Hamner and Fleming (2007)

Hamner and Fleming (2007)
Design: Retrospective case series (therapy), evidence level: 3
Country: United States
Inclusion criteria:
None stated
Exclusion criteria:
None stated
Population:
Number of patients = 135, age range 23 to 92 years, mean age = 54 years
Interventions:
All patients received a standard protocol of complete decongestive therapy (CDT) comprising: manual lymphatic drainage (MLD), skin care, compression bandages and exercise.

MLD was given twice a week and patients wore elastic compression garments (changed twice daily) between these sessions. Participants were also instructed on skin and nail care and given a personalised exercise program to facilitate lymph flow and improve range of motion for the affected limb.
Outcomes:
A comparison of before and after treatment limb volume determined by water displacement, patient subjective assessment of levels of chronic pain (10-point scale) and their need for analgesia.
Follow up:
Limb volume assessments were made before and after patients received CDT.
Results:
119/135 women received this protocol of which 119 had unilateral (as opposed to bilateral) lymphoedema as a result of breast cancer treatment.

The average number of treatments per patient was 14.3 ± 6.8 and the average number of weeks that CDT was received was 7.5 ± 3.4. The variability between patients is unknown but is assumed to be fairly large.

Mean lymphoedema volume before therapy = 709ml ± 76 ml
Mean lymphoedema volume after therapy = 473.2 ± 48.9 ml (P = 0.004). Percentage reduction in lymphoedema volume = 41.7%.

Mean score of pain perception before CDT (n = 76) = 6.9 (± 2.3) on a scale of 0–10.
Mean score after CDT = 1.1 (± 2.3) (P < 0.001)

56/76 (76%) patients who had experienced pain before CDT became pain-free after treatment. Of the 76 patients who had pain, 41 required analgesia before CDT but this was reduced to 11% after completing the CDT protocol. 1 patient reported increased pain and 2 previously pain-free patients experienced pain after CDT.
General comments:
This low quality evidence describes a retrospective study of case files from patients at a lymphoedema clinic who had been treated using a standard protocol of CDT. There was no comparator.

The participants had severe oedema (mean of 31%) which was significantly reduced by CDT. Pain was also significantly reduced, either from the CDT or from a placebo effect of the constant hands-on therapy.

Unfortunately, there is no time frame within which to assess the results since it is not obvious from the data when the follow-up lymphoedema measurements were obtained i.e. after one session or several, and the actual number of sessions per patient is unknown.

The presentation of data does not help an assessment of the variability in results over the entire patient group and hence the conclusions of efficacy must be viewed with caution.

Patient compliance and motivation were also assessed but no results were reported.

From: Chapter 6, Management of specific problems

Cover of Advanced Breast Cancer
Advanced Breast Cancer: Diagnosis and Treatment.
NICE Clinical Guidelines, No. 81.
National Collaborating Centre for Cancer (UK).
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