The Effectiveness of Manual Lymph Drainage (MLD) in Breast Lymphedema and Generalized Oedema after Mastectomy: A Case Study Volume 49- Issue 2

Bonia Κ Dimitra*, PE, PT, MSc, MLD-CDT, Clinical Exercise Physiologist

• Clinical Exercise Physiologist, Institute of Occupational Science and Rehabilitation, Metropolitan College, Greece

Received:March 03, 2023;   Published:March 13, 2023

*Corresponding author: Bonia Κ Dimitra, PE, PT, MSc, MLD-CDT, Clinical Exercise Physiologist, Clinical Exercise Physiologist, Institute of Occupational Science and Rehabilitation, Metropolitan College, 74, Sorou str., 151 25, Maroussi, Attica, Greece

DOI: 10.26717/BJSTR.2023.49.007769

Abstract PDF

Background: After a mastectomy a very common pathology for patients is to develop breast or arm lymphedema. The reasons are unknown. Lymphedema has described as a very uncomfortable situation that concerns many patients after mastectomy. Also, during chemotherapy these patients may develop generalized oedema, especially to the ankles, torso, and face. The most easy and painless way to treat this oedema is the Manual Lymph Drainage (MLD), with very good results to patient’s health.

Case Study: A 67-year-old woman has developed a lymphedema on the left breast, three months after a mastectomy and placement of a breast prefix. During the chemotherapy with taxanes and anthracyclines, she also developed a generalized oedema to her legs and torso. Her medical history was mitral valve stenosis without any significant issues, and a fully recovery after a valve replacement. The medication for her heart disease was medicines for the blood pressure and anticoagulant drugs. The patient started being treated with MDL for the oedema, for one hour a day, two times a week, for eight weeks. Five measurements of the oedema were taken. The individual was tested before, every two weeks and at the end of the intervention program. In addition to MLD, the usage of a mastectomy bra was suggested, and instructions for arm and legs exercise, and daily care of the skin around the breast area, were given for better results. The results were a major progressive reduction of the generalized oedema and lymphedema in this patient.

Conclusions: The MLD has a great effect on generalized oedema and breast lymphedema in patients with an oedema after a mastectomy and chemotherapy.

Keywords: Breast Cancer; Mastectomy; MLD; Rehabilitation; Lymphedema; Oedema

In the US, 65% of adults whose is diagnosed with cancer have a 5year life expectancy of which 22% are breast cancer survivors (CDC [1]). The main treatment for breast cancer is mastectomy which is the dissection of the breast gland and axillary lymph-nodes to prevent the spread and metastasis of the cancer, after the mastectomy chemotherapy (taxanes) and radiotherapy is following (Verbelen, et al. [2]). Even though those treatments are suitable for breast cancer, patients develop a toxicity after the treatment which create Lymphedema and generalized oedema up to 90% of the patients (Todd [3,4]). Lymphedema is a deformity of proteins’ deposition to the intercellular fluid and create loss of function, physical discomfort, psychological distress, and erysipelas infection as a result of chemoradio therapy and mastectomy, and it may occur to 12-26% of post cancer treatment patients (Stanton et al. [5-9]). Lymphedema is a tough condition that can be very difficult to be treated and it becomes chronic. The main treatment for Lymphedema is the Complex Decongestive Therapy (CDT). CDT is a fourfold conservative treatment and comprise from two parts. The Phase 1 includes Manual Lymphatic Drainage (MLD), Compressing Bandages, Skin Care and Exercise. The Phase 2 includes the use of Compressing Garments to maintain the oedema reduction in long-terms. More specific, MLD is a specific type of hand manipulations, collecting the excess lymphatic fluid from the area of treatment, and directing it back to the main blood stream. These hand manipulations are slow, circular, painless, with flow and provide the feeling of relaxation to the patient (Ezzo et al. [10,11]).

A 67-year-old woman was diagnosed with left breast cancer and underwent total mastectomy and dissection of 13 axillary lymphnodes. She was treated one cycle of Cyclophoshamide (FEC), and three cycles of Taxanes. After the end of the second cycle of chemo, the patients began to develop an oedema to the left breast and torso, and severe oedema to the lower and upper extremities. Even though, she developed breast lymphedema, she did not develop upper arm lymphedema. Her physicians suggested to her to start treatment for oedema and lymphedema. Her previous history was mitral valve stenosis without any significant issues, and a fully recovery after a valve replacement. The medication for her heart disease was medicines for the blood pressure and anticoagulant drugs, also suffered from fibromyalgia.

Protocol

The patient started being treated during the fourth cycle of chemo to prevent further oedema. The protocol started with phase 1 of CDT rehabilitation and lasted 8 weeks. The MLD sessions performed 1 hour per day, two times per week, for 8 weeks. They were 5 measurements to insure the oedema and lymphedema reduction. Except MDL, Compressing Garment (Bra), directions of skin care and exercise were given to the patient between MLD sessions. The first measurement occurred before the first treatment started, and the rest of them every 2 weeks duration. To determine and establish the loss of oedema, 10 stable body points were chosen to being measured with a measure tape, and for weight control a home body scale was used.

Table 1. Oedema body measurements during 8 weeks of MLD treatment.

The progression of oedema reduction was noticeable during the 8 weeks duration of treatment, furthermore, there was a major reduction of the body weight, torso, and left breast perimeter (Table 1). In Figure 1, the results of the oedema reduction on the first body point of the ankle were from 25,5 cm to 23 cm for the left ankle, and from the 23,7 cm to 22 for the right ankle. The total reduction was 2,5 cm for the left ankle and 1,07 cm for the right. In Figure 2, the results of the oedema reduction on the second body point of the middle of the Tibia were from 23,4 cm to 23 cm for the left limp and 25 cm to 23 for the right limp. The total loss was 0,4 cm for the left limp and 2 cm for the right limp. In Figure 3, the results of the oedema reduction on the third body point of the middle of the calf were from 33 cm to 27 cm for the left limp and from 34 cm to 28 for the right limp. The total loss was 6 cm for both limps. In Figure 4, the results of the oedema reduction on the fourth body point of 5 cm under Patela were from 32 cm to 30,1 cm from the left limp and from 34,5 cm to 30 cm for the right limp. The total loss was 1,9 cm for the left limp and 4,5 for the right limp. In Figure 5, the results of the oedema reduction on the fifth body point of wrist joint were from 17 cm to 16 cm for the left arm and from 18 cm to 16 cm for the right arm. The total loss was 1 cm for the left arm and 2 cm for the right arm. In Figure 6, the results of the oedema reduction on the sixth body point of the middle of forearm were from 18 cm to 20 cm for the left arm and from 21 cm to 20 cm for the right arm. The total loss of the right arm was 1 cm and the left arm gained 2 cm. In Figure 7, the results of the oedema reduction on the seventh body point of 3cm over the elbow were from 26,7 cm to 23 cm for the left arm and from 27 cm to 23 cm for the right arm. The total loss was 3,3 cm for the left arm and 4 cm for the right arm. In Figure 8, the results of the oedema reduction on the eighth body point of middle of upper arm were from 27 cm to 27,1 cm for the left arm and 30 cm to 27 cm for the right arm. The total loss was 3 cm for the right arm and the left arm gained 0,1 cm. In Figure 9, the results of oedema reduction on the torso were from 94 cm perimeter to 88 cm and the total loss was 6 cm. In Figure 10, the results of the lymphedema reduction on the left breast perimeter were from 55 cm to 49cm and the total loss was 6cm. Finally, in Figure 11, the results of the total loss of body weight were from 79,9 kg to 72 kg and the total weight loss was 7 kg.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Figure 7.

Figure 8.

Figure 9.

Figure 10.

Figure 11.

The patient in this case study developed lymphedema and generalized oedema after mastectomy of left breast and chemotherapy due to breast cancer. In addition, torso oedema also observed. The major reduction of oedema after an eight-weeks MLD protocol was significant and helped the patient to have better mobility of upper body and less discomfort. Additionally, even though the mastectomy area was on the left site of the body, the right site was found to have the largest amount of oedema. The left site of the body had less oedema, although some increase in two body points was found. The major oedema of the torso had had an enormous reduction through time. The body weight had also a significant reduction. Finally, the lymphedema on the left breast had been reduced and become softer and more flexible. The most important notice during the procedure was that the patient did not perform any type of exercise due to her poor condition and did not change her diet. That gives the conclusion that the reduction of the oedema and lymphedema was the result of MLD protocol. Some other researchers conducted the same results in three patients with lymphedema after mastectomy and chemotherapy. They found that the most common reason to develop lymphedema is chemotherapy and radiotherapy and must be prevented in an early stage (Park, et al. [12]). Even though, the patient would continue the treatment to phase 2, she developed respiratory systemic infection due to a common cold and the therapy stopped. After, that the patient started the phase 2 with compressive garment (bra and belt) and exercise twice a week.

This case study shown that the eight-week protocol of MLD was effective and helped the patient to feel better. Furthermore, the treatment did not have any side effects and the patient did not feel any pain during the procedure. According to the results MLD is an effective, pain-free, and suitable treatment for the reduction of Lymphedema and generalized oedema after mastectomy and chemotherapy.

1. (2004) Centers for Disease Control Prevention (CDC) Cancer Survivorship-United States 1971-2001. 5(3): 526-529.
2. Verbelen H, Gebruers N, Beyers N, De Monie A, Tjalma W (2014) Breast edema in breast cancer patients following breast-conserving surgery and radiotherapy: A systematic review. Breast Cancer Research and Therapy 147(3): 463-471.
3. Todd M (2018) Identification, Assessment, and management of breast oedema after treatment for cancer. International Journal of Palliative Nursing 23(8): 440-444.
4. Agrawal S (2014) Late effects in breast cancer survivors. South Asian Journal of Cancer 3(2): 112-115.
5. Stanton A, Modi S, Mellor R, Levick J, Mortimer P (2009) Recent advances in breast cancer-related lymphedema of the arm: lymphatic pump failure and predisposing factors. Lymphatic Research Biology 27: 29-45.
6. Fleissing A, Fallowfield L, Langridge C, Johnson L, Newcombe R, et al. (2006) post-operative arm morbidity and quality of life. Results of the ALMANAC randomized trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Research and Treatment 95: 279-293.
7. Karki A, Simomen R, Malkia E, Selfe E (2005) Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Journal of Rehabilitation Medicine 37: 180-188.
8. Szuba A, Achalu R, Rockson S (2002) Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 95: 2260-2267.
9. Badger M, Peacock L, Mortimer P (2006) A randomized controlled, parallel-group clinical trial compering multilayer bandaging followed by hosiery versus hosiery alone in treatment of patients with lymphedema of the limp. Cancer 88: 2832-2837.
10. Ezzo J, Manheimer E, McNeely M, Howell D, Weiss R, et al. (2015) Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Systematic Review (5): CD003475.
11. Rose K, Taylor H, Twycross R (1993) Volume reduction of arm lymphedema. Nursing Standard 7(35): 29-32.
12. Park S, Jeon WH, Jeung HJ, Kim GG, Kim DK, et al. (2014) Clinical Features of Docetaxel Chemotherapy-Related Lymphedema. Lymphatic Research and Biology 12(3): 197-202.