Randheer, S., Kadambari, D., Srinivasan, K., Bhuvaneswari, V., Bhanumathy, M., & Salaja, R. (2011). Comprehensive decongestive therapy in postmastectomy lymphedema: an Indian perspective. Indian Journal of Cancer, 48(4), 397–402.

To evaluate the effectiveness of complete decongestive therapy (CDT) in Indian patients

Patients had clinical evidence of lymphedema (with a difference in arm volumes of at least 200 ml) and were being treated with CDT. They also were at least four months since surgery or radiation therapy. CDT consisted of intensive therapy using manual lymph drainage for 45 minutes four times a week followed by multilayer compression bandaging. Patients were educated on skin and nail care, use of isotonic exercises with bandages on, and re-application of bandages. After the intensive phase, patients were to massage themselves twice daily, perform isotonic limb exercises, and care for skin and nails three times a day. They also applied low-stretch compression bandages and elevated the limb at night. Assessments were performed before and after the intensive phase and monthly for three months.

• Mean age of the sample (N = 32) was 52 with a range of 30–76.
• All patients were females who had surgery for breast cancer with level II axillary dissection.
• Patients with recurrent disease were excluded.
• Twenty-four percent of patients had puckered scars, indicative of severe infection or radiodermatitis. 
• Ninety-two percent had adjuvant chemotherapy and post-operative radiotherapy. 
• Most patients had lymphedema of the right arm and were right handed

• Single site
• Outpatient
• India

The phase of care was the transition phase after active treatment.

 The study used a prospective trial design.

• Water displacement was used to measure volume.
• Circumferential arm measurements were taken.
• Skin and subcutaneous thickness was measured using high-frequency ultrasound probes.
   

After intensive therapy, the mean reduction in absolute limb volume was 485 ml by volumetry and 2,274 ml by measurement (p < 0.001).  In the maintenance phase, there was a non-significant increase in limb volume of 20.3 ml.  Reductions in skin and subcutaneous thickness showed the same pattern as the volume reduction. Three patients developed skin irritation and blistering following bandage application, and one patient who developed recurrent cellulitis following bandaging in the maintenance phase was excluded from the study.

The study demonstrates effectiveness of intensive CDT for management of lymphedema.

• The study had a small sample size (N < 100).
• There was no control group, binding, random assignment, or appropriate attention control condition.
• Subjects who developed skin problems with bandaging were removed from the study with no intent-to-treat analysis.
• Information about degree of adherence to maintenance therapy is not provided.
• The follow-up period for maintenance evaluation was relatively short. 

Findings demonstrated effectiveness of intensive CDT for lymphedema management and effectiveness of maintenance therapy for several months. Findings also showed the need for patients and caregivers to closely monitor skin condition with use of compression bandaging as well as have knowledge of related self care. It appears that self massage and bandaging can be used effectively for maintenance. It is important for patients to know how to perform self care and mointor side effects and be able to adhere to self-care regimens.