Tacani, P.M., Franceschini, J.P., Tacani, R.E., Machado, A.F., Montezello, D., Goes, J.C., & Marx, A. (2014). Retrospective study of the physical therapy modalities applied in head and neck lymphedema treatment. Head and Neck, 38, 301–308. 

To determine the overall symptom benefit of various physical therapy (PT) modalities applied on patients with head and neck cancer and lymphedema

This was a retrospective chart review of 32 patients with head and neck cancer who participated in physical therapy from August 2008 to July 2010. Patients were excluded if three or more variables were missing from the chart.

• N = 20  
• AVERAGE AGE = 54 years (SD = 12 years)
• MALES: 80%, FEMALES: 20%
• KEY DISEASE CHARACTERISTICS: All patients received surgical treatment with radiation and/or chemotherapy. Patients had head and neck cancer-related lymphedema. 
• OTHER KEY SAMPLE CHARACTERISTICS: Information gathered included body mass index, alcohol use, tobacco use, chief complaints, physical examinations of lymphedema, measurements of head and neck pre- and post-PT, presence or absence and intensity of pain, PT modalities, and number of sessions. The average time span from diagnosis to the start of physical therapy was 65.4 months (SD = 26 months).  

• SITE: Brazilian Institute of Cancer Central
• SETTING TYPE: Outpatient physical therapy
• LOCATION: Brazil

• PHASE OF CARE: After physical therapy

This was a retrospective study. The authors conducted a chart review of 20 patients who participated in physical therapy for complaints of swelling and pain related to head and neck surgery.

• Physical examination for assessment of lymphedema with a tape measure
• Occurrence and intensity of pain (Visual Analog Scale [VAS] from 0–10)
• Physical therapy modalities
• Number of physiotherapy sessions

• 100% of patients received program education.    
• 85% of patients experienced pain. This measure reduced to 70% by the end of the study.  
• Pain intensity reduced from 7.8 (SD = 2.2) to 3.6 (SD = 1.6) on the VAS (p < 0.001).
• Lymphedema volume reduction was successful (p < 0.05).  
• Modalities varied and included strategic manual lymphatic drainage versus physiologic manual lymphatic drainage (85%).
• Facial exercises were done by 75% of patients.
• Shoulder and neck exercises included stretching (80%), strengthening (55%), and range of motion (45%). 
• The average number of sessions was 23.9 (SD = 14.8) twice per week.  
• Compression therapy recommendations were documented for 70% of patients.

This study examined variables retrospectively to assess which practices might prove meaningful in a prospective study of patients with head and neck cancer. Pain would be an important symptom to study because of the interval between diagnosis and referral to physical therapy. Multiple physical therapy modalities were used, and a study supporting this would be useful. The findings from this study provided valuable information regarding designing future prospective studies.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 

The duration between diagnosis of disease and referral to physical therapy was greater than two years in most cases. Excellent pain assessment skills are needed for this patient population because stiffness and tightness are usually caused by fibrosis. Fibrosis is progressive and needs to be addressed early. Physical therapy might be beneficial in the management of lymphedema.