Clemens, K.E., Jaspers, B., Klaschik, E., & Nieland, P. (2010). Evaluation of the clinical effectiveness of physiotherapeutic management of lymphoedema in palliative care patients. Japanese Journal of Clinical Oncology, 40(11), 1068–1072.

To determine the effectiveness and frequency of manual lymphatic drainage (MLD) in patients with lymphedema secondary to advanced stage cancer undergoing palliative care

Patients were included in the study if they had lymphedema-related symptoms, pain, and dyspnea. The intervention strategy consisted of utilizing demographic information and disease-related data to calculate and compare the effects of MLD on lymphedema-related symptoms. MLD was performed daily on patients until discharge, and the effects were documented.

• The study sample (N = 90) was comprised of 36.7% male and 63.3% female patients.
• Mean age was 65.5 years. 
• Patients had a variety of cancer types, including thoracic, gastrointestinal, genitourinary, breast, and pancreatic. 
• Seventy-four percent of patients reported pain, 88.1% reported somatic pain, 11.9% reported somatic and neuropathic pain, and 25.6% reported dyspnea.

The study took place in an in-patient setting in a palliative care unit from January to December 2007.

Patients were undergoing active treatment for lymphedema. The study has clinical applicability for palliative care.
 

The study used a retrospective, reflexive control design.

• A numeric rating scale was used to measure pain and dyspnea.
• A four-point Likert scale assessed lymphedema reduction.
• The Karnofsky Performance Scale Index determined the level of functional impairment.
• SPSS Statistics evaluated data.

Sixty-seven patients reported pain (59 somatic, 8 somatic and neuropathic) and 23 patients reported dyspnea. Patients in the study received an average of seven MLD treatments. MLD treatment lasted an average of 41.3 minutes. The treatment was tolerated well in 92.2% of patients. Ninety-four percent of patients reported a reduction of pain and 73.9% of patients reported a reduction of dyspnea  post-treatment. Four of the eight patients with reported neuropathic pain had to discontinue the MLD intervention because of increased intensity of pain during treatment. The patient self-report of lymphedema reduction on the Likert scale was reported as 18.9% as little, 64.4% as good, and 16.7% as good.

The study suggests a positive correlation between a significant decrease in pain and dyspnea after MLD in patients with advanced disease or cancer undergoing palliative care but increased pain with MLD in patients with neuropathic pain.

• The sample size was small, with less than 100 patients.
• The study had a risk of bias because there was no control group, blinding, random assignment, or an appropriate attentional control condition. 
• Because opioid analgesics were given a few days prior to the intervention (although they were discontinued before beginning), patients' perception of pain may have been altered.

In patients undergoing palliative care, the top priority is comfort. Given the positive outcomes of the study, nurses may recommend that their patients partake in MLD as a mechanism to alleviate burden because of their disease process, if the pain is not of neuropathic origin. It should be recognized that some patients experienced increased pain with MLD, so nurses need to be aware of assessing these effects if MLD is used. Further studies should be completed using a more rigorous study design and larger sample size to further support findings reported in the study.