Physical therapies for reducing and controlling lymphoedema of the limbs

  • Review
  • Intervention

Authors


Abstract

Background

Lymphoedema is the accumulation of excess fluid in the body caused by obstruction of the lymphatic drainage mechanisms. Management involves decongesting the reduced lymphatic pathways in order to reduce the size of the limb. There is a great deal of debate as to which components of a physical treatment programme are the most crucial.

Objectives

To assess the effect of physical treatment programmes on:

volume, shape, condition and long-term control of oedema in lymphoedematous limbs;
psycho-social benefits.

Search methods

We searched the Cochrane Breast Cancer Group trials register (October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2008), MEDLINE, EMBASE, CINAHL and the National Research Register (February 2008) and UnCover, PASCAL, SIGLE, reference lists produced by The British Lymphology Society and The International Society of Lymphology congress proceedings (September 2003).

Selection criteria

Randomised controlled clinical trials that tested physical therapies with a follow-up period of at least six months.

Data collection and analysis

Two blinded reviewers independently assessed trial quality and extracted data . Meta-analysis was not performed due to the poor quality of the trials.

Main results

Only three studies involving 150 randomised patients were included. Since none studied the same intervention it was not possible to combine the data. One crossover study of manual lymph drainage (MLD) followed by self-administered massage versus no treatment, concluded that improvements seen in both groups were attributable to the use of compression sleeves and that MLD provided no extra benefit at any point during the trial. Another trial looked at hosiery versus no treatment and had a very high dropout rate, with only 3 out of 14 participants in the intervention group finishing the trial and only 1 out of 11 in the control group. The authors concluded that wearing a compression sleeve is beneficial. The bandage plus hosiery versus hosiery alone trial, concluded that in this mixed group of participants bandage plus hosiery resulted in a greater reduction in excess limb volume than hosiery alone and this difference in reduction was maintained long-term.

Authors' conclusions

All three trials have their limitations and have yet to be replicated, so their results must be viewed with caution. There is a clear need for well-designed, randomised trials of the whole range of physical therapies if the best approach to managing lymphoedema is to be determined.

摘要

背景

減少與控制四肢淋巴水腫之物理治療法

淋巴水腫起因於淋巴循環阻塞,造成過多的體液堆積在身體. 治療的方式包括活絡已狹隘的淋巴途徑,以減少肢體的大小. 至於物理治療計畫那一部份是是最關鍵的,則有許多的爭論.

目標

對淋巴水腫的四肢,在體積,形狀,條件和長期控制水腫方面,評估物理治療計畫的成效.

搜尋策略

我們搜尋了考科藍乳癌群組登記(2003年9月),考科藍中心登記的控制試驗(考科藍圖書館2003 Isuu), MEDLINE, EMBASE, CINAHL, UnCOver, PASCAL, SIGLE, 英國淋巴學會參考清單, 國家研究登記處(NRR),以及淋巴學國際學會發表記錄.

選擇標準

物理治療的隨機控制臨床試驗並且追蹤至少六個月.

資料收集與分析

兩皆不知情的評估者,獨立評估試驗的品質和收集的資料. 因為試驗品質不佳,所以沒有進行統合分析.

主要結論

只有三個研究被納入,共有150個隨機的病人. 沒有研究是用同樣的介入方式,所以不可能合併資料. 一個針對手動淋巴排液後自己按摩與沒有治療的交叉研究顯示, 兩組都有改善, 因為兩組都有使用彈性袖套, 所以手動淋巴排液並沒有額外的助益. 另外一個研究針對使用彈性襪與沒有使用的結果,因為有很高的退出率, 14個參與者只有3個人完成試驗, 對照組11個之中只有一個完成試驗. 作者的結論是, 壓迫性的彈性袖套是有益處的. 繃帶加上彈性襪與只用彈性襪的比較試驗發現前者大大減少肢體的水腫量, 而且效果維持很長的時間.

作者結論

三個試驗都有其限制, 還沒有被重現,因此結果必須審慎地看待。 很明顯地,需要設計一種良好的隨機試驗來檢視許多的物理療法,以找出最好的方式來處理淋巴水腫的問題。

翻譯人

本摘要由中山醫學大學附設醫院張集武翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

目前沒有足夠的證據可以定論哪種淋巴水腫的物理治療是最好的. 淋巴水腫多半是在手臂和腿部聚積體液. 有些人可能出生就有,有些是寄生蟲感染引起(開發中國家偏多),手術也會引起(乳癌手術後引起的手臂水腫最常見). 治療方式一般是使用彈性襪(例如: 包紮,袖套),皮膚護理和運動治療. 這篇回顧發現,目前尚無足夠的好證據可以定論哪種治療是最有用的.

Plain language summary

Physical therapies for reducing and controlling lymphoedema of the limbs

Lymphoedema is the build up of excess fluid in the body tissues because of obstruction of lymphatic drainage back into the bloodstream. The affected limb becomes swollen, distorted in shape with pain, discomfort all of which impair movement and daily activities. It can be caused by a congenital abnormality, chronic venous insufficiency, damage to the lymphatic system following treatment of cancer or filariasis, a parasitic infection endemic in parts of India and Africa. Skin care is important as the affected tissues gradually thicken and are susceptible to inflammation and infections. People are also encouraged to exercise regularly and control their weight. Different physical treatments aimed at improved lymph drainage include multi-layer bandaging, manual lymph drainage (MLD), self-administered massage and compression sleeves or hosiery.

The authors of this review, which aimed to assess the effect of physical treatment programmes on the long-term control of lymphoedema, identified only three controlled trials for inclusion. These randomised a total of 150 adults to different levels of physical treatment. One trial involved 42 women with unilateral lymphoedema of the upper limb following treatment for breast cancer. One group received eight sessions of MLD in two weeks and training in self-massage and both this group and the control group wore flat-knit compression sleeves. The reductions in excess arm volume and symptoms were similar in the two groups.

A second trial involved 25 women from a local follow-up breast clinic. They were trained in self-administered massage and randomised to wear an elastic compression sleeve or no additional treatment. The dropout rate was high, particularly in the control group, although the authors concluded that wearing a compression sleeve was beneficial. The third trial involved 83 mostly female participants from a lymphoedema clinic. Around two thirds had upper limb oedema. They were all taught self-administered massage. One group received a 19-day bandaging course before being fitted with hosiery. The other group wore hosiery from the start of the trial. The reduction in excess limb volume was consistently greater in those who started with multi-layer bandaging.

All three trials had methodological limitations, and as their data could not be combined, and they recruited only small numbers of participants, questions relating to the effect of this type of treatment could not be answered by this review.

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