The effects of bandaging with an additional pad and taping on secondary arm lymphedema in a patient after mastectomy.

[Purpose] The purpose of this case study was to determine the effectiveness of bandaging the arm of a patient with secondary lymphedema on the patient's quality of life, arm volume and arm function using an additional pad and taping along with some other standard therapy modalities for lymphedema.
[Subjects and Methods] I used a bandage with an additional pad and taping, along with MLD, exercise, and skin care to treat a patient with unilateral breast-cancer-related arm lymphedema who had fibrotic tissue on her lower arm and hand. I made a pad called a "muff" and applied it under tape while using Vodder's technique. Treatment was performed during 5 therapy sessions a week for 2 weeks.
[Results] After the physiotherapy sessions, the excess edema volume decreased to 608 ml, and the percentage of excess volume (PEV) was 9.6%. The therapeutic efficacy, measured as percentage reduction of excess volume (PREV), was -79.5%, meaning that the edema volume was reduced 79.5%. The use of an additional pad and taping on a large edematous site with fibrotic changes can produce more efficacious lymphedema care.
[Conclusion] The use of an additional pad and taping on a large edematous site with fibrotic changes has demonstrated a positive result in lymphedema management for a post mastectomy patient and, therefore, further studies on this method are suggested with a larger sample size.

INTRODUCTION

Upper-extremity lymphedema after breast cancer surgery is one of the most disruptive symptoms to a patient’s daily life1). Lymphedema is defined as the abnormal accumulation of protein-rich fluid in extracellular spaces, caused by decreased lymphatic transport capacity and an increased lymphatic load2). Upper-extremity lymphedema after a mastectomy is the most complained-about symptom of breast cancer treatment. Both surgery and radiotherapy, involving lymph drainage routes of the breast and axillary areas, are causes of the development of lymphedema3). Lymphedema can appear as swelling of the arm, hand, trunk, or breast. It can lead to pain and a sensation of heaviness in the affected area. These symptoms can affect physical functions and also cause psychological distress4). Consequently, it decreases the patient’s quality of life.

Currently, the standard care for lymphedema consists of complex decongestive physiotherapy (CDP), which includes manual lymphatic drainage (MLD), bandaging, therapeutic exercise, skin care, and offering precautions about daily activities5). Several studies have reported that physical therapy reduces the volume of the lymphedematous limb and improves the patient’s quality of life6, 7). Sites that have additional fibrotic tissue require the application of greater pressure on the affected area than for edema alone. Therefore, pads made from short stretch bandages are commonly applied to the area first, then surrounded by multilayer inelastic lymphedema bandaging. This increases the resting pressure as well as the working pressure on the site, and also reducing the apparent volume of the arm.

Clinically, we formed the pads from short-stretch bandages. However, only one study has been conducted regarding the effects of this type of pad, and it was the case of edema only of the hand8). Taping is a recent consideration for lymphedema. Kinesio tape (Kinesio Holding Company, Albuquerqe, NM, USA) is elastic tape which can be stretched up to 120–140% of its original length, invented by Kenzo Kase in 1996. Kinesio tape can create space between the skin and muscle, which increases the lymph uptake9). Kinesio tape has been reported to be safe for patients with lymphedema, offering them improved function in their daily lives10).

We describe below a case regarding a patient with unilateral arm lymphedema, for whom we used an additional pad and taping on the lower arm using short-stretch bandages. Ethnic approval was received from Asan Medical Center (IRB number: 2015-796)

CASE REPORT

A 69-year-old female with a medical history of right breast cancer had been diagnosed in 2010. She had had a radical mastectomy modified with axillary lymph node dissection and wide excision. She had received regular chemotherapy 8 times and undergone radiation therapy. She reported that she hadn’t had lymphedema after surgery. She developed lymphedema 3 months ago before her recent visit to the hospital. She said that she had peeled garlic for 7 consecutive hours 1 week before the lymphedema appeared. She visited our clinic due to the progressive swelling and fibrosis of her right arm that had by then lasted for months was disrupting her daily activities.

Upon physical examination, stage II lymphedema and fibrosis of the right forearm was found (Fig. 1). A complete laboratory work-up and imaging studies were unremarkable for infection or venous obstruction of the right arm. The results of lymphoscintigraphy showed that her right axillary lymph node uptake was not observed and diffuse increased uptake by dermal backflow had appeared. I arranged 5 therapy sessions a week for her for 2 weeks. In every therapy session over a total of 10 sessions, 30 minutes of MLD was performed by one physical therapist certified in the Vodder’s technique which is known as lymphatic massage technique. The same therapist made a short-stretch bandage pad and applied it to the patient. The pad was made by the physical therapist. According to the Vodder School, this pad is called a “muff.” A stockinette was cut into a 1 × 1 cm square piece of Rosidal soft bandage placed inside it, then the stockinette’s edges were stitched together. The pad was put on the patient’s lower arm and dorsum before another Rosidal soft bandage was applied. Kinesio tape was applied to the hand, arm, and trunk. The Kinesio tape used was designed to make a 30–40% longitudinal stretch. The patient did 20 therapeutic exercises to facilitate venous and lymphatic flow, and received instructions for skin and nail care. Exercises included an active range of motion of upper extremity and deep breathing exercise. The short stretch bandage was kept on for 23 hours and replaced at the next day.

Fig. 1.

Status of a lymphedema before treatment

Circumferential measurements were taken at every 4 cm from the wrist to the axilla, and at the dorsum to below 4 cm from the wrist, using the formula ∑ Circumference2 /π3. The measurements were made before the beginning of the treatment and after 2 weeks of treatment11). The severity of the lymphedema was defined as the percentage of excess volume (PEV) or the excess lymphedema volume relative to the healthy arm: PEV=((volume of lymphedema arm −volume of healthy arm)/ (volume of healthy arm)) × 100%. The response to the therapeutic intervention was quantified as the percentage reduction of excess volume (PREV): PREV=100% × (posttreatment volume of lymphedema arm − baseline volume of lymphedema arm)/ excess volume.

The initial excess volume was 764 ml, and the lymphedema severity-baseline PEV was 47.1%, which indicated severe lymphedema, based on the definition from the International Society of Lymphology. After the 10 physiotherapy sessions, the excess volume decreased by 608 ml, and PEV was 9.6%. The therapeutic efficacy, PREV, was −79.5%, meaning that the edema volume could be reduced by 79.5% after 10 sessions of therapy (Table 1) (Fig. 2).

Table 1.

Volume reducation

Variable	Baseline	Post-10-TimeTreatment
Excess volume (EV)	764 ml
Post-t/x decreased EV, ml		–608 ml
PEV, %	47.1%	9.6%
PREV, %		–79.5%

PEV: percentage of excess volume; PREV: percentage reduction of excess volume

Fig. 2.

Status of a lymphedema on dorsum after treatment

The patient followed the entire course of treatment well. After 2 weeks, the score for her quality of life (QOL) question in the EORTC QLQ-C30 questionnaire improved to 100, compared to a baseline score of 50 baseline. Also, the score for her disabilities of the arm, shoulder and hand (DASH) also improved (Table 2).

Table 2.

QOL and arm function

	Baseline	Post-10-TimeTreatment
EORTC QLQ-C30*
Global health status/QOL	50	100
DASH	47.5	15

*Quality of life questionnaire-cancer. DASH: disabilities of the arm, shoulder and hand

DISCUSSION

This patient’s PEV improved from 47.1 to 9.6% after therapy, from severe lymphedema to minimal lymphedema. The lymphedema reduction was 79.5% after 10 sessions of therapy; therefore the lymphedema treatment was successful, as per Ramos’s definition. According to Ramos, S. M. et al., the definition of successful lymphedema treatment is a mean reduction of 50% or more of pre-treatment edema fluid volume12). In this case, the result was as good as those in previous studies, which have demonstrated that the CDP program can reduce fluid volume13, 14). I wished to determine if the additional pad contributed further to the positive results of this treatment.

The role of MLD by itself as a treatment method for lymphedema is still controversial in breast cancer related lymphedema (BCRL) studies. Bergmann, A. et al. reported that MLD did not significantly increase the therapeutic response in women with lymphedema after breast cancer15). McNeely et al. showed MLD only had an effect on mild early-stage lymphedema16). Based on the results of the meta-analysis, Huang, T. W. did not recommend the addition of MLD to compression therapy for patients with breast-cancer-related lymphedema17). Though he/she demonstrated that exercises improve mobility and muscular activity and lead to the internal compression of lymph vessels, and that intermittent pressure changes between muscles and external compression (bandages or compressive garments) stimulate lymph drainage, Korpan et al. who studied the effects of exercise on lymphedema, concluded that further research is needed18).

A specific application of additional pads combined with Kinesio tape may assist improve the effect of conventional lymphedema management using the MLD and/or the CDP. As this study suggested the effect of the standard CDP may be enhanced when it follows the Vodder’s school method and combined with Kinesio tape. The strongest contributor for the enhancement was probably the specific application method of the compression pads. Compression therapy using a multilayer bandage acts by modifying the capillary dynamics of veins, lymph vessels and tissues. It promotes increased interstitial pressure and increased ability of muscle and joint pumping. Foldi said that CDP would not be successful if the patients were not able to cooperate with the compression therapy19). The compression therapy on its own should be considered as a part of the treatment option in reducing arm lymphedema volume, while additional taping should be considered for further decreasing the fluid volume.

Many researchers have discussed the various physiological symptoms of lymphedema. One study measured 11 lymphedema-related symptoms, such as sensations of pain, discomfort, heaviness, fullness, bursting, hardness, heat, cold, numbness, weakness, and tingling to evaluate the effects of intervention2). The patient in this case also felt discomfort, heaviness, fullness, and hardness. The impact of lymphedema on QOL ranges from subtle to drastic, and sequelae include frustration, distress, depression, and anxiety, particularly with regard to body image20). Therefore, this patient’s quality of life (QOL) was affected both physically and psychologically. After her lymphedema status improved, her DASH score also improved compared to her baseline evaluation. Therefore the improvement of her symptoms most likely positively affected her quality of life.

The use of an additional pad and taping underneath a compression bandage had an excellent effect on this case of secondary arm lymphedema. A large-sample study may further clarify this case study’s findings.