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Evaluation of the Clinical Effectiveness of Physiotherapeutic Management of

Lymphoedema in Palliative Care Patients

Article in Japanese Journal of Clinical Oncology · November 2010

DOI: 10.1093/jjco/hyq093 · Source: PubMed

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 Jpn J Clin Oncol 2010;40(11)1068 – 1072
doi:10.1093/jjco/hyq093
Advance Access Publication 17 June 2010

Evaluation of the Clinical Effectiveness of Physiotherapeutic

Management of Lymphoedema in Palliative Care Patients
Katri Elina Clemens 1,2,*, Birgit Jaspers 1,3, Eberhard Klaschik 1 and Peter Nieland 4
1
Department of Science and Research, Centre for Palliative Medicine, University of Bonn, 2Department of Palliative
Medicine and Pain Therapy, Malteser Hospital Bonn/Rhein-Sieg, Bonn, 3Department of Palliative Medicine,
University of Goettingen, Goettingen and 4Department of Physiotherapy and Rehabilitation, Malteser Hospital Bonn/
Rhein-Sieg, Bonn, Germany

*For reprints and all correspondence: Katri Elina Clemens, Department of Science and Research, Centre for
Palliative Medicine, Malteser Hospital Bonn/Rhein-Sieg, Von-Hompesch-Str. 1, D-53123 Bonn, Germany.
E-mail: katri-elina@malteser.org
Received January 7, 2010; accepted May 10, 2010; published online June 17, 2010

Objective: Lymphoedema is a common sequela of cancer or its treatment that affects lymph
node drainage. The physiotherapist, as member of the multiprofessional team in palliative
care, is one of the keys to successful rehabilitation and management of patients with cancer
and non-malignant motoneuron disease such as amyotrophic lateral sclerosis and palliative
care needs. The aim of the study was to evaluate the frequency and effect of manual lym-
phatic drainage in palliative care patients with lymphoedema in a far advanced stage of their
disease.
Methods: Retrospective study (reflexive control design) of data of the 208 patients admitted
to our palliative care unit from January 2007 to December 2007. Demographic and disease-
related data (diagnosis, symptoms, Karnofsky performance status and effect of manual lym-
phatic drainage interventions) were documented and compared. Statistics: mean + SD,
median; Wilcoxon’s test.
Results: Of the 208 patients, 90 who reported symptom load due to lymphoedema were
included; 67 (74.4%) had pain, 23 (25.6%) dyspnoea due to progredient trunk oedema. Mean
age 65.5 + 13.0 years; 33 (36.7%) male; Karnofsky index 50% (30 – 80%), mean length of
stay 15.6 + 8.0 days. The mean number of physiotherapeutic treatment interventions was
7.0 + 5.8. Manual lymphatic drainage was well tolerated in 83 (92.2%) patients; 63 of 67
(94.0%) patients showed a clinically relevant improvement in pain, and 17 of 23 (73.9%) in
dyspnoea.
Conclusions: The majority of the patients showed a clinical improvement in the intensity of
symptoms after manual lymphatic drainage.

Key words: palliative care – lymphoedema – manual lymphatic drainage – physiotherapy –

symptom control

INTRODUCTION
who have undergone resection and/or irradiation of a lymph
Lymphoedema is defined as the abnormal accumulation of node bed. Upper-extremity lymphoedema most often occurs
protein-rich fluid of the lymphatic system (1) due to failure with breast cancer and lower-extremity lymphoedema most
of physiological lymphatic drainage in the interstitial tissue. often with prostate cancer, uterine cancer, lymphoma or mel-
It is a common concomitant symptom of terminal cancer or anoma (2).
sequela of antineoplastic cancer therapy such as chemother- Patients undergoing axillary surgery and/or radiation
apy and/or radiation therapy and one of the most underesti- therapy for breast cancer are at higher risk for developing
mated and least researched complications of cancer diseases lymphoedema of the arm (3,4). Breast cancer survivors with
or its treatment. The incidence is highest among patients arm lymphoedema have been found to be more disabled and
# The Author (2010). Published by Oxford University Press. All rights reserved.
 Jpn J Clin Oncol 2010;40(11) 1069

have more psychological distress than do survivors without achieving maximum physical, psychological functioning and
lymphoedema (5,6). In addition, patients having lymphoe- performing the activities of daily living within the limits
dema reported significantly lower quality of life with mul- imposed by disease or treatment (13). Adopting a rehabilita-
tiple functional assessments (7). Patients with lymphoedema tive approach shifts the focus from a preoccupation with the
may report a wide variety of complaints: heaviness or full- disease to one which is needs-led (14). Cancer patients may
ness related to the weight of the limb, a tight sensation of present with a wide range of needs that may benefit from
the skin or a decreased flexibility of the affected joint and physiotherapeutic intervention (15).
not least increasing pain and dyspnoea. Lymphoedema has McDonnell and Shea (16) stated that the role of phy-
been reported to occur within days and up to 30 years after siotherapy in oncological rehabilitation includes restoring
treatment for breast cancer (8). Eighty per cent of patients function, reducing pain, reducing disability, increasing con-
experience onset within 3 years after surgery; the remainder ditioning and mobility, and ultimately improving quality of
develop oedema at a rate of 1%/year (7). The prevalence and life. There are few powerful studies concerning the effi-
incidence of pain in lymphoedema are not well known. No ciency and hardly any concerning combined or comparative
prospectively controlled data exist, nor are there any large management of lymphoedema in PC patients, and none in
population-based reviews attempting to define the scope of PC patients in a far advanced stage of their disease.
pain in this population. Its prevalence has been reported as Supportive therapy options are rarely being discussed.
ranging from 30 to 60%. However, these numbers are based In our PC unit, physiotherapists with expertise in MLD
on small studies of women with breast cancer receiving are frequently used for the management of lymphoedema in
therapy for lymphoedema. Therefore, these reports may be our patients with far advanced cancer and amyotrophic
biased towards over-representation. Clinical experience does lateral sclerosis (ALS). The aim of the present study was to
suggest that pain is present in a significant number of evaluate the patient documentation for frequency and effects
women with post-axillary node dissection lymphoedema. of these measures with regard to a reduction in lymphatic
Part of the difficulty in determining the prevalence of pain is oedema, pain and dyspnoea.
that different types of pain are encountered in individuals
afflicted with lymphoedema. Additionally, an important
question remains unanswered: is lymphoedema itself painful, PATIENTS AND METHODS
or is pain reported due to concomitant pathologies in the
affected region, such as loss of muscle tissue and function; In a retrospective study, data of the 208 patients with far
or scar tissue causing shortening of muscles and less move- advanced cancer or ALS admitted to our PC unit from
ment at joints; or is pain the result of oedema causing January 2007 to December 2007 were evaluated. Patients
increased pressure on certain structures in sensitive areas (9). with lymphoedema and receiving MLD were included.
However, the occurrence of lymphoedema is a devastating Documented demographic patient and disease-related data,
problem of patients suffering from cancer and may have a such as diagnosis, symptoms and side effects, Karnofsky
major impact on their quality of life. In most cases, it indi- performance status, intensity of pain and dyspnoea at admis-
cates the progression of illness and also results in multiple sion and daily during the course of stay were analysed. In all
physical changes, which add to the already existing patients, pain therapy with opioids and co-analgesics was
disease-related impairments. Therapeutic interventions are adjusted prior to the first MLD. The effect of MLD interven-
limited and symptoms due to lymphoedema are mostly chal- tions, as evaluated and documented by the physiotherapist in
lenging for the therapeutic team. Current management con- charge at our PC unit at the time of treatment, was evaluated.
sists of combined physical therapy and pharmacological Compared, using a reflexive control (before and after)
symptom control. design, were data on the intensity of pain and dyspnoea at
In palliative care (PC), physiotherapy has an important admission with documented data directly prior to and after
supportive role in the management of pain and other distres- MLD and reduction of lymphoedema as documented after
sing symptoms, such as respiratory symptoms due to lym- each individual MLD. The occurrence of adverse effects of
phoedema. Most often used in PC patients is manual medications had been categorized as either absent or exist-
lymphatic drainage (MLD), a sophisticated procedure based ing; thereafter, side effects and symptoms were assessed and
on a technique developed by Vodder (10) and perfected by documented on a daily basis.
Foldi (11) and other investigators, which requires specialized
and costly training.
ASSESSMENTS
It has been stated that the absence of physiotherapy inter-
vention would be detrimental to patient care and the ability The intensity of pain and dyspnoea was measured on a
of the patient to cope with the effects of the disease or its numeric rating scale (NRS) (NRS: 0, no pain/dyspnoea; 10,
treatment on their functional capacity and quality of life worst possible pain/dyspnoea), rated by the patients them-
(12). On the PC agenda, rehabilitation is finally enjoying a selves, and the reduction of lymphoedema was measured
high profile. Within the context of cancer, the primary goal using a four-point Likert scale (reduction: ‘none’, ‘little’,
of rehabilitation is to assist the person with cancer in ‘moderate’ or ‘good’), rated and documented by the
1070 Effectiveness of physiotherapeutic management of lymphoedema

physiotherapist (17). The Karnofsky performance scale Table 1. Patient and disease-related data (n ¼ 90)
index (0 – 100%) was used to classify patients’ functional
impairment (18,19). Characteristics n Per cent

Sex
DATA ANALYSIS AND STATISTICS
Male 33 36.7
SPSS software was used for statistical evaluation of the Female 57 63.3
anonymized data. Descriptive methods (mean + SD) were
Primary cancer diagnosis or other disease
used for comparative quantification of pain and dyspnoea at
Thoracic 16 17.8
admission and before/after MLD. Karnofsky performance
index was given as a median (range). Wilcoxon’s test was Gastrointestinal 14 15.6
used for comparative testing. The P values cited were two- Gynaecologic or genitourinary 33 36.7
sided, and P values ,0.05 were regarded as statistically Breast 10 11.1
significant. Pancreas 5 5.5
CUP 3 3.3
Other cancer disease 7 7.8
RESULTS
ALS 2 2.2
Of the 208 patients, 90 with symptom load due to lymphoe-
Type of pain (n ¼ 67)
dema were included; at admission, 67 (74.4%) reported pain
Somatic 59 88.1
and 23 (25.6%) suffered dyspnoea due to progredient trunk
oedema. Mean age was 65.5 + 13.0 years; 33 (36.7%) male; Somatic and neuropathic 8 11.9
the median Karnofsky index was 50% (30 – 80%), mean Dyspnoea 23 25.6
length of stay 15.6 + 8.0 days; survival time after admission Survival time 22.0 + 33.0 days
22.0 + 33.0 days. Fifty-nine patients had somatic pain and
eight somatic and neuropathic pain. Demographics and diag-
noses at admission are shown in Table 1. The number of
MLD interventions during stay was in mean 7.0 + 5.8 and
individual treatment interventions lasted in mean 41.3 +
19.4 min (dependent on the affected body region). MLD was
well tolerated in 83 (92.2%) patients; 63 of the 67 (94.0%)
patients with pain showed a clinically relevant reduction of
pain intensity (Fig. 1), and in 17 of 23 (73.9%) patients with
dyspnoea, a significant relief was achieved (Fig. 2). In four
patients with neuropathic pain components, the physiothera-
peutic treatment was discontinued due to increased pain
during manual therapy.
Prior to physiotherapy, all patients were treated with
WHO Step III opioids in combination with WHO Step I
analgesics and co-analgesics. After improvement in pain or
dyspnoea mostly on day 2 or 3 after admission, MLD was
begun and performed daily until discharge or as long as
compatible with the patients’ performance status. The
reduction of lymphatic oedema was documented as ‘little’ in
17 (18.9%) patients, as ‘moderate’ in 58 (64.4%) and as
‘good’ in 15 (16.7%) patients; the category ‘none’ was not
Figure 1. Intensity of pain at admission (n ¼ 67) (A), after adjusted analge-
used in the documentation for any of the patients. sic treatment and prior to first physiotherapeutic intervention (B) and after
first (C) and second (D) manual lymphatic drainage. Wilcoxon’s test:
PAB , 0.0001; PBC , 0.0001, PBD , 0.0001, PCD , 0.0001.
DISCUSSION
In this study, we evaluated the effect of MLD on the inten- experienced a significant decrease in pain intensity within
sity of pain and dyspnoea in PC patients with lymphoedema. the first few days of their stay. We found that each of pain
As in all patients who are admitted to our PC unit for pain assessments directly after the first two MLD interventions
therapy and symptom control, the medical pre-treatment was showed another, again significant reduction in pain intensity
optimized (dose adjustment, switching of the medication). in nearly all patients. Those without benefit from this
Physiotherapy was begun on a daily basis after the patients measure and in whom it was stopped during or after the first
 Jpn J Clin Oncol 2010;40(11) 1071

encouragement, independence, relief and well-being, secur-

ity and hope (24).
The physical effects of MLD include an increase in the
contraction rate of lymphatics (25), increased reabsorption of
protein into lymphatics (26), reduced microlymphatic hyper-
tension (27) and improved collateral lymph drainage between
the lymphatic territories of the skin (28). Improved drainage
enables fluid to be redirected away from oedematous areas
towards the functioning lymph nodes in unaffected areas, an
important principle in lymphoedema management. Wittlinger
and Wittlinger (29) also suggest that MLD influences the
sympathetic nervous system, promoting relaxation. In lym-
phoedema, the displacement of interstitial fluid as a result of
the calliper pressure is influenced by the degree of oedema,
thus adding to the sensation of pain and discomfort (29). The
relief of limps and rump from interstitial fluid by means of
careful manual drainage has a pain-reducing effect in limps
and rump; it will also take pressure from the midriff/dia-
phragm and thus has a positive effect on breathing capacity.
Figure 2. Intensity of dyspnoea (n ¼ 23) at admission (A), after adjusted In general, one of the supporting measures for relief of dys-
opioid treatment and prior to first physiotherapeutic intervention (B) and pnoea could be a head-up position with leg elevation, but this
after first (C) and second (D) manual lymphatic drainage. Wilcoxon’s test:
was not feasible in patients with severe trunk oedema.
PAB , 0.0001, PBC ¼ 0.001, PBD ¼ 0.001, PCD ¼ 0.083.
Intensive lymphoedema management, often referred to as
combined decongestive therapy (CDT), aims to reduce limb
intervention were overly sensitive to touch due to somatic volume, restore limb shape and improve skin and tissue con-
pain with neuropathic components. Patients with dyspnoea dition. Together with MLD, it may include multilayer ban-
also showed a significant decrease in the intensity of breath- daging, isotonic exercises, skin care and, for some,
lessness after the first intervention, whereas the second MLD pneumatic compression pumps. This is followed by a main-
led to no further significant relief. These positive outcomes tenance phase of self-treatment when the person wears
may be related to physical and/or psychological effects of elastic hosiery and undertakes regular self-massage, skin
this intervention. care and exercise. These additional measures, however, are
Physiotherapy takes places in a calm, relaxed and trustful also scarcely possible in PC patients with far advanced
atmosphere; it is a one-to-one encounter where the patient disease and poor performance status. Therefore, along with
gets the full attention of a caring health professional that MLD, in this study, only kinesiatrics were used in some
will explain every single step and stop at any time, if this patients, whereas massages, heat/cold interventions and
is the patient’s wish. This may contribute to the relief of elastic compression played a very marginal role. Research
pain and dyspnoea which are both known to have also into the benefit of physiotherapy in far advanced PC patients
psychological aspects (20,21). Furthermore, the role of phy- is scarce. Most studies are concerned with cancer patients at
siotherapist should include thinking beyond the physical res- much earlier stages of their disease, mostly with CDT or at
toration of the client and incorporate elements of least two combined methods (30 – 32). A recent systematic
psychosocial support, i.e. attention to the individual, non- review in physiotherapeutic interventions included studies
physical aspects of client care (15,22). A mixed-method with advanced cancer patients, but excluded all non-
study, undertaken by Smith et al. (23) to collect information randomized studies and those that went beyond ‘classical
for preparing massage therapists for what to expect when massage’, e.g. MLD (33).
providing therapy to people with advanced cancer, showed A major concern about MLD some years ago was to what
that most patients looked forward to sessions with positive extent this measure may stimulate cancer cell activity and
anticipation and expectations of pleasure. They expressed spread cancer, respectively. However, it is known that many
regret when sessions were ending. Therapists noted that a factors cause the growth of metastases, and cancer research
few patients without experience of massage therapy were supports the contention that this therapy does not contribute
anxious at the beginning, often due to concerns about pain to the spread of disease and should not be withheld from
and other symptoms. Patients also shared more general patients with metastases (11,34,35).
assessments of their mood such as happy, sad, anxious or
tense, and concerns about death, family and financial
issues. Another study explored how patients with incurable LIMITATIONS OF THE STUDY
cancer experience physical therapy, identifying positive We are well aware that the retrospective, reflexive control
categories such as participation, motivation and design of the study with the group serving as its own control
1072 Effectiveness of physiotherapeutic management of lymphoedema

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