Zhang, L., Fan, A., Yan, J., He, Y., Zhang, H., Zhang, H., . . . Xin, M. (2016). Combining manual lymph drainage with physical exercise after modified radical mastectomy effectively prevents upper limb lymphedema. Lymphatic Research and Biology, 14, 104–108. 

To evaluate the efficacy of self-manual lymph drainage (MLD) added to physical exercise for the prevention of lymphedema and scar formation

Self MLD for a total 30 minutes, three sessions a day, after incision closure and suture removal was divided into three steps: Surgical incision scar (10 minutes a session), activate lymph nodes (10 minutes a session), ,stimulate lymph drainage (10 minutes a session). All patients were to continue active remedial exercises for six months following surgery. Women with breast cancer scheduled for surgery were randomly assigned to physical exercise (control) or self MLD plus exercise, with measurements for limb circumference and shoulder abduction recorded 24 hours before and after surgery at week 1, and at 1, 3, 6, and 12 months; evaluation of scar formation was conducted after suture removal at week 1, and at 1, 3, 6, and 12 months.

• N = 1,000   
• AGE: 538 younger than 50 years, 462 50 years or older
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Women with breast cancer scheduled for modified radical mastectomy
• OTHER KEY SAMPLE CHARACTERISTICS: Age, pathological subtypes, differentiation, tumor node metastasis, ER/PR, HER 2 status, lymph node metastasis

• SITE: Single site   
• SETTING TYPE: Multiple settings    
• LOCATION: Sun Yat-sen University Cancer Center, Guangdong Shen, China

PHASE OF CARE: Multiple phases of care

• Randomized, controlled trial

• Limb volume circumference at wrist, 8 cm above and below elbow and 8 cm below shoulder joint
• Vancouver Scar Scale (VSS)
• Maximum shoulder abduction

Fewer patients in the MLD group had scar contracture (p < 0.05, MLD versus PE). Prevalence of upper limb lymphedema was lower in the MLD group at various time points (p < 0.05, MLD versus PE). Maximum shoulder abduction was better in the MLD group (p < 0.05, MLD versus PE).

The findings suggest that self-administered MLD with exercise was more effective in preventing lymphedema than exercise alone.

• Risk of bias (no blinding)
• Selective outcomes reporting
• No discussion of subject withdrawals or loss to follow-up was provided. No assessment of patient adherence to exercise and self-administered MLD was reported. Whether patients had additional radiation or chemotherapy during the 12-month period of the study was unclear.

Patient education regarding the lymphatic system, self MLD, combined with physical exercise and adherence to the therapeutic routine may help in preventing scar formation, shoulder dysfunction, and upper extremity lymphedema.