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Indian Journal of Physiotherapy and Occupational Therapy

Pilot Study with Myolymphokinetic Activities in the Treatment of Lymphedema After Breast Cancer

Author(s): Maria de Fátima Guerreiro Godoy, José Maria Pereira de Godoy, Domingo Marcolino Braile

Vol. 2, No. 3 (2008-07 - 2008-09)

Maria de Fátima Guerreiro Godoy1, José Maria Pereira de Godoy2, Domingo Marcolino Braile3

1Occupational Therapist, Teacher of post graduation Lato-Sensu course in Rehabilitation of Lymphedema of the Medical School in São José do Rio Preto (FAMERP)
2Livre Docente of the Cardiology and Cardiovascular Surgery Department of the Medical School in São José do Rio Preto (FAMERP), Professor of the Graduation and post graduation courses of FAMERP and CNPq researcher
3Livre Docente of the Cardiology and Cardiovascular Surgery Department of the Medical School in São José do Rio Preto (FAMERP); Coordinator of the post graduation Stricto Sensu course of FAMERP.

Abstract

Background: Lymphedema is one of the main complications seen after breast cancer treatment. Clinical treatment of lymphedema has been recommended as the main approach over the last few years in which an association of therapies is suggested and recently, several forms of treatment.
Purpose: The objective of the current study was to evaluate the reduction in edema associated with myolymphokinetic exercises using a non-elastic contention sleeve (‘gorgurão’) in patients suffering from lymphedema of the upper limbs.
Method: Twelve female patients, who were being treated for lymphedema of the arms, were selected to continue their myolymphokinetic activities using non-elastic contention sleeves daily during a period of 30 days. Their ages ranged between 32 and 76 years with a mean of 52,6 years. They were assessed using displacement of water before and after the 30-day treatment program. Statistical analysis was achieved using the paired student t-test with an alpha error of 5% considered acceptable.
Results: Analysis demonstrated a statistically significant difference between the volumetric evaluations before and after the treatment period (p-value = 0.001). Conclusion: In conclusion, myolymphokinetic activities associated with a ‘gorgurão’ sleeve as a contention mechanism can contribute in reducing the size of arms in the treatment of lymphedema.
Key words: Myolymphokinetic, activities, lymphedema, treatment, upper limbs.

Introduction

Lymphedema is one of the main complications seen after breast cancer treatment and consists of an abnormal accumulation of fluids and substances in the tissues resulting from a failure of the lymph drainage system associated with insufficiency of the extracellular proteolysis of proteins in the cellular interstice and of the mobilization of macromolecules such as for example hyaluronic acid1. Clinical treatment of lymphedema has been recommended as the main approach over the last few years in which an association of therapies is suggested2-5. The most commonly used association was first described by Földi and includes lymph drainage, bandaging and a daily hygiene routine which became known as the complex physical therapy6. More recently, several forms of treatment have been suggested however there is no consensus when used in isolation. There have been no studies published evaluation the effect of exercising or performing manual activities, although it is well known that excessive strenuous activities increase edema.

The aim of this study was to evaluate volumetric reduction of the upper limbs by associating myolymphokinetic activities with the use of a non-elastic contention sleeve made of gorgurão (a cotton-polyester material).

Method

Twelve female patients with lymphedema of the upper limb and being treated in the Godoy Clinic were randomly selected for this study. All patients had been submitted to radical mastectomy with axilary dissections and after a radiotherapy and chemotherapy regimen. The patients remained without normal treatment sessions during December 2006. Their normal treatment included two weekly sessions of manual lymph drainage using the Godoy technique5,7,8, myolymphokinetic exercises using facilitating devices developed by Godoy9 and myolymphokinetic activities10, that is, occupational activities and personal hygiene routines. The patients were requestd not to use excessive force or lift heavy objects with guidance on how they should be performed. To repeat one specific movement over a long period of time and to avoid incorrect when performing the movement avoiding joint injuries together with the use of daily non-elastic contention (gorgurão sleeve).

The ages of the women varied from 32 to 76 years old with a mean age of 52.6 years old. The patients were advised to maintain the myolymphokinetic activities and contention during the period of their vacation. Volumetric displacement of water was performed in the consultation immediately before the vacation and on their return to the normal treatment program 30 days later. Volumetric displacement of water was achieved using a glass container with 35 cm in width and 65 cm in height. The displacement of water volume was measured on a calibrated digital scales. The activities common to all the women were washing up, cooking in small and medium-sized pans, brushing the floor using the affected limb, brushing the teeth, brushing the hair, washing clothes (small pieces) without scrubbing, ironing clothes (small and light pieces) during the morning, making the bed, hanging clothes on the washing line (small pieces) at shoulder height evaluated for each patient and watering the garden. The study received the approval of the Local Ethics Research Committee and participants signed written consent forms. For statistical analysis the paired student t-test using the PAD program was utilized with an alpha error of 5% considered acceptable (p-value < 0.05).

Results

The volumetric evaluations, before and after thirty days of follow up, are illustrated in Table 1. The paired t-test identified statistically significant differences (p-value < 0.001) for the volumetric evaluations before and after the thirty day study period with the women using myolymphokinetic activities and personal hygiene routine.

Discussion

The current study evaluated the volumetric reduction in patients with lymphedema of the upper limbs associating myolymphokinetic activities with a gorgugão non-elastic contention sleeve and showed that this association is an alternative treatment giving greater independence to these patients, by maintaining the volumetric size of the limb. The patients were already being treated and constantly presenting with reductions in the size of the affected limb and the 30-day vacation did not aggravate the edema; in fact there was a continued volume loss in most participants.

It is important to stress that these activities were evaluated and each patient received guidance in their transformation into myolymphokinetic activities. The day-to-day activities common to all the patients were identified and a specific analysis of these activities was made considering the types of movements, the groups of muscles involved, the extent of the movement, the necessary muscle force, the intensity of performing the movement and posture. These activities were adapted to modify the posture so as not to harm the joints, the intensity was moderated, there was a control of repeated movements and the use of excessive force was avoided so that, associated with contention, a working pressure favoring lymph drainage was generated, as well as movements favoring motor activities which frequently suffer with lymphedema. The routine evaluations using volume plethysmography is another important factor as it shows, by means of measurement, the results of treatment, serving as motivation for patients.

Daily tasks, as a form of treatment for lymphedema, are also an alternative for better compliance to the proposed treatment. This new perspective contemplates a series of important aspects in the treatment of post-breast cancer lymphedema, as for example, returning patients to their occupations from which, in the majority of cases, they were given sick leave.

The study evaluates experiences in the daily lives of women affected by lymphedema after breast cancer surgery demonstrating changes in the practical and psychosocial order. The most common themes related to changes were the attitudes of people in their setting in respect to their problem, the appearance of lymphedema, understanding about a chronic disease, the treatment, the emotional difficulties to understand and accept the problem, and the difficulties to perform day-to-day activities11-13.

It is also important to stress that, even when there is a considerable reduction of the lymphedema of the limb, it is necessary to continue with specific precautions. These include the daily use of contention, specific activities and exercises that favor lymph drainage in order to maintain the improvements in size as lymphedema is a chronic disease. With the patients of this study, there was a reduction in volume with five of them and for the sixth the affected arm was a size similar to the healthy arm. Guidance by a specialist and involvement of the family from the start of treatment with facts about the disease and its treatment including the association of myolymphokinetic activities at home contribute to the good results.

These preliminary results suggest that normal occupational activities can be associated with contention in the treatment14, thereby constituting myolymphokinetic activities. Patients who use this form of treatment for long periods have confirmed the benefits of this approach.

Table 1: Volumetric evaluations, before and after thirty days using.

Patient # Initial Evaluation (grams) After 30 days (grams)
1 2038 1961
2 2128 2040
3 1980 1907
4 1363 1260
5 1902 1820
6 2303 2216
7 1826 1785
8 2465 2326
9 3129 3050
10 2213 2171
11 3167 3100
12 1325 1335

Conclusion

Myolymphokinetic activities associated with a contention sleeve made from gorgurão cause volumetric reductions in the treatment of lymphedema of the upper limb.

References

  1. Godoy JMP. Fisiopatologia do Sistema Linfático. In Godoy JMP, Belczack CEQ, Godoy MFG. Reabilitação Linfovenosa. Rio de Janeiro: DiLivros, 2005. p.37.
  2. Foldi M, Foldi E. Therapy of lymphedema. Med Welt. 1980 May 23;31(21):801-6.
  3. Casley-Smith JR, Boris M, Weindorf S, Lasinski B. Treatment for lymphedema of the arm—the Casley- Smith method: a noninvasive method produces continued reduction. Cancer. 1998 Dec 15;83(12 Suppl American):2843-60.
  4. Ciucci1 JL, Marcovecchio LD. Método Transdiciplinario. In Ciucci JL. Linfedema del Miembro Superior. Buenos Aires: Nayarit, 2004. p.79-100.
  5. Godoy JMF, Godoy MFG, Batigalia F. Preliminary Evaluation Of A New, More Simplified Physiotherapy Technique For Lymphatic Drainage. Lymphology 2002; 35: 91-93.
  6. Foldi M, Foldi E, Kubik S. Textbook of Lymphology. Munchen: Elsevier, 2003. p. 517-9.
  7. Godoy JMP, Torres CAA. Self-Drainage Lymphatic Technique. Angiology 2001;52(8): 573-4.
  8. Godoy JMP, Braile DM, Godoy MFG. A Thirty-month Follow-up of the Use of a New Technique for Lymph Drainage in Six Patients. European Journal Vascular Endovascular Surgery 2002, 3: 91-3.
  9. Godoy JMP, Godoy MFG, Destito EC. Directives for the creation and adaptation of myolymphokinetic exercises in the treatment of lymphovenous diseases. Abstracts Book XIX International Congress of Lymphology, Freiburg, 2003. p 63
  10. Godoy MFG. Atividades de Vida Diária no Tratamento do Linfedema. Lymphology 2002/03; 35(Suppl 2): 213-5.
  11. Johansson K, Holmstrom H, Nilsson I, Ingvar C, Albertsson M, Ekdahl C. Ekdahl C. Breast cancer patients’ experiences of lymphoedema. Scandinavian Journal of Caring Sciences 2003 Mar; 17(1):35-42.
  12. Karki A, Simonsen R, Malkia E, Selfe J. Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Journal Rehabilitation Medicine 2005 May; 37(3):180-8.
  13. Godoy MFG, Godoy JMP, Braile DM. Tratamento do Linfedema de Membros. Exercícios e Atividades Linfomiocinéticas. Rio de Janeiro:DiLivros 2005. 130p.
  14. Godoy JMP, Godoy MFG. Assessment of inelastic sleeves in patients with upper limb of lymphoedema. Indian Journal of Physiotherapy and Occupational Therapy 2007; 1(4):3-5.

Corresponding Author:
José Maria Pereira de Godoy
Rua Floriano Peixoto, 2950 São José do Rio Preto-SP, Zipe code: 15020-010
E-mail: godoyjmp(at)riopreto.com.br

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