Effects of Complex Physical Therapy and Multimodal Approaches on Lymphedema Secondary to Breast Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Published:August 15, 2021DOI:



      What are the immediate, short-term, and long-term effects of complex physical therapy and multimodal approaches on lymphedema secondary to breast cancer?

      Data Sources

      Four electronic databases (MEDLINE, Embase, Cochrane Library, Physiotherapy Evidence Database) were searched from inception up to August 2020.

      Study Selection

      Randomized controlled trials comparing complex physical therapy and multimodal approaches to the conservative treatment of lymphedema secondary to breast cancer.

      Data Extraction

      Two independent researchers performed data extraction and assessed the risk of bias, respectively, using the predefined form and Cochrane Collaboration of Risk of Bias. The determination of evidence quality was carried out using the Grading of Recommendations Assessment, Development, and Evaluation tools.

      Data Synthesis

      Fourteen studies were identified for the systematic review and 11 studies for the meta-analysis with standardized mean difference (SMD), 95% CI, and random-effect model. The common outcomes involved total volume, pain, and physical function of the upper limb. Complex physical therapy has shown a favorable tendency to control outcomes in the short- and long-term. The meta-analysis indicated a small effect for volume reduction (SMD, −0.18; 95% confidence interval [CI], −0.35 to 0.00) and a moderate effect for short-term pain reduction (SMD, −0.61; 95% CI, −1.19 to –0.02).


      High-quality evidence suggests a more significant effect of complex physical therapy on multimodal approaches to the control of the upper limb total volume, substantiating the absence of changes in the current clinical practice in the management of lymphedema secondary to breast cancer. Future research should aim to identify concrete effect of therapeutic modalities in the immediate-, short-, and long-term.


      List of abbreviations:

      CI (Confidence interval), SMD (standardized mean difference)
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        • Gebruers N
        • Verbelen H
        • De Vrieze T
        • Coeck D
        • Tjalma W.
        Incidence and time path of lymphedema in sentinel node negative breast cancer patients: a systematic review.
        Arch Phys Med Rehabil. 2015; 96: 1131-1139
        • McDuff SGR
        • Mina AI
        • Brunelle CL
        • et al.
        Timing of lymphedema after treatment for breast cancer: when are patients most at risk?.
        Int J Radiat Oncol Biol Phys. 2019; 103: 62-70
        • He L
        • Qu H
        • Wu Q
        • Song Y.
        Lymphedema in survivors of breast cancer.
        Oncol Lett. 2020; 19: 2085-2096
        • Penha TR
        • Botter B
        • Heuts EM
        • Voogd AC
        • von Meyenfeldt MF
        • van der Hulst RR.
        Quality of life in patients with breast cancer-related lymphedema and reconstructive breast surgery.
        J Reconstr Microsurg. 2016; 32: 484-490
        • Anbari AB
        • Wanchai A
        • Armer JM.
        Breast cancer-related lymphedema and quality of life: a qualitative analysis over years of survivorship.
        Chronic Illn. 2019 Sep 4; ([Epub ahead of print])
        • Balzarini A
        • Lualdi P
        • Lucarini C
        • et al.
        Biomechanical evaluation of scapular girdle in patients with chronic arm lymphedema.
        Lymphology. 2006; 39: 132-140
      1. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology.
        Lymphology. 2020; 53: 3-19
        • Huang TW
        • Tseng SH
        • Lin CC
        • et al.
        Effects of manual lymphatic drainage on breast cancer-related lymphedema: a systematic review and meta-analysis of randomized controlled trials.
        World J Surg Oncol. 2013; 11: 15
        • Ezzo J
        • Manheimer E
        • McNeely ML
        • et al.
        Manual lymphatic drainage for lymphedema following breast cancer treatment.
        Cochrane Database Syst Rev. 2015; 5CD003475
        • Rogan S
        • Taeymans J
        • Luginbuehl H
        • Aebi M
        • Mahnig S
        • Gebruers N.
        Therapy modalities to reduce lymphoedema in female breast cancer patients: a systematic review and meta-analysis.
        Breast Cancer Res Treat. 2016; 159: 1-14
        • Tambour M
        • Holt M
        • Speyer A
        • Christensen R
        • Gram B.
        Manual lymphatic drainage adds no further volume reduction to complete decongestive therapy on breast cancer-related lymphoedema: a multicentre, randomised, single-blind trial.
        Br J Cancer. 2018; 119: 1215-1222
        • Lasinski BB
        • McKillip Thrift K
        • et al.
        A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011.
        PM R. 2012; 4: 580-601
        • Finnane A
        • Janda M
        • Hayes SC.
        Review of the evidence of lymphedema treatment effect.
        Am J Phys Med Rehabil. 2015; 94: 483-498
        • Freire de Oliveira MM
        • Costa Gurgel MS
        • Pace do Amaral MT
        • et al.
        Manual lymphatic drainage and active exercise effects on lymphatic function do not translate into morbidities in women who underwent breast cancer surgery.
        Arch Phys Med Rehabil. 2017; 98: 256-263
        • Moseley AL
        • Carati CJ
        • Piller NB.
        A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment.
        Ann Oncol. 2007; 18: 639-646
        • Oremus M
        • Dayes I
        • Walker K
        • Raina P.
        Systematic review: conservative treatments for secondary lymphedema.
        BMC Cancer. 2012; 12: 6
        • Li L
        • Yuan L
        • Chen X
        • et al.
        Current treatments for breast cancer-related lymphoedema: a systematic review.
        Asian Pac J Cancer Prev. 2016; 17: 4875-4883
        • Jeffs E
        • Ream E
        • Taylor C
        • Bick D.
        Clinical effectiveness of decongestive treatments on excess arm volume and patient-centered outcomes in women with early breast cancer-related arm lymphedema: a systematic review.
        JBI Database System Rev Implement Rep. 2018; 16: 453-506
        • Stout NL
        • Pfalzer LA
        • Springer B
        • et al.
        Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care.
        Phys Ther. 2012; 92: 152-163
        • De Vrieze T
        • Nevelsteen I
        • Thomis S
        • et al.
        What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review.
        Support Care Cancer. 2020; 28: 439-449
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • Group PRISMA
        Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Higgins JP
        • Altman DG
        • Gøtzsche PC
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. Version 2.
        BMJ. 2011; 343: d5928
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale1988
        • Higgins JP
        • Thompson SG
        • Deeks JJ
        • Altman DG.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Atkins D
        • Eccles M
        • Flottorp S
        • et al.
        Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group.
        BMC Health Serv Res. 2004; 4: 38
        • Kim DS
        • Sim YJ
        • Jeong HJ
        • Kim GC.
        Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial.
        Arch Phys Med Rehabil. 2010; 91: 1844-1848
        • Do JH
        • Kim W
        • Cho YK
        • et al.
        Effects of resistance exercises and complex decongestive therapy on arm function and muscular strength in breast cancer related lymphedema.
        Lymphology. 2015; 48: 184-196
        • Didem K
        • Ufuk YS
        • Serdar S
        • Zümre A.
        The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery.
        Breast Cancer Res Treat. 2005; 93: 49-54
        • Pekyavaş NÖ
        • Tunay VB
        • Akbayrak T
        • Kaya S
        • Karataş M.
        Complex decongestive therapy and taping for patients with postmastectomy lymphedema: a randomized controlled study.
        Eur J Oncol Nurs. 2014; 18: 585-590
        • Ergin G
        • Şahinoğlu E
        • Karadibak D
        • Yavuzşen T.
        Effectiveness of Kinesio taping on anastomotic regions in patients with breast cancer-related lymphedema: a randomized controlled pilot study.
        Lymphat Res Biol. 2019; 17: 655-660
        • Szolnoky G
        • Lakatos B
        • Keskeny T
        • et al.
        Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex decongestive physiotherapy for breast cancer treatment-related lymphedema.
        Lymphology. 2009; 42: 188-194
        • Haghighat S
        • Lotfi-Tokaldany M
        • Yunesian M
        • Akbari ME
        • Nazemi F
        • Weiss J.
        Comparing two treatment methods for post mastectomy lymphedema: complex decongestive therapy alone and in combination with intermittent pneumatic compression.
        Lymphology. 2010; 43: 25-33
        • Dayes IS
        • Whelan TJ
        • Julian JA
        • et al.
        Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer.
        J Clin Oncol. 2013; 31: 3758-3763
        • Bergmann A
        • da Costa Leite
        • Ferreira MG
        • de Aguiar SS
        • et al.
        Physiotherapy in upper limb lymphedema after breast cancer treatment: a randomized study.
        Lymphology. 2014; 47: 82-91
        • Gradalski T
        • Ochalek K
        • Kurpiewska J.
        Complex decongestive lymphatic therapy with or without Vodder II manual lymph drainage in more severe chronic postmastectomy upper limb lymphedema: a randomized noninferiority prospective study.
        J Pain Symptom Manage. 2015; 50: 750-757
        • Buragadda S
        • Alhusaini AA
        • Melam GR
        • Arora N.
        Effect of complete decongestive therapy and a home program for patients with post mastectomy lymphedema.
        J Phys Ther Sci. 2015; 27: 2743-2748
        • Uzkeser H
        • Karatay S
        • Erdemci B
        • Koc M
        • Senel K.
        Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: a randomized controlled trial.
        Breast Cancer. 2015; 22: 300-307
        • Tastaban E
        • Soyder A
        • Aydin E
        • et al.
        Role of intermittent pneumatic compression in the treatment of breast cancer-related lymphoedema: a randomized controlled trial.
        Clin Rehabil. 2020; 34: 220-228
        • Davies C
        • Levenhagen K
        • Ryans K
        • Perdomo M
        • Gilchrist L.
        Interventions for breast cancer-related lymphedema: clinical practice guideline from the Academy of Oncologic Physical Therapy of APTA.
        Phys Ther. 2020; 100: 1163-1179
        • Azhar SH
        • Lim HY
        • Tan BK
        • Angeli V.
        The unresolved pathophysiology of lymphedema.
        Front Physiol. 2020; 11: 137
        • Box RC
        • Reul-Hirche HM
        • Bullock-Saxton JE
        • Furnival CM.
        Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema.
        Breast Cancer Res Treat. 2002; 75: 51-64
        • Shah C
        • Arthur DW
        • Wazer D
        • Khan A
        • Ridner S
        • Vicini F.
        The impact of early detection and intervention of breast cancer-related lymphedema: a systematic review.
        Cancer Med. 2016; 5: 1154-1162
        • Forner-Cordero I
        • Muñoz-Langa J
        • Forner-Cordero A
        • DeMiguel-Jimeno JM.
        Predictive factors of response to decongestive therapy in patients with breast-cancer-related lymphedema.
        Ann Surg Oncol. 2010; : 17744-17751
        • Torres Lacomba M
        • Yuste Sánchez MJ
        • Zapico Goñi A
        • et al.
        Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial.
        BMJ. 2010; 340: b5396
        • Gençay Can A
        • Ekşioğlu E
        • Çakçı FA.
        Early detection and treatment of subclinical lymphedema in patients with breast cancer.
        Lymphat Res Biol. 2019; 17: 368-373
        • Vignes S
        • Porcher R
        • Arrault M
        • Dupuy A.
        Factors influencing breast cancer-related lymphedema volume after intensive decongestive physiotherapy.
        Support Care Cancer. 2011; 19: 935-940
        • Brown JC
        • Cheville AL
        • Tchou JC
        • Harris SR
        • Schmitz KH.
        Prescription and adherence to lymphedema self-care modalities among women with breast cancer-related lymphedema.
        Support Care Cancer. 2014; 22: 135-143
        • Dawes DJ
        • Meterissian S
        • Goldberg M
        • Mayo NE.
        Impact of lymphoedema on arm function and health-related quality of life in women following breast cancer surgery.
        J Rehabil Med. 2008; 40: 651-658
        • Park JE
        • Jang HJ
        • Seo KS.
        Quality of life, upper extremity function and the effect of lymphedema treatment in breast cancer related lymphedema patients.
        Ann Rehabil Med. 2012; 36: 240-247
        • Hwang JM
        • Hwang JH
        • Kim TW
        • Lee SY
        • Chang HJ
        • Chu IH.
        Long-term effects of complex decongestive therapy in breast cancer patients with arm lymphedema after axillary dissection.
        Ann Rehabil Med. 2013; 37: 690-697