Drenagem manual do linfedema para reduzir o risco e controlar o linfedema relacionado ao câncer de mama após cirurgia de mama uma revisão sistemática

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<p>P</p><p>ho</p><p>to</p><p>ª</p><p>Jo</p><p>di</p><p>Ja</p><p>co</p><p>bs</p><p>on</p><p>/</p><p>is</p><p>to</p><p>ck</p><p>ph</p><p>ot</p><p>o.</p><p>co</p><p>m</p><p>REVIEW</p><p>women's & gender-related health</p><p>nwhjou</p><p>Manual Lymphedema Drainage for</p><p>Reducing Risk for and Managing Breast</p><p>Cancer–Related Lymphedema After Breast</p><p>Surgery: A Systematic Review</p><p>Ausanee Wanchai & Jane M. Armer</p><p>ABSTRACT</p><p>Objective: To examine the effects of manual lymphatic drainage</p><p>(MLD) on reducing the risk of and managing breast cancer–</p><p>related lymphedema (BCRL).</p><p>Data Sources: The electronic databases ScienceDirect, Scopus,</p><p>PubMed, and CINAHL were searched for articles published in the</p><p>English language from January 2000 to June 2020.</p><p>Study Selection: A total of 518 articles were retrieved. After the</p><p>removal of duplicates, 472 articles remained, 433 of which were</p><p>excluded based on title and abstract consideration. Thereafter,</p><p>39 studies were further inspected, and 27 articles were excluded</p><p>because they were not randomized controlled trials, did not</p><p>measure BCRL, and/or were an incomplete study. Ten studies</p><p>were included for the final review.</p><p>Data Extraction: Data from the 10 studies were extracted and</p><p>compiled into a summary table.</p><p>rnal.org</p><p>Downloaded for Anonymous User (n/a) at ANDROSCOGGIN VAL</p><p>August 27, 2024. For personal use only. No other uses without p</p><p>Data Synthesis: Based on the results of this systematic review, it</p><p>cannot be concluded that MLD helps reduce the risk of BCRL for</p><p>women after breast surgery. Regarding the effect of MLD on</p><p>managing BCRL, the findings indicate that MLD alone or MLD</p><p>combined with other treatments was likely to give similar benefits</p><p>in terms of reducing arm volume for women diagnosed with BCRL.</p><p>Conclusion: Scientific evidence to support the benefits of MLD on</p><p>preventingor reducingBCRL remains unclear.More rigorous studies</p><p>to confirm findings on the effectiveness of MLD are needed.</p><p>doi: 10.1016/j.nwh.2021.07.005</p><p>Accepted July 21, 2021; published online August 28, 2021</p><p>KEYWORDS: breast cancer, complete decongestive therapy,</p><p>intermittent pneumatic compression, limb volume, lymphedema,</p><p>manual lymphatic drainage, self lymphatic drainage, systematic</p><p>review</p><p>ª 2021 AWHONN; doi: 10.1016/j.nwh.2021.07.005 377</p><p>LEY HOSPITAL from ClinicalKey.com/nursing by Elsevier on</p><p>ermission. Copyright ©2024. Elsevier Inc. All rights reserved.</p><p>https://doi.org/10.1016/j.nwh.2021.07.005</p><p>http://istockphoto.com</p><p>http://nwhjournal.org</p><p>https://doi.org/10.1016/j.nwh.2021.07.005</p><p>http://crossmark.crossref.org/dialog/?doi=10.1016/j.nwh.2021.07.005&domain=pdf</p><p>CLINICAL IMPLICATIONS</p><p>n Manual lymphatic drainage (MLD) is one of the gold standard</p><p>treatments for women diagnosed with breast cancer–related</p><p>lymphedema (BCRL).</p><p>n Because of the limitations of the studies reviewed, it cannot be</p><p>concluded that MLD reduces the risk of BCRL after surgery.</p><p>n MLD did not contribute to additional reduction beyond the</p><p>standard therapy in the primary outcome of limb volume.</p><p>n Further rigorous research to examine the effectiveness of MLD on</p><p>BCRL is needed.</p><p>Manual Lymphedema Drainage for Breast Cancer–Related Lymphedema</p><p>reast cancer has been reported as the most common</p><p>cancer in women worldwide. In 2018, approximately 2</p><p>Bmillion new cases of breast cancer were reported.</p><p>Breast cancer also has been known as the most frequent</p><p>cause of death from cancer among women worldwide (Ferlay</p><p>et al., 2019). The World Health Organization (2020) reported</p><p>that worldwide breast cancer survival rates vary from 40% to</p><p>80% or greater. Although breast cancer predominantly affects</p><p>women, and women are most commonly reported as study</p><p>participants in research studies, men diagnosed with and</p><p>treated for breast cancer may face a similar risk for treatment-</p><p>related effects. Because studies predominantly report on</p><p>female breast cancer survivors, we use the term “women” to</p><p>refer to this population of survivors when only women were</p><p>studied.</p><p>Breast cancer treatments may include more than one of</p><p>the major therapeutic modalities: surgery, radiotherapy, or</p><p>systemic therapy (World Health Organization, 2020). Howev-</p><p>er, choices of breast cancer treatments depend on the tumor</p><p>type, cancer stage, and preferences of women with the cancer</p><p>(Waks & Winer, 2019). Cancer treatments can reduce the risk</p><p>of cancer recurrence and extend the overall survival rate for</p><p>individuals with breast cancer. However, after the treatments</p><p>are complete, they may experience the short- and long-term</p><p>side effects that may occur months or even years after</p><p>treatments are completed. Some examples of those side ef-</p><p>fects are cardiac toxicity, reproductive dysfunction, neuropa-</p><p>thy, skin changes, and lymphedema (Agrawal, 2014).</p><p>Women treated for breast cancer experience up to a</p><p>40% risk of developing lymphedema (Fu, 2014). Lymphedema</p><p>Ausanee Wanchai, PhD, RN, is Deputy Director for Academic Services and</p><p>Research at the Boromarajonani College of Nursing in Buddhachinaraj,</p><p>Thailand. ORCID: https://orcid.org/0000-0003-2656-1108. Jane M. Armer,</p><p>PhD, RN, FAAN, CLT, is a professor in the Sinclair School of Nursing at the</p><p>University of Missouri; Director of the T32 Health Behavior Science Research</p><p>Training Program; Director of Nursing Research at the Ellis Fischel Cancer</p><p>Center; and Director of the American Lymphedema Framework Project in</p><p>Columbia, MO. ORCID: https://orcid.org/0000-0003-2473-5063. Address</p><p>correspondence to: ausanee@bcnb.ac.th.</p><p>378 Volume 25 Issue 5</p><p>Downloaded for Anonymous User (n/a) at ANDROSCOGGIN VALL</p><p>August 27, 2024. For personal use only. No other uses without per</p><p>is a chronic condition in which there is accumulation of</p><p>protein-rich fluid in the interstitial spaces of the affected body</p><p>part due to a blockage in the lymph system; it can occur</p><p>immediately after surgery or even 20 years after treatment</p><p>(Armer & Stewart, 2010; Petrek et al., 2001). Arm swelling</p><p>can affect the physical and psychological aspects of women’s</p><p>survival (Armer & Stewart, 2010). They may experience</p><p>numbness or pain or have difficulty wearing clothes or jewelry</p><p>(Fu, 2014). Many women with lymphedema may feel anxious,</p><p>stressed, or fearful or may have a lack of confidence because</p><p>of enlarged arms (Taghian et al., 2014).</p><p>Treatments for women with breast cancer–related lym-</p><p>phedema (BCRL) include invasive treatments, such as surgi-</p><p>cal approaches, and noninvasive treatments, such as</p><p>intermittent pneumatic compression (IPC) and complete</p><p>decongestive therapy (CDT; Gillespie et al., 2018). However,</p><p>the gold standard first-line intervention to treat BCRL is CDT</p><p>involving two phases: a reduction therapy period (or intensive</p><p>phase) and a maintenance therapy period (or maintenance</p><p>phase). In the first phase, the goal is to reduce limb volume by</p><p>using manual lymphatic drainage (MLD), compression</p><p>bandaging, exercise, skin care, and health education. All are</p><p>administered by an individual trained in lymphedema therapy.</p><p>Then, when limb volume reduction is achieved, the mainte-</p><p>nance therapy is started by the women or a family member to</p><p>continue proper MLD, compression garment use, exercise,</p><p>and skin care. This phase aims at maintaining the achieve-</p><p>ments of the first phase over the lifetime (Gillespie et al.,</p><p>2018; Wanchai et al., 2016).</p><p>Authors of many previous studies reported the effective-</p><p>ness of CDT in its entirety, but few reported the effects of</p><p>each CDT component (Gillespie et al., 2018). MLD has</p><p>become a common treatment for lymphedema worldwide,</p><p>especially in European hospitals and clinics (Huang et al.,</p><p>2013), because it is not only safe and well tolerated, but it</p><p>may also be most beneficial for women with mild to moderate</p><p>lymphedema (Ezzo et al., 2015). Therefore, this highlights the</p><p>need for more synthesis of scientific evidence to find out</p><p>whether MLD can be beneficial for reducing the risk of BCRL</p><p>and maintaining volume reduction in women experiencing arm</p><p>swelling.</p><p>In 2013, authors of one meta-analysis reported that there</p><p>was no evidence to support the use of MLD in preventing or</p><p>reducing BCRL. However, the poor methodologic quality of the</p><p>included studies was mentioned. In one article in 2015, re-</p><p>searchers reported</p><p>the effectiveness of MLD on the man-</p><p>agement of BCRL through the use of a meta-analysis (Ezzo</p><p>et al., 2015). The authors reported that MLD might offer</p><p>additional benefits to bandaging for swelling reduction,</p><p>particularly in those with mild to moderate BCRL. However,</p><p>because only six articles were cited at that time, confirmation</p><p>with data from are randomized controlled trial (RCT) are</p><p>needed. Recently, the authors of one published meta-analysis</p><p>focused on the effect of MLD on quality of life in women with</p><p>lymphedema or mixed edema (M€uller et al., 2018). However,</p><p>doi: 10.1016/j.nwh.2021.07.005</p><p>EY HOSPITAL from ClinicalKey.com/nursing by Elsevier on</p><p>mission. Copyright ©2024. Elsevier Inc. All rights reserved.</p><p>https://orcid.org/0000-0003-2656-1108</p><p>https://orcid.org/0000-0003-2473-5063</p><p>mailto:ausanee@bcnb.ac.th</p><p>https://doi.org/10.1016/j.nwh.2021.07.005</p><p>Lymphedema is a chronic condition</p><p>in which there is accumulation of</p><p>protein-rich fluid in the interstitial</p><p>spaces of the affected body part due</p><p>to a blockage in the lymph system; it</p><p>can occur immediately after surgery</p><p>or even 20 years after treatment</p><p>Wanchai & Armer</p><p>the study also involved women with chronic venous insuffi-</p><p>ciency, not breast cancer specifically.</p><p>Purpose and Aim</p><p>The aim of this systematic review was to determine the best</p><p>evidence available for determining the effects of MLD on</p><p>reducing the risks of and managing BCRL through June 2020.</p><p>We report on the evidence that is available. Our research</p><p>question was as follows: what is the association of the use of</p><p>MLD with reducing the risk of and management of BCRL? We</p><p>hope that this review will enhance our ability to provide</p><p>beneficial information regarding the use of MLD in women with</p><p>or at risk of BCRL.</p><p>Search Methods</p><p>The Preferred Reporting for Systematic Reviews and Meta-</p><p>Analyses (PRISMA) was used to conduct this systematic re-</p><p>view (Moher et al., 2009). Research articles published in the</p><p>English language from January 2000 to June 2020 were</p><p>searched from the following electronic databases: Science-</p><p>Direct, Scopus, PubMed, and CINAHL. Search terms included</p><p>a combination of subject headings, terms, and keywords:</p><p>“manual lymphatic drainage,” “breast cancer-related lymphe-</p><p>dema,” “lymphoedema,” and “lymphedema.” Additionally,</p><p>reference lists of electronically retrieved articles were hand-</p><p>searched to retrieved additional relevant citations within the</p><p>search time frame.</p><p>Inclusion criteria were as follows:</p><p>� Population: Participants were women with breast</p><p>cancer.</p><p>� Intervention: The study was required to have MLD as the</p><p>intervention.</p><p>� Control: The study was required to have a control group</p><p>or at least two comparative groups.</p><p>� Outcomes: The primary outcome was BCRL volume that</p><p>could be measured by using water displacement,</p><p>perometry (a noninvasive technique that uses infrared</p><p>light for scanning a limb volume), or circumferential</p><p>measure.</p><p>� Study: Only RCTs were included in the review.</p><p>Cross-sectional or longitudinal design, qualitative design,</p><p>case studies, reviews, and expert opinion papers were</p><p>excluded.</p><p>When the title and abstract appeared to meet the inclusion</p><p>criteria, two authors independently scanned the article. Then,</p><p>the full-text articles were also screened based on the inclu-</p><p>sion and exclusion criteria. If there was disagreement, it was</p><p>resolved by consensus with a third expert. The risk of bias for</p><p>each study was assessed by using the Cochrane risk-of-bias</p><p>tool (Higgins et al., 2019). The tool has seven domains:</p><p>random sequence generation, allocation concealment, blind-</p><p>ing of participants and personnel, blinding of outcome</p><p>assessment, incomplete outcome data, selective reporting,</p><p>October 2021</p><p>Downloaded for Anonymous User (n/a) at ANDROSCOGGIN VALL</p><p>August 27, 2024. For personal use only. No other uses without per</p><p>and other sources of bias. Only published materials were</p><p>used to assess the risk of bias, and authors were not con-</p><p>tacted to seek clarification. Therefore, a number of items</p><p>remained unclear in some cases, and it could not be decided</p><p>whether the quality criteria were met or unmet. However,</p><p>based on available information, four studies were assessed</p><p>as low risk of bias (Devoogdt et al., 2011; Gradalski et al.,</p><p>2015; McNeely et al., 2004; Sitzia et al., 2002), and the</p><p>balance of the studies were assessed as uncertain risk of</p><p>bias because there was insufficient information about the</p><p>sequence generation, allocation concealment, and blinding</p><p>(see Supplementary Table S1).</p><p>The database search yielded 518 records. After checking</p><p>for duplicates, 472 articles were screened for eligibility.</p><p>Thereafter, 433 articles were excluded based on title and</p><p>abstract. Thirty-nine articles were further inspected, after</p><p>which 27 articles were excluded because they were not RCTs,</p><p>did not measure BCRL, and/or were protocol papers. The</p><p>remaining 10 articles were included in the final review (see</p><p>Figure 1). Data were extracted and are synthesized in a</p><p>summary table (see Supplementary Table S2).</p><p>Results</p><p>General Characteristics of the Included</p><p>Studies</p><p>Of the 10 included articles, only one was from North</p><p>America, one was from Australia, and the rest were con-</p><p>ducted in European countries. None were conducted in the</p><p>United States. All women had undergone breast surgery</p><p>with axillary lymph node dissection, and the ages of par-</p><p>ticipants ranged from 34 to 81 years. All 10 studies were</p><p>two-arm RCTs. Eight studies concentrated on women</p><p>determined to have BCRL (Andersen et al., 2000; Gradalski</p><p>et al., 2015; Gurdal et al., 2012; Maher et al., 2012;</p><p>McNeely et al., 2004; Sitzia et al., 2002; Szolnoky et al.,</p><p>2009; Williams et al., 2002), whereas two studies focused</p><p>on women at risk of BCRL (Devoogdt et al., 2011;</p><p>Zimmermann et al., 2012). A total of 520 women with</p><p>breast cancer were evaluated in the included studies. The</p><p>sample size of the studies varied from 27 to 160</p><p>Nursing for Women’s Health 379</p><p>EY HOSPITAL from ClinicalKey.com/nursing by Elsevier on</p><p>mission. Copyright ©2024. Elsevier Inc. All rights reserved.</p><p>Many women with lymphedema may</p><p>feel anxious, stressed, or fearful or</p><p>may have a lack of confidence</p><p>because of enlarged arms</p><p>to</p><p>ª</p><p>FG</p><p>Tr</p><p>ad</p><p>e</p><p>/</p><p>is</p><p>to</p><p>ck</p><p>ph</p><p>ot</p><p>o.</p><p>co</p><p>m</p><p>Manual Lymphedema Drainage for Breast Cancer–Related Lymphedema</p><p>participants. Among these participants, 227 were women</p><p>after breast surgery, and 293 were women diagnosed with</p><p>BCRL. Arm volumes were evaluated in all included studies.</p><p>Seven trials used a single method to measure arm volume:</p><p>one trial used water displacement (Zimmermann et al.,</p><p>2012), and six used limb circumference measures</p><p>(Andersen et al., 2000; Gradalski et al., 2015; Gurdal</p><p>et al., 2012; Sitzia et al., 2002; Szolnoky et al., 2009;</p><p>Williams, et al., 2002). Three trials used dual methods to</p><p>measure arm volume: two used water displacement and</p><p>circumference measures (Devoogdt et al., 2011; McNeely</p><p>et al., 2004), and one used perometry with bioimpedance</p><p>spectrometry (Maher et al., 2012).</p><p>Reported Efficacy of MLD for Women at Risk</p><p>of BCRL</p><p>There were two teams of investigators that conducted a two-</p><p>arm RCT to study the effectiveness of MLD on arm volume</p><p>changes in women at risk for BCRL (Devoogdt et al., 2011;</p><p>Zimmermann et al., 2012). The intervention in one study</p><p>started on the second day after surgery with the standard</p><p>physiotherapy program and followed participants with MLD or</p><p>without MLD for 6 months (Zimmermann et al., 2012). The</p><p>results indicated that MLD was likely to be effective because</p><p>the arm volume, measured by water displacement, on the</p><p>operated side in women who underwent MLD was not signif-</p><p>icantly increased, whereas the arm volume on the operated</p><p>side in the control group was significantly increased (p ¼</p><p>.0033; Zimmermann et al., 2012). However, another study</p><p>examined the effectiveness of MLD plus education about</p><p>BCRL prevention versus education about BCRL prevention</p><p>alone. Those authors reported that at 12 months after sur-</p><p>gery, the cumulative incidence rate of BCRL, measured by</p><p>water displacement and circumference, was not</p><p>significantly</p><p>different between the two groups (p ¼ .45; Devoogdt et al.,</p><p>2011).</p><p>Reported Efficacy of MLD for Women With</p><p>BCRL</p><p>For women with BCRL, based on eight included trials, it may</p><p>be concluded that applying MLD alone or MLD combined with</p><p>other interventions could help reduce arm volume for women</p><p>diagnosed with BCRL, but the between-group differences were</p><p>not significant.</p><p>In the first category, authors of three studies tested MLD</p><p>plus standard therapy for women diagnosed with BCRL</p><p>(Andersen et al., 2000; McNeely et al., 2004; Szolnoky et al.,</p><p>2009). First, the findings from a two-arm RCT indicated that</p><p>the reduction of arm volume between women who received</p><p>MLD plus standard therapy (including garment, education,</p><p>skin care, and lymphedema precautions) and those who</p><p>received standard therapy alone without MLD were not</p><p>significantly different (Andersen et al., 2000). When adding</p><p>compression bandaging (CB) into both groups (group 1:</p><p>380 Volume 25 Issue 5</p><p>Downloaded for Anonymous User (n/a) at ANDROSCOGGIN VALL</p><p>August 27, 2024. For personal use only. No other uses without per</p><p>standard education on proper arm and skin care plus MLD;</p><p>group 2: standard treatment plus CB without MLD), the results</p><p>showed that the reduction of arm volume in both groups was</p><p>also not significantly different (McNeely et al., 2004). How-</p><p>ever, the results of a two-arm RCT by Szolnoky et al. (2009)</p><p>indicated that upon adding IPC into the treatment, MLD plus</p><p>IPC and standard treatment (CB plus exercise plus skin care)</p><p>was more likely to enhance the reduction of arm volume for</p><p>women with BCRL than MLD plus the standard treatment.</p><p>For the second category, three RCTs examined the effects</p><p>of MLD plus CB on the reduction of arm volume for women</p><p>with BCRL. First, Maher et al. (2012) examined MLD alone</p><p>versus MLD plus CB among 30 women with and without BCRL</p><p>in Australia. The results showed no significant differences for</p><p>changes in arm volume between the groups. In two previous</p><p>studies, investigators conducted two-arm RCTs to compare</p><p>the effects of MLD plus CB versus IPC plus simple lymphatic</p><p>drainage (SLD; Gurdal et al., 2012) and MLD plus CB versus</p><p>standard therapy plus CB (Gradaski et al., 2015) on arm</p><p>volume reduction among women with BCRL. Neither of these</p><p>two studies showed significant differences on arm volume</p><p>changes.</p><p>Finally, for the third category, MLD alone was tested for its</p><p>effectiveness on reducing arm volume for women with BCRL</p><p>by comparing with SLD alone in one study (Sitzia et al., 2002).</p><p>Authors of another study examined the effect of MLD plus SLD</p><p>on change in BCRL volume by ordering MLD and SLD differ-</p><p>ently: Group A received MLD first, followed by a nontreatment</p><p>washout period, and finished with daily SLD; Group B received</p><p>SLD, nontreatment washout, and MLD. However, these two</p><p>studies reported that no significant differences were found for</p><p>the two groups.</p><p>P</p><p>ho</p><p>doi: 10.1016/j.nwh.2021.07.005</p><p>EY HOSPITAL from ClinicalKey.com/nursing by Elsevier on</p><p>mission. Copyright ©2024. Elsevier Inc. All rights reserved.</p><p>http://istockphoto.com</p><p>https://doi.org/10.1016/j.nwh.2021.07.005</p><p>FIGURE 1 PRISMA FLOW CHART</p><p>Note. BCRL ¼ breast cancer–related lymphedema; RCT ¼ randomized controlled trial.</p><p>Wanchai & Armer</p><p>Discussion</p><p>This topic has not been studied recently in the United States,</p><p>but rather, most studies were conducted in European coun-</p><p>tries. This disparity may be due to the fact that the MLD</p><p>method was originally developed by the Vodders in the 1930s</p><p>in Paris and then expanded to other countries in Europe and</p><p>other countries (Dr. Vodder School International, n.d.). In the</p><p>meantime, in the United States, MLD is often administered as</p><p>part of a fourfold conservative treatment known as complex</p><p>decongestive therapy (CDT). Therefore, authors of U.S.</p><p>studies then focused more on testing the effectiveness of</p><p>CDT as a gold standard treatment for lymphedema instead of</p><p>testing one component, such as MLD, alone (Gillespie et al.,</p><p>2018).</p><p>Based on this systematic review, it may be difficult to</p><p>conclude whether MLD can reduce the risk of arm edema</p><p>among women at risk of BCRL because of the limitations of</p><p>the included RCTs, including the small sample numbers. In</p><p>addition, authors of two previous studies, with study durations</p><p>of 6 months after surgery, reported different results regarding</p><p>October 2021</p><p>Downloaded for Anonymous User (n/a) at ANDROSCOGGIN VALL</p><p>August 27, 2024. For personal use only. No other uses without per</p><p>the effects of MLD on reducing the risk of BCRL; therefore,</p><p>more rigorous studies with follow-up periods of longer than</p><p>6 months after cancer treatment are needed. Moreover, the</p><p>differences of baseline risk factors for BCRL among women</p><p>after breast surgery, such as receiving axillary lymph node</p><p>dissection, reconstruction, or radiation therapy or being</p><p>overweight, should be noted as confounding factors for future</p><p>RCTs (Gillespie et al., 2018).</p><p>Similarly, regarding MLD for women with BCRL, the eight</p><p>RCTs showed that MLD alone or combined with other treat-</p><p>ments was likely to have similar results in terms of reducing</p><p>arm volume. The results of this review are consistent with a</p><p>previous critical review in which researchers found that MLD</p><p>showed limited benefit for BCRL when compared with stan-</p><p>dard treatments (Shah & Vicini, 2011). In other words, MLD</p><p>did not contribute to additional reduction beyond the standard</p><p>therapy in the primary outcome (limb volume). By contrast,</p><p>Ezzo et al. (2015) reported that MLD could add more benefits</p><p>when used with compression bandaging. MLD may reduce</p><p>arm edema because it increases lymphatic mobility by</p><p>Nursing for Women’s Health 381</p><p>EY HOSPITAL from ClinicalKey.com/nursing by Elsevier on</p><p>mission. Copyright ©2024. Elsevier Inc. All rights reserved.</p><p>Manual Lymphedema Drainage for Breast Cancer–Related Lymphedema</p><p>increasing the contraction of lymphatic vessels (Haesler,</p><p>2015; Iannello et al., 2020). Furthermore, evidence indicates</p><p>that MLD may improve the psychosocial aspects of the con-</p><p>dition for these women. For example, the authors of one</p><p>previous systematic review reported that MLD was more likely</p><p>It is recommended that MLD be</p><p>performed by certified lymphedema</p><p>therapists</p><p>to improve quality of life for women with lymphedema, and</p><p>importantly, no adverse effects were found from the MLD</p><p>method (M€uller et al., 2018). Therefore, MLD should be</p><p>considered as a complementary treatment for these women</p><p>with lymphedema. In addition, the effectiveness of MLD on</p><p>psychosocial outcomes may be further explored because no</p><p>harm has been found. Precautions include that pressure</p><p>applied for MLD should be appropriately light, not to exceed</p><p>10 mm Hg, to avoid occlusion of superficial lymphatics.</p><p>Therefore, nurses who use this technique should be con-</p><p>cerned about this issue. However, it is recommended that</p><p>MLD be performed by certified lymphedema therapists</p><p>(Iannello et al., 2020), and the trained person should teach</p><p>SLD to the women. Training and certification in complete</p><p>decongestive therapy, including the component of MLD, is</p><p>available to all health professionals, including nurses in</p><p>several countries, and should be available more widely. Most</p><p>importantly, however, at this time, all other standard lym-</p><p>phedema treatments should still be provided.</p><p>Methodologic Limitations</p><p>Because our included articles were limited to only those pub-</p><p>lished in the English language, this may lead to some selection</p><p>bias. The small number of included studies also should be of</p><p>concern for the confirmation of the findings. The consistency of</p><p>the application of MLD (dose byminutes per session, times per</p><p>week, and number of weeks) and training of the interventionist</p><p>(therapist) are important methodologic factors.</p><p>Implications for Practice</p><p>Current evidence from the small number of reviewed RCTs</p><p>does not yet support the sole use of MLD as applied in the</p><p>studies in reducing or managing BCRL. Health care providers,</p><p>therefore, may be transparent in sharing this information with</p><p>women treated with breast cancer for their</p><p>decision making</p><p>about MLD. An example of plain language for communicating</p><p>with individuals with lymphedema may be, “Women with BCRL</p><p>may benefit from MLD. However, further research to confirm</p><p>its effectiveness is needed.” In addition, based on these</p><p>studies, to achieve the positive results found in the relevant</p><p>studies as well as positive effects on quality of life, women</p><p>with BCRL may need to maintain other components of the</p><p>intensive course of the gold standard treatment, such as skin</p><p>care, exercise, and bandaging.</p><p>382 Volume 25 Issue 5</p><p>Downloaded for Anonymous User (n/a) at ANDROSCOGGIN VALL</p><p>August 27, 2024. For personal use only. No other uses without per</p><p>For the research methodology issues, some suggestions</p><p>are as follow. First, because of the limited numbers of included</p><p>RCTs in the review and small samples in each trial, future RCTs</p><p>with larger sample sizes are warranted. Second, because none</p><p>of the reviewed studies were conducted in the United States,</p><p>future research to examine the effectiveness of MLD on BCRL</p><p>in the United States is needed to obtain results applicable to</p><p>individuals and policies in the U.S. health care system. Third,</p><p>the low profiles of methodologic quality of the included studies</p><p>were also of concern. Higher-quality RCTs should be performed</p><p>to reduce the risk of bias and more fully evaluate the effec-</p><p>tiveness of MLD in reducing the risk of and managing lym-</p><p>phedema. It is not of small importance that MLD may improve</p><p>quality of life, regardless of its added impact on limb volume.</p><p>Finally, because all included studies in this systematic review</p><p>did not present the cost of MLD, further research should</p><p>examine the costs associated with MLD.</p><p>Conclusion</p><p>Arm swelling is a common complication after breast cancer</p><p>treatments. MLD is a noninvasive treatment that may be</p><p>feasible and helpful for women treated for breast cancer.</p><p>However, based on our review, it is likely that there is as yet</p><p>little scientific evidence to support the effectiveness of the</p><p>use of MLD alone on reducing the risk of or managing BCRL.</p><p>Therefore, further research to examine the effectiveness of</p><p>MLD on BCRL is needed.</p><p>Supplementary Materials</p><p>Note: To access the supplementary materials that accompany</p><p>this article, visit the online version of Nursing for Women’s</p><p>Health at http://nwhjournal.org and at https://doi.org/10.1</p><p>016/j.nwh.2021.07.005.</p><p>Author Disclosures</p><p>The authors report no conflicts of interest or relevant financial</p><p>relationships.</p><p>Funding</p><p>This work was supported by a grant from the Praboromarajchanok</p><p>Institute of Heath Workforce Development, Ministry of Public Health,</p><p>Thailand. NWH</p><p>References</p><p>Agrawal, S. 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