上肢功能锻炼与乳腺癌术后淋巴水肿

 乳腺癌术后淋巴水肿主要是由于淋巴系统结构受损,导致淋巴系统的负荷量超过其运转能力,从而使淋巴液在组织间积聚,主要表现为患肢的肿胀、沉重感和紧绷感、疼痛以及活动受限。淋巴水肿的发生与术式、化疗、肥胖、高血压以及个体基因改变相关。为了防止淋巴水肿的发生或加重,应避免患肢过度使用,功能锻炼强调循序渐进,然而仅循序渐进是不够的,在为患者选择锻炼方法时,应该综合考虑各种方式,根据患者暴露的危险因素情况,科学的选择个性化的锻炼方案,并准确选择淋巴水肿的评价标准,实时评价效果,以达到最佳治疗的目的。     

Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study.

PURPOSE: To examine the effect of a progressive upper-body exercise program on lymphedema secondary to breast cancer treatment. METHODS: Fourteen breast cancer survivors with unilateral upper extremity lymphedema were randomly assigned to an exercise (n = 7) or control group (n = 7). The exercise group followed a progressive, 8-week upper-body exercise program consisting of resistance training plus aerobic exercise using a Monark Rehab Trainer arm ergometer. Lymphedema was assessed by arm circumference and measurement of arm volume by water displacement. Patients were evaluated on five occasions over the experimental period. The Medical Outcomes Trust Short-Form 36 Survey was used to measure quality of life before and after the intervention. Significance was set at alpha < or = 0.01. RESULTS: No changes were found in arm circumference or arm volume as a result of the exercise program. Three of the quality-of-life domains showed trends toward increases in the exercise group: physical functioning (P =.050), general health (P =.048), and vitality (P =.023). Mental health increased, although not significantly, for all subjects (P =.019). Arm volume measured by water displacement was correlated with calculated arm volume (r =.973, P <.001), although the exercise and control group means were significantly different (P <.001). CONCLUSIONS: Participation in an upper-body exercise program caused no changes in arm circumference or arm volume in women with lymphedema after breast cancer, and they may have experienced an increase in quality of life. Additional studies should be done in this area to determine the optimum training program.     

Current status of selenium and other treatments for secondary lymphedema

The unsatisfactory status of lymphedema treatment in patients with cancer warrants an intensified search for new treatment approaches, especially since survival of cancer patients has improved markedly. Lymphedema, regardless of etiology, is essentially incurable, but current therapeutic approaches can reduce swelling, restore shape, and prevent inflammatory episodes.The most conservative approach is physical therapy, including a combination of compression, exercise, and, if possible, massage.Meticulous skin care is needed to avoid recurrent inflammatory episodes. If physical therapy fails, surgery, in the form of reducing or "debulking" operations, is indicated, while microsurgical interventions for certain forms of lymphedema continue to be evaluated. Drug therapy has included the use of diuretics, corticosteroids, and coumarin- or flavonoid-type compounds. Diuretics and corticosteroids may be useful in edema of mixed origin and in palliative circumstances but cannot be recommended for persistent lymphedemas. Coumarin and flavonoids reduce swelling in all types of lymphedema, but their long-term use is problematic. One promising step in drug therapy seems to be the introduction of free-radical scavengers, such as selenium. Present data demonstrate that selenium can enhance the benefits of physical therapy in radiation-induced lymphedemas.The very low toxicity profile of selenium and its cost effectiveness are further arguments for its use in lymphedema treatment.     

Feasibility of a Pilot Randomized Controlled Trial Examining a Multidimensional Intervention in Women with Gynecological Cancer at Risk of Lymphedema

There is limited knowledge on non-invasive lymphedema risk-reduction strategies for women with gynecological cancer. Understanding factors influencing the feasibility of randomized controlled trials (RCTs) can guide future research. Our objectives are to report on the design and feasibility of a pilot RCT examining a tailored multidimensional intervention in women treated for gynecological cancer at risk of lymphedema and to explore the preliminary effectiveness of the intervention on lymphedema incidence at 12 months. In this pilot single-blinded, parallel-group, multi-centre RCT, women with newly diagnosed gynecological cancer were randomized to receive post-operative compression stockings and individualized exercise education (intervention group: IG) or education on lymphedema risk-reduction alone (control group: CG). Rates of recruitment, retention and assessment completion were recorded. Intervention safety and feasibility were tracked by monitoring adverse events and adherence. Clinical outcomes were evaluated over 12 months: presence of lymphedema, circumferential and volume measures, body composition and quality of life. Fifty-one women were recruited and 36 received the assigned intervention. Rates of recruitment and 12-month retention were 47% and 78%, respectively. Two participants experienced post-operative cellulitis, prior to intervention delivery. At three and six months post-operatively, 67% and 63% of the IG used compression ≥42 h/week, while 56% engaged in ≥150 weekly minutes of moderate-vigorous exercise. The cumulative incidence of lymphedema at 12 months was 31% in the CG and 31.9% in the IG (p = 0.88). In affected participants, lymphedema developed after a median time of 3.2 months (range, 2.7–5.9) in the CG vs. 8.8 months (range, 2.9–11.8) in the IG. Conducting research trials exploring lymphedema risk-reduction strategies in gynecological cancer is feasible but challenging. A tailored intervention of compression and exercise is safe and feasible in this population and may delay the onset of lymphedema. Further research is warranted to establish the role of these strategies in reducing the risk of lymphedema for the gynecological cancer population.     

Lymphedema: separating fact from fiction

Lymphedema is a feared complication of cancer treatment and one that negatively impacts survivorship. The incidence of breast cancer-related lymphedema ranges from 6% to 70%, but lymphedema may be a common and under-reported morbidity. No standard guidelines for its diagnosis and assessment exist. Although the true etiology of lymphedema remains unknown, radiation, chemotherapy, type of breast surgery, and extent of axillary surgery are commonly cited risk factors. However, the relationship between the number of nodes removed and the risk of lymphedema is not clearly correlated. Clinical trials are focusing on ways to reduce the need for axillary dissection even in the setting of a positive sentinel node, to help minimize axillary morbidity. Risk-reduction practices, including avoidance of skin puncture and blood pressures in the ipsilateral upper extremity, and precautionary behaviors such as wearing compression garments during air travel continue to be advocated by the medical and survivor communities, despite a lack of rigorous evidence supporting their benefit. Emerging data support exercise in at-risk and affected women with lymphedema when started gradually and increased cautiously.     

Exercise in patients with lymphedema: a systematic review of the contemporary literature

Background  

Controversy exists regarding the role of exercise in cancer patients with or at risk for lymphedema, particularly breast. We conducted a systematic review of the contemporary literature to distill the weight of the evidence and provide recommendations for exercise and lymphedema care in breast cancer survivors.     

The effects of complex exercise on shoulder range of motion and pain for women with breast cancer-related lymphedema: a single-blind,randomized controlled trial

Background

This study was to investigate the effects of complex exercise on shoulder range of motion and pain for women with breast cancer-related lymphedema.

Methods

69 women participated in this study and then they were randomly allocated to complex exercise group (n = 35) or the conventional decongestive therapy group (n = 34). All subjects received 8 sessions for 4 weeks. To identify the effects on shoulder range of motion and pain, goniometer and visual analog scale were used, respectively. The outcome measurements were performed before and after the 4 week intervention.

Results

After 4 weeks, complex exercise group had greater improvements in shoulder range of motion and pain compared with the conventional decongestive therapy group (p < 0.05).

Conclusion

These results suggest that complex exercise is beneficial to improve shoulder range of motion as well as pain of the women with breast cancer-related lymphedema. Complex exercise would be useful to improve shoulder range of motion and pain of the women with breast cancer-related lymphedema.

     

Neues aus der Onkologischen Trainings- und Bewegungstherapie

Scientific evidence for the efficacy of therapeutic exercise interventions in oncology is, in part, so convincing that the next step would have to be implementation of quality assured exercise programs within the organs of oncologic care. It has been demonstrated that targeted physical activity can positively influence fatigue syndrome, urinary incontinence in prostate cancer patients, and physical performance in general. Furthermore, in this context, there are strong indications for beneficial effects on secondary lymphedema and chemotherapy-induced polyneuropathy. Ideally, oncologic exercise therapy should be implemented before the start of medical treatment, in order to stabilize the patients and, by this means, minimize complications and side effects during the acute phase, as supported by initial studies (prehabilitation). The available data on therapeutic exercise inventions in pediatric oncologic diseases are still very heterogeneous; however, all demonstrate the feasibility and necessity of exercise therapy and sport in pediatric oncology, and also exclude adverse events.     

Prospective trial of intensive decongestive physiotherapy for upper extremity lymphedema

BACKGROUND: The aim of this study was to evaluate the effects of kinesiophobia, quality of life, and home exercise programs on women with upper extremity lymphedema. METHODS: A total of 62 women with lymphedema after breast cancer treatments were provided a protocol of complete decongestive therapy (CDT). This protocol involved manual lymphatic drainage (MLD), compression garments, skin care, and remedial exercises. The women were taken to a 12-week therapy program once per day, 3 days per week. A home program, consisting of compression bandage exercises, skin care and walking was recommended. Absolute volume and percentage of volume of the lymphedema were compared before and after treatment. The kinesiophobia, quality of life, and home-based program were assessed before and after physiotherapy. RESULTS: Strong correlations were found between the severity of edema and fear of movement. There was a significant negative relationship among the fear of movement, quality of life, and home-based exercises program. Mean initial lymphedema volume was 925 ml, and the percentage of lymphedema was 47.1%. After decongestive physiotherapy, the lymphedema volume and percentage were 510 ml and 21.3% (P < 0.05), respectively. There was also a trend toward improvement in general well-being (P < 0.05). CONCLUSION: In upper extremity lymphedema, the use of complex physiotherapy programs (CDP) can decrease edema and fear of activity, and increase the quality of life.     

Lymphedema: How Do We Diagnose and Reduce the Risk of This Dreaded Complication of Breast Cancer Treatment?

Lymphedema is an under-recognized, progressive, life-long condition estimated to impact 2-3 million people in the United States. The incidence of breast cancer related lymphedema varies greatly in the literature largely due to different measurement techniques, competing thresholds for defining lymphedema, and variation in length of follow-up. Multiple imaging techniques have become useful for diagnosis. Lymphoscintigraphy is one of the most commonly used, as it can identify pathways of lymphatic drainage, quantify extent of dermal backflow, and help determine functional and morphologic changes in the lymphatic system. Early detection and intervention hold the greatest promise of reducing the incidence of lymphedema. Health care providers involved with cancer patients need to become more educated about lymphedema, aware of current risk-reduction practices, and familiar with methods of diagnosis and assessment, so that patients with early swelling can be referred to lymphedema treatment specialists at a time when treatment is more effective.     

Treatment for upper-limb and lower-limb lymphedema by professionals specializing in lymphedema care

Up to 60% of patients with cancer of the vulva, and between 20 and 30% of patients with breast or abdominal cancers may develop lymphedema following treatment. The aims of this study were to assess health professionals' knowledge about treatment, diagnostic procedures, advice and confidence in treatment of patients with either upper-limb (ULL) or lower-limb lymphoedema (LLL), and whether these differed by health professionals' background or for patients with ULL compared with LLL. A cross-sectional telephone interview was undertaken in 2006, of 63 health professionals (response rate 92.6%) known to treat lymphedema. Sixty-three per cent of the health professionals were physiotherapists; the majority were university-trained, with 20 years' experience or more. Ninety-five per cent of health professionals used circumferential measurements to establish lymphedema status, and most health professionals advised avoiding scratches and cuts (100%), insect bites (98.4%), sunburn (98.4%) and excessive exercise (65.1%) on the affected limb. Health professionals reported that compared with patients with LLL, patients with ULL were more likely to present within the first 3 months of being symptomatic (P < 0.01). Patients with LLL were more likely to present with swelling (P = 0.001), heaviness (P = 0.003), tightness (P = 0.007) and skin problems (P < 0.001) compared with patients with ULL. Treatment and advice differed according to health professionals' background, but not location of lymphedema (ULL vs. LLL). Assessment, treatment and advice for lymphedema vary across professional groups. Our results suggest that improvements should be attempted in the early detection of lymphedema, in particular of LLL among cancer patients.     

Prevention and management of arm lymphedema in the patient with breast cancer

Arm lymphedema develops in 10%-35% of patients who undergo axillary dissection and/or nodal radiation therapy for breast cancer. Lymphedema that occurs in the first 18 months after surgery or radiation is described as acute lymphedema, and can be managed with conservative measures such as elevation of the arm and mild compression. Chronic lymphedema, the more serious form, has a progressive and generally irreversible course. Risk factors associated with the development of lymphedema include greater extent of axillary surgery; more positive axillary nodes; a postoperative axillary hematoma, seroma, or infection; and use of nodal radiation.The most common method of lymphedema measurement is the circumference 10 cm above and below the olecranon process, although most clinicians do not take measurements in the preoperative setting for comparison.Treatment strategies include elevation, complete decongestive physiotherapy, pneumatic pumps, and, after failure of all other methods, surgery. Lymphangiosarcoma is a rare and late complication of longstanding extremity lymphedema.The advent of sentinel lymph node biopsy as an alternative to axillary dissection should decrease the rate of lymphedema.The increasing number of breast cancer survivors and the high prevalence of the disease will continue to make lymphedema a significant consequence of breast cancer treatment.     

护理干预对控制乳腺癌手术后发生淋巴水肿的研究

目的探讨护理干预对控制乳腺癌手术后淋巴水肿发生的作用。方法采用历史对照研究,选取64名拟接受乳腺癌改良根治术的患者为实验组,对实验组患者提供电话随访和淋巴水肿自我行为管理指导的护理干预。另选60例非同期相同手术方式乳腺癌患者为对照组,对淋巴水肿的发生情况做历史对照。结果实验组患者淋巴水肿发生率低于历史对照组,差异有统计学意义（Х^2=4.75,P〈0.05）。结论对乳癌患者在淋巴水肿亚临床期给予护理干预,可以控制淋巴水肿的发生,电话随访、自我管理手册可以促进乳腺癌术后患者淋巴水肿的自我行为管理。     

Lymphedema management

Lymphedema, defined as the abnormal accumulation of protein rich fluid dysfunction of the lymphatic system, is a common sequela of cancer therapy. The incidence is highest among patients who have undergone resection and irradiation of a lymph node bed. Recently, increased attention has been focused on the modification of anticancer therapies in an effort to minimize lymphatic compromise. Sentinel lymph node biopsy is an example of a surgical procedure developed to preserve lymphatic function. Concurrent with the development of less invasive treatments, the field of lymphedema management has evolved rapidly over the past decade. Combined manual therapy, often referred to as complex decongestive physiotherapy (CDP), has emerged as the standard of care. CDP combines compression bandaging, manual lymphatic drainage (a specialized massage technique), exercise, and skin care with extensive patient education. Case series collectively describing a mean 65% volume reduction in over 10,000 patients attest its efficacy. Pneumatic compression pumps were historically widely used to control lymphedema. Their use as an isolated treatment modality is now rare. Reliance on pumps diminished with the recognition that they may exacerbate truncal and genital lymphedema, as well as injure peripheral lymphatics when applied at high pressures. Many noncompressive approaches, particularly the use of benzopyrone medications and liposuction, continue to be used abroad.     

Challenging the myth of exercise-induced lymphedema following breast cancer: a series of case reports

Women who have had axillary lymph nodes removed for the management of breast cancer are at increased risk of developing upper extremity lymphedema. Physical therapists, surgeons, and other health professionals have warned these women to avoid vigorous, repetitive, or excessive upper body exercise, believing that such types of exercise might actually induce lymphedema. The purpose of this series of case reports was to challenge that belief by systematically measuring the arm circumferences, across three points in time, of 20 women who had received axillary dissection and who were competing in the vigorous, upper body sport of Dragon Boat racing. Measurably different change was defined as an increase in circumference of the ipsilateral upper extremity at any of the four landmarks of >0.5 inches between Time 1 and Time 2 or between Time 1 and Time 3; only two women showed a measurably different change (5/8 in). Furthermore, none of the women showed a clinically significant difference in arm circumference between the ipsilateral and contralateral extremities at Time 3.     

The Addition of Manual Lymph Drainage to Compression Therapy For Breast Cancer Related Lymphedema: a Randomized Controlled Trial

PURPOSE: The purpose of this investigation was to compare the reduction in arm lymphedema volume achieved from manual lymph drainage massage (MLD) in combination with multi-layered compression bandaging (CB) to that achieved by CB alone. METHODS AND MATERIALS: Fifty women with lymphedema (mean age of 59 years +/- 13 years) were randomly assigned to 4 weeks of combined MLD/CB or CB alone. The primary study endpoint was the reduction in arm lymphedema volume, which was determined by water displacement volumetry and measurement of circumference. Independent assessors, blinded to subject treatment assignment, performed the outcome measurements. RESULTS: Arm lymphedema volume decreased significantly after 4 weeks irrespective of treatment assignment (p < 0.001). Individuals with mild lymphedema receiving combined MLD/CB had a significantly larger percentage reduction in volume compared to individuals with mild lymphedema receiving CB alone, and compared to individuals with moderate or severe lymphedema receiving either treatment. CONCLUSION: These findings indicate that CB, with or without MLD, is an effective intervention in reducing arm lymphedema volume. The findings suggest that CB on its own should be considered as a primary treatment option in reducing arm lymphedema volume. There may be an additional benefit from the application of MLD for women with mild lymphedema; however, this finding will need to be further examined in the research setting.     

乳脉通络洗剂治疗乳腺癌术后上肢水肿的临床研究

目的:研究乳脉通络洗剂治疗乳腺癌术后上肢水肿的临床效果。方法:选取2019年01月至2020年03月期间内我院普外科收治的乳腺癌相关性上肢淋巴水肿患者60例,随机分为对照组和治疗组,每组30例。对照组采用佩戴弹力绷带同时配合局部功能锻炼,治疗组在物理疗法的基础上外敷中药乳脉通络洗剂治疗,对比两组患者治疗前后腕横纹上10 cm和肘横纹上10 cm周径变化及主观FCAT-B+4量表评分。结果:治疗后治疗组腕横纹上10 cm处周径为(21.67±3.19) cm,对照组为(22.68±3.26) cm;治疗组肘横纹上10 cm处周径为(28.82±2.96) cm,对照组为(29.58±3.18) cm;治疗组总有效率为83.33%,对照组为66.67%,治疗组主观症状FCAT-B+4量表评分为(3.14±3.04)分,对照组为(5.96±3.12)分。以上两组比较,差异均有统计学意义(P<0.05)。结论:乳脉通络洗剂外敷能够显著缓解乳腺癌术后上肢水肿,提高患者的生活质量,值得推广。     

Prevalence and risk factors for development of lymphedema following breast cancer treatment

BACKGROUND: Early detection and multimodality therapy has resulted in an overall improvement of survival among breast cancer patients. Despite a significant shift in the treatment approach from radical mastectomy to breast conservation a significant number of patients develop lymphedema. This study was conducted to evaluate the prevalence and risk factors for development of lymphedema. SETTINGS AND DESIGN: Retrospective analysis for prevalence of lymphedema in a tertiary care regional cancer centre. MATERIAL AND METHODS: Three hundred treated breast cancer patients with a minimum follow up of one year were evaluated for the prevalence and risk factors for lymphedema. Lymphedema was assessed using a serial circumferential measurement method. More than 3 cm difference in circumference is considered as clinical significant lymphedema. Univariate and multivariate analysis were performed for evaluating the risk factors by using the Chi square test and Cox logistic regression analysis. RESULTS: The prevalence of clinically significant lymphedema was 33.5 % and 17.2 % had severe lymphedema. The prevalence of lymphedema was 13.4 % in patients treated with surgery only where as the prevalence was 42.4% in patients treated with surgery and radiotherapy. Stage of the disease, body surface area > 1. 5 m2, presence of co-morbid conditions, post operative radiotherapy and anthracycline based chemotherapy were significant risk factors in univariate analysis where as axillary irradiation and presence of co-morbid conditions have emerged as independent risk factors in multivariate analysis (P < 0.001). CONCLUSION: Post treatment lymphedema continues to be a significant problem following breast cancer therapy. Presence of co-morbid conditions and axillary radiation significantly increases the risk of lymphedema. A combination of axillary dissection and axillary radiation should be avoided whenever feasible to avoid lymphedema.