equally experienced a reduction in the symptoms of heaviness and tightness, whilst the control group also had a reduction in reported discomfort. The reduction in absolute oedema (66%) was maintained at 12-months follow up (pooled data). Four studies investigated the effect of MLD in combination with compression (bandaging or garment). All four studies had a clearly stated inclusion/exclusion criterion, with the rst two studies investigating MLD plus compression bandaging. These two studies [34, 35] involved 1824 women who received MLD plus compression bandaging over 1 week to 1 month. After 1 week there was a signicant volume reduction of 47 ml (11% in oedema) [34], whilst over 1 month the reduction was 260 ml (46.1%), with signicant improvements in tension, heaviness and pain [35]. The third study investigated the effect of

a compression (3040 mmHg) sleeve worn for 2 weeks followed by 2 weeks of additional MLD (n = 12) [36]. Wearing the sleeve alone resulted in a signicant volume reduction of 49 ml (7%), with the addition of MLD resulting in a signicant reduction of 75 ml (15%). Both phases also signicantly improved arm tension and heaviness. The last study investigated MLD in combination with a compression garment or bandaging once a week for 12 weeks [37]. Both treatment groups experienced signicant reductions in oedema of 84% and 78% respectively. One study compared MLD and pneumatic pump therapy [38], with one group receiving 1 hour of MLD over 43 sessions (n = 27) and the other receiving 0.5 h of pump therapy (40 mmHg) followed by 0.5 h of MLD over 25 sessions (n = 62). Results showed that the MLD alone and when combined with pneumatic pump therapy yielded similar reductions in oedema volume (40% and 45% respectively), however, there were no accompanying statistical values so signicance is not known. The follow up period in this study (1424 months) demonstrated an oedema volume increase of 33% in those who underwent no further treatment, whilst those who underwent regular treatment (type not stated) experienced a slight reduction (1%) in oedema volume. The volume reductions achieved by MLD alone varied from 104156 ml, with the greatest percentage reduction being 48% [33]. Larger reductions were achieved from MLD in combination with compression, which varied from 47260 ml (784%), with these studies demonstrating that either form of compression (garment or bandaging) could be effectively used in combination with MLD. MLD in combination with pneumatic pump therapy was also shown to be effective [38]. The majority of volume reductions were achieved after a 4 week treatment period, although volume reductions were also seen to occur over 2 weeks of treatment [31, 33, 36]. Only three of the reviewed studies included a follow up period which demonstrated that the initial volume reductions were maintained [31, 33, 38]. The overall lack of follow up in these studies makes it difcult to formulate strong conclusions on the long term benets of MLD ( bandaging).

pneumatic pump therapy

Five studies were reviewed which investigated the effect of pneumatic pump therapy. The rst was a poorly reported study which involved a group that received a combination of MLD (0.5 h) and pump therapy (0.5 h) over 25 sessions (n = 62) and another that received 6 hours of sequential (40 mmHg) pump therapy (only) over 5 days (n = 14) [38]. Both groups experienced identical oedema volume reductions (45%), with this reduction being achieved over a shorter treatment duration (5 days) in the pump only group. However, considering this group had a sample size of 14, it is hard to determine whether this volume reduction is a true reection of what can be achieved with this form of sequential (40 mmHg) pump. Szuba et al. (2002) performed two randomised studies which investigated the use of a four-chambered, sequential pump as an adjunct therapy [39]. The rst study compared 10 days of complex physical therapy (CPT) alone (n = 11) and in combination with 30 min of 3040 mmHg pump therapy (n = 12). Results showed that the CPT plus pump therapy

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volume (14.9% and 13.2% respectively) and reductions in heaviness, pain and cramps. The second study used a cross over design to investigate a 6-month phase of Coumarin (400 mg) and a 6 month phase of a placebo (n = 138) [44]. Results demonstrated a volume increase (and therefore worsening) of 58 ml (6%) in the treatment phase and 21 ml (2.1%) in the placebo phase. Despite this, participants reported improvements in arm swelling, pressure, tightness, heaviness and mobility. The third study investigated Daon (Diosmin plus Hesperidin 1g, n = 46) or placebo (n = 48) over 6 months [45]. After this period the treatment group experienced a 7% volume reduction whilst the placebo group experienced a volume increase of 10%. Both groups experienced a signicant reduction in reported discomfort, with the treatment group also having a signicant reduction in heaviness. The fourth study investigated three capsules of Cyclo-Fort (Ruscus Aculeatus and Hesperidin Methyl Chalcone) three times a day (n = 27) compared to placebo (n = 30) over 3 months, with the addition of MLD (2 week) in the rst month of the trial [46]. After the rst month both the treatment and placebo groups experienced volume reductions of 1.2% and 0.5% respectively. By 3 months the treatment (Cyclo-Fort) group had an overall volume reduction of 12.9% whilst the placebo group had an increase of 2.5%. Both groups experienced improvements in heaviness and limb mobility, with these being signicant in the Cyclo-Fort group. The last study used a cross over design to investigate a 6 month phase of 56 Benzo-a-pyrone (200 mg) and placebo (n = 31) [47]. Results demonstrated a volume reduction of 840 ml (35.6%) in the treatment phase, with this reduction being signicant in comparison to the control phase in which the limb increased in volume by 490 ml (41.6%). A 1-month follow up demonstrated an additional decrease of 3.3% in oedema (treatment phase) and an additional increase of 1.2% (placebo phase). The two studies which investigated Coumarin had conicting results, with one showing a decrease in arm volume (dosage 90 mg, 135 mg) [43] and the other showing an increase in volume (dosage 400 mg) [44]. As neither study had a follow up period it is not known whether the initial volume reduction or increase would have continued. The other reviewed studies [4547] demonstrated that varying volume reductions and subjective improvements could be obtained from oral pharmaceuticals such as Daon (1000 mg) and Cyclo-fort, with the greatest limb reduction (840 ml, 35.6%) being obtained from the 56 Benzo-a-pyrone (200 mg) [47]. It is also important to note that two studies [43, 47] reported gastrointestinal upsets in 13.7% and 22.6% of participants.

resulted in a greater and signicant limb volume reduction in comparison to CPT alone (45.3% versus 26% respectively). Interestingly, the CPT plus pump therapy reduction was not maintained at 1 month follow up (increase of 15%), whilst the CPT alone reduction was maintained. The second study investigated a 1 month phase of arm self maintenance including self massage and compression garment wear, followed by a phase of applying 1 hour of pump therapy for a further 1 month period (n = 25). The self maintenance phase resulted in an arm volume increase of 32.7 ml (3.3%), with the addition of the 1 h of pump therapy resulting in a statistically signicant reduction of 89.5 ml (9.0%). Some participants continued using the pump an average of four times a week for 6 months, with 19 participants having an additional reduction in limb volume of 29.1 ml (3.0%) and ve having an increase of 35 ml (3.5%). Why this sub-group of participants had a worsening in limb volume was not explored. One study investigated 2 h of pump therapy (4060 mmHg) 5 days a week for 2 weeks [36]. After this time there was a non signicant reduction in arm volume (28 ml; 7%) and reported tension and heaviness. One study investigated the wearing of a compression (3040 mmHg) garment for 6 months then 6 h of pump therapy (3560 mmHg) over 10 sessions followed by the continued wear of the compression garment (n = 54) [40]. Results showed a signicant 8% reduction after wearing the compression garment and an additional 9% signicant reduction after the pump therapy (with the assumption that the total edema reduction at this time point was 17%). A 6-month follow up demonstrated a 19.8% reduction in those who continued to wear the compression garment. The last study investigated 23 h of sequential (100150 mmHg) pump therapy, three times a day for 3 days (n = 25) [41]. After 3 days the percentage reduction ranged from 1244% (statistical values not stated). After trial cessation, 2 h of maintenance therapy was applied onefour times a week over the following 6 months. Follow up at this time showed that the initial treatment reductions had been maintained. However, it was not reported whether the maintenance of limb volume was the result of one or four sessions of treatment per week. Two studies [38, 41] demonstrated that volume reductions could be achieved from pump therapy alone, although the high pressures (100150 mmHg) used by Zelikovski et al. (1980) [41] are above the 60 mmHg of pressure normally recommended for the treatment of lymphoedematous limbs [42]. Three of the reviewed studies [36, 38, 40] demonstrated that better results in volume reduction were achieved when the pneumatic pump was combined with other therapies, including; manual lymphatic drainage, compression garments and self massage. Three studies [38, 40, 41] also demonstrated that continuing the pump therapy or wearing a compression garment were benecial in maintaining the initial volume reductions.

low level laser therapy

Three studies were reviewed which investigated concentrated or scanning laser therapy. The rst study was a double-blinded, randomised controlled trial involving one group which received two cycles of active laser to the axilla three times a week for 3 weeks (n = 37) and another group who received one cycle of placebo laser and one cycle of active laser (n = 27) over the same time periods [48]. At trial end there were volume reductions in all phases: placebo; 35 ml (3.5%), one cycle; 15 ml (1.5%), two cycles; 25 ml (2.5%). A 3-month follow up demonstrated

oral pharmaceuticals
Five studies were reviewed that investigated the effect of oral pharmaceuticals. Two studies investigated Coumarin [43, 44], with the rst study investigating two dosages; 90 mg (n = 23) and 135 mg (n = 30) over 12 months [43]. At trial end, both groups experienced a similar reduction in percentage limb

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a volume increase of 30 ml (3.0%) in those who received placebo and volume reductions in the one cycle (10 ml 1.0%) and two cycle (90 ml 9.0%) phases. The two cycle phase also resulted in a signicant reduction in the mean perceptual score and improvements in quality of life parameters. The second study investigated 30 min of scanning laser, twice a week for 6 weeks and then once a week for a further 4 weeks (n = 10) [49]. This resulted in a volume reduction of 19.3% and progressive improvements in subjective symptoms. A follow up study of these participants (n = 8) [50] demonstrated that there were continued volume reductions of 397 ml (40%) at 6 months and 288 ml (29%) at 36 months, with subjective symptoms returning to pre-treatment levels by the 36-month mark. These three studies demonstrate that benets including volume reduction, improved subjective symptoms and quality of life can be derived from either concentrated or scanning laser therapy. The best results in the Carati et al. (2003) study [48] were seen at 3 months post treatment, which suggests that there maybe ongoing benets from laser therapy. This is supported by the Piller and Thelander (1998) study [50] (albeit with a much smaller sample size), which found that there were continued reductions in arm volume and reported arm tightness 6 months after treatment cessation.

Annals of Oncology

achieved when the wearing of a compression garment was combined with limb exercise or self massage.

exercise
Five studies were reviewed which investigated a variety of exercise regimes. The rst study investigated a 10-minute arm exercise and deep breathing regime (n = 38) [52] which resulted in an arm volume reduction of 52 ml (5.8%) and improvements in heaviness and tension, with some reductions maintained over 24 h and 1 week follow up. After 1 month of performing this regime (n = 24) there was a volume reduction of 101 ml (9%) and signicant improvements in heaviness and perceived limb size. Two studies investigated the effects of 4045 min of hydrotherapy [11, 53], with neither study stating the exclusion criteria. The rst was a randomised study which involved a control group (n = 8) and a hydrotherapy exercise group (n = 8) [53]. After 4 weeks there was a volume reduction of 48 ml (4.8%) in the hydrotherapy group, with continued reductions at 3 and 6 weeks follow up (30 ml 2.9% and 86 ml 8.6% respectively). This in comparison to the control group, which increased in limb volume. The exercise group also had reductions in reported aching, heaviness, tightness, limb swelling, stiffness and heat intolerance. The second study investigated hydrotherapy performed by seven participants in two different pool temperatures (28 C; 82 F and 34 C; 93 F) [11]. After the rst session (28 C) there was a decrease in arm volume of 32 ml (12% oedema change), whilst after the second session (34 C) there was a slight increase in volume of 2 ml (0.7% change). Subjective symptoms remained unchanged after both pool sessions. One study investigated a 30 min regime of instructed deep breathing, self massage and sequential limb exercises (n = 7) [54]. Directly after performing the regime there was a slight increase in arm volume (12 ml, P = n.s.), with a net decrease (12 ml, P = n.s.) experienced 20 minutes post regime. Despite the minimal volume reduction, the group reported improvements in arm range of movement, subjective limb temperature difference, heaviness and tightness. Two studies investigated the effect of resistive arm exercises. The rst of these studies involved a regime of shoulder exion and abduction and elbow extension and exion using 0.5 kg hand weights, performed rstly with no compression garment and secondly when wearing a compression garment (n = 23) [11]. Results showed an initial increase in arm volume after performing the regime, plus or minus garment wear (12 ml, 0.5% and 10 ml, 0.3% respectively). However, at the 24 h follow up the volume increases had been reversed, with both phases demonstrating a volume reduction of 15 ml (0.71.0%) at this time point. Reported tension and heaviness remained unchanged in both phases, however, when the regime was performed without a compression garment there was a signicant increase in reported physical exertion. The second study investigated latissimus dorsi, bicep and tricep exercises with weights and the wearing of a compression garment undertaken three times a week for 8 weeks (n = 7) [55]. This resulted in a limb volume reduction of 2% plus signicant improvements in physical functioning, general health and vitality. The ve studies reviewed demonstrated that exercise regimes can have a varying impact upon limb volume, ranging from

compression
Four studies investigated the effect of compression (garment or bandaging) alone. Two studies [30, 35] which involved 3555 participants investigated compression bandaging. These studies demonstrated a volume reduction of 38 ml (7%) [30] and 20 ml (4% oedema) [35] respectively and signicant improvements in arm heaviness and tension. Two studies investigated the effect of a 3040 mmHg compression garment. The rst study involved 12 participants who wore the garment over a 2-week period [36], after which time there was a signicant volume reduction of 49 ml (5.0%) and improvements in tension and heaviness. The second study involved participants (n = 26) wearing the compression garment over a 6-month period [40]. Results showed an 8% reduction in actual oedema, however, at the 6-month point only 12 women remained in the study. Two studies investigated the effect of wearing a compression garment in combination with other activities. One study [33] demonstrated that after 3 months of limb exercise and compression wear (n = 22) there was a 60% reduction in absolute oedema, with the other study showing a 243 ml (24.4%) volume reduction after 4 weeks of self massage combined with compression wear [51]. Neither study reported statistical values, so the signicance of these volume reductions are not known. Four of the reviewed studies [30, 35, 36, 40] demonstrated that modest volume reductions of 2049 ml (48%) and signicant improvements in heaviness and tension could be achieved when wearing compression (bandaging or garment) alone. However, none of these studies included a follow up period, so the ongoing effects of compression cannot be determined. Two studies [33, 51] demonstrated that greater volume reductions of 243 ml (24.4%) and 60% could be

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demonstrates the chronic nature of this condition. Despite the range of positive outcomes identied in this review, the evidence to support them is, in some instances, poor. Therefore, there is still a need for large scale, high level clinical trials in this area.

12101 ml (0.49%), with three studies demonstrating improvements in subjective symptoms [5254]. Sustained volume reductions were also seen to occur 24 h to 6 weeks after exercise program cessation [11, 52, 53]. The hydrotherapy study [11] suggests that this form of exercise is best undertaken in a pool temperature of 28 C (82 F).

elevation
Only one study was reviewed that investigated the effects of limb elevation [56]. It involved 33 women who elevated their arm at 80 angle over a 5-h period. At the end of this time there was a signicant 3.1% reduction in arm volume. Subjective symptoms and adverse effects were not recorded, so it is not known how well this regime was tolerated.

references
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discussion
In recent times, sentinel lymph node biopsy (SLNB) has become a more common procedure in breast cancer surgery, resulting in less arm morbidity [57], including lymphoedema [58]. However, there is still the possibility of developing arm lymphoedema after SLNB, especially if the sentinel node is located at the level of the axillary vein and lymphatic collectors [59] and if SLNB is combined with axillary radiotherapy [60]. Although the number of women developing arm lymphoedema maybe reduced as a consequence of SLNB, it is still important to know the benets of conservative therapies for the proportion of women who do go on to develop this condition after breast cancer treatment. The current review investigated conservative therapies for arm lymphoedema that can essentially be divided into intensive treatments administered by trained health professionals and limb maintenance therapies undertaken by the patient. As demonstrated by Figure 1, treatments that are predominantly administered by health professionals, such as complex physical therapy, manual lymphatic drainage (with and without compression), laser therapy and pneumatic pump therapy generally yielded the larger percentage volume reductions. Maintenance therapies (normally undertaken by the patient), such as wearing a compression garment, limb exercises, elevation and self massage generally yielded smaller percentage reductions. There is some research to suggest that undertaking therapies such as arm rehabilitation and exercise may prevent the onset of lymphoedema [61], but further research is required to determine the true benets of such programs. Although those therapies which would be categorised as self maintenance yielded smaller volume reductions, this review has demonstrated that they are more benecial than doing nothing at all for the lymphoedematous limb. This indicates that such therapies maybe useful when health professional based therapies are not accessible or economically viable for the patient. The review also demonstrated the positive impact upon subjective limb complaints and quality of life issues, indicating that these conservative therapies can be initiated by the health professional or patient with the anticipation of some benet. Follow up periods (when incorporated) indicated that some form of continuing therapy (intensive or patient based) needed to be undertaken to maintain the initial volume reductions, which

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review
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