Cho, Y., Do, J., Jung, S., Kwon, O., & Jeon, J.Y. (2016). Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection. Supportive Care in Cancer, 24, 2047–2057. 

To assess the benefits of standard physical therapy (PT) compared to PT with manual lymph drainage (MLD) on lymphedema incidence, shoulder function, pain, and cording in patients with breast cancer with axillary web syndrome (AWS)

• Participants were divided into one of two groups: Participants in group 1 (n = 20) received PT (three times per week for four weeks). Participants in group 2 (n = 21) received PT combined with MLD (five times a week for four weeks), where participants independently performed MLD therapy on their own when not at rehab. All outpatient visits were supervised. All participants were prescribed nonsteroidal anti-inflammatories twice a day.  
• Exercise interventions included 10-minute warm up and 10-minute cool down stretches.  
• Upper extremity strength: Three different pulley exercises (3 sets of 10 repetitions)
• Shoulder flexion, abduction, and elbow flexion strength exercise: Theraband (3 sets of 10 repetitions)  
• MLD: 30 minutes of tissue mobilization of tight tissues of the chest wall, and antecubital fossa with full-hand or two-finger contact. Longitudinal tissue stretches of the cords with the arm in abduction, followed by scapular mobilization

• N = 41   
• AGE = 46.6 years (group 1), 50.7 years (group 2)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer with postoperative palpable and visible axillary cording in the axilla and the arm, pain rated greater than 3 on a numeric rating scale (NRS)

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: South Korea

PHASE OF CARE: Late effects and survivorship

This was a prospective, randomized trial of patients with breast cancer who had undergone surgery and were randomized to two therapy interventions.

• Participants were measured at the start of therapy and again at the end of therapy. The therapist who performed the measurements was blinded to the study groups. 
• Arm volume was measured using a measuring tape. Circumference measurements were taken at 4-cm intervals from the wrist to the axilla, with which volume was calculated.
• Muscular strength: Handheld Dynameter measured three times the average used for shoulder flexion and abduction, elbow flexion
• Active ROM (AROM) measured with a digital inclinometer in the shoulder positions supine flexion and supine abduction; each were performed three times, and the averages were used.
• Quality of life: The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), 30 questions with five functional and three symptom areas; the EORTC QLQ-BC, 23 questions, either functional or symptom
• Visible and palpable cording in the arm and the axilla: The presence or absence of the authors' recording was determined by the rehabilitation physician.  
• Arm disability: The 30-item Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, which is not breast cancer specific, was used to assess upper limb function. High scores indicate greater disability.
• Pain: Patients rated their pain on a scale of 0–10 when performing shoulder abduction.

• Quality of life based on the two questionnaires (EORTC QLQ-C and EORTC QLQ-BC) showed significant improvement in both the physical therapy group and the physical therapy combined with MLD group (p > 0.05).  
• Shoulder flexor strength, shoulder flexion, and abduction range of motion (ROM) improved; DASH score and pain NRS score also improved in both groups (p > 0.05). NRS scores decreased more in the PT and MLD group (p > 0.05). Visible cording: 28.5% continued in the PT and MLD group and 35% in the PT only group.  
• Arm volume significantly increased in the physical therapy group (p > 0.05). Six patients developed lymphedema, which was verified with a lymphoscintigraphy. The typical incidence range of lymphedema is 13%–65%. In this study, 33.3% developed lymphedema. 
• Overall significant changes occurred in all areas in both groups but not between groups except for the PT and MLD group, which did not experience any volume increase. A significant increase of lymphedema was seen in the PT group.

All patients benefited from postoperative PT, but patients who had PT and MLD did not develop lymphedema. Measurements were not taken weekly, so when the changes in arm volume occurred cannot be identified. This study supports wearing compression during therapy. Patients are at risk for lymphedema even when engaging in supervised exercise.

• Small sample (< 100)
• As stated by the authors, a control group would have allowed an observation of the natural course of AWS. NSAIDs were prescribed, but their use was not monitored. Also, patients were not told to perform or not perform exercises on their own. Perhaps the patients with lymphedema were performing more exercises.

Nurses need to vigilantly monitor for symptoms of pain in the ipsilateral limbs of patients with breast cancer to prevent loss of function, chronic pain, and lymphedema. As seen in this study, even pain at level 3 is significant. Patients need early PT referral to prevent arm disability and early lymphedema therapy.