Early Physiotherapy of the Arm After Breast Cancer Surgery Reduces Lymphedema

Clinical trial recommends that early physio can reduce deblitating complication such as lymphedema of the arm after radiotherapy or surgery lymphedema.

Present statistics indicate that women with breast cancer have a 77% chances of survival for at least 10 years; therefore it is important to effectively prevent and manage complications after treatment of the cancer.

Any node excision can lead to stasis of lymph in the area and it is no different when it comes to breast cancer surgical treatment. The axillary lymph nodes drain from breast tissue and are responsible for spread of the cancer to other parts of the body, hence their removal is indicated when doing curative surgery in breast cancer. A randomized, single- blinded, clinical trial of women after unilateral breast cancer surgery with axillary lymph node dissection was carried out at the Príncipe de Asturias Hospital in Madrid between May 2005 and June 2007 by Maria Torres et al and their findings were published recently in British Medical Journal.

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The study strived to analyze the unaddressed needs of women, in whom symptoms and signs indicate the presence of lymphoedema, post breast cancer treatment.

The study tried to determine the efficacy of an early physiotherapy programme in reducing the risk of lymphoedema in women after breast cancer surgery involving dissection of axillary lymph nodes.

Subjects - 237 women with signs and symptoms of lymphoedema formed the subject of study.

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Women without axillary lymph node dissection or with bilateral breast cancer, systemic disease, loco-regional recurrence, or any contraindication to physiotherapy were excluded from the study.

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An acquired interruption or damage to the axillary lymphatic system after breast cancer surgery, or after radiotherapy for breast cancer, may result in generalized or regional accumulation of lymph fluid in the interstitial space. This condition, known as secondary lymphoedema, is the most important chronic complication after axillary lymph node dissection. It has a tendency to progress.

Secondary lymphoedema can cause physical discomfort, disfigurement, and functional impairment. Other factors seen in patients with secondary lymphoedema include anxiety, depression, and emotional distress.

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The condition can badly undermine self esteem and can affect social relationships. It can aggravate cellulitis, erysipelas, lymphangitis, and can occasionally cause lymphangiosarcoma ( a form of cancer).

The factors that influence secondary lymphoedema development after surgery:

• Number of lymph nodes removed

• Radiotherapy to the axilla

• Post -surgery wound infection,

• Post-surgical drainage time

• Lack of mobility,

• Obesity.

The incidence rates for secondary lymphoedema, ranges from 5% to 56%, two years post- surgery.

Method - Each subject was evaluated pre-operatively and also between days 3 and 5 after hospital discharge. Equal numbers of participants were then randomly assigned to either:

• The early physiotherapy and an educational strategy (early physiotherapy group) or

• The educational strategy only (control group).

The incidence of secondary lymphedema was the main outcome.

Management/ Interventions - Early physiotherapy group and control group would receive the same educational intervention.

a) Early physiotherapy group - In this group, manual lymph drainage technique was used to treat post-operative oedema. This group also did shoulder exercises and stretching in their homes, once daily during the three -week intervention period.

b) Educational strategy (both groups)- Here, printed materials with instructions about the lymphatic system, concepts of normal load versus overload, the factors leading to secondary lymphoedema, identification of potential precipitating factors, and the four categories of interventions to prevent secondary lymphoedema were given to the patients.

Follow-up - Four follow-up visits were to be carried out. They were four weeks three months, six months, and 12 months after surgery. These dates were flexible, depending on the availability of the participant. If patients experienced pain, discomfort, or any other symptoms a physiotherapist was asked to visit them.

If secondary lymphoedema developed, complex decongestive physiotherapy was carried out on those patients.

Results and Conclusion - Of 120 women studied, 60 were slotted in the early physiotherapy and an educational strategy group and 60 to the educational strategy only group.

It was discovered through the study that early physiotherapy along with an educational strategy helped to lower the risk of secondary lymph edema in women post breast cancer surgery involving dissection of axillary lymph nodes, in comparison to the educational strategy only (control group).

Secondary lymphoedema developed from six to 12 months post surgery. The authors suggest that the manual lymph drainage after breast cancer surgery in the early physiotherapy group could be one of the contributing factor towards better results in that group.

The study concludes that early physiotherapy could play a role in preventing and reducing secondary lymphoedema in post- breast cancer surgery patients involving dissection of axillary lymph nodes, at least for one year following surgery.As for understanding its role long-term, more work is required.

The researchers also stress upon the positive role of physiotherapy in creating awareness, prevention, early diagnosis, and management of secondary lymphoedema.

Source: Priorities for women with lymphoedema after treatment for breast cancer: population based cohort study; Maria Torres et al; BMJ 2010; 340:b5396

* http://www.bmj.com/content/342/bmj.d3442

Source-Medindia