The experimental group underwent complete decongestive therapy that included lymph drainage using the Foldi method, multilayer compression bandage, elevation, remedial exercises, and skin care. The control group underwent standard physical therapy that included compression bandages, elevation, head-neck and shoulder exercises, and skin care. Both groups had a home program of bandaging, skin care, and walking. Therapy was three times per week for four weeks.

• The study sample (N = 53) was comprised of patients with lymphedema post-breast cancer treatment.
• Patients were randomly assigned and blinded to the intervention in the experimental group (n = 27) or the control group (n = 26).
• Average duration of lymphedema at the time of treatment was three years.
• Patients were experiencing mild-to-moderate lymphedema; mild lymphedema (n = 21) was defined as a 2 cm circumference difference and moderate (n = 32) a difference of 2–5 cm.
• Patients were excluded from the study if they had
  • Obvious psychiatric illness
  • Severe pain in the axillary region
  • Severe cardiac disease
  • Uncontrolled hypertension
  • Malignancy.
• The average mean volume was 580 ml.
• Patients were assessed for type of breast cancer procedures, but this was not used for characterizing the sample.
• Of patients in the sample, 24.4% had lumpectomies, 64.2% had modified radical mastectomies, and 11.3% had radical mastectomies.
• Nine patients had a history of cellulitis, and 44 had no infection.
• All patients had axillary dissection with a range of 2–35 nodes removed.

The study used a prospective trial design.

• Range of motion, circumference measurement, and volumetric measurement were assessed before and after treatment.
• Circumference measurements were taken using a standard one inch, retractable, fiberglass tape measure.
• Measurements were taken from 10, 15, and 20 cm above and below the olecranon process, at wrist, and at metacorpophalangial joints.
• Measurements always were taken twice.
• The same procedure was used for the unaffected arm of each participant.
• The arm was placed in water-filled container and displaced water was measured.
• Shoulder mobility was measured using goniometry.
• Function was measured as the active mobility with extension-flexion, abduction-adduction, and external rotation.

Mean percentage reduction in edema was 55.7% in the experiential group and 36% in control group (p < 0.05). Only 45% had limitation of range of motion to start. Reduction in shoulder mobility was 48.1% in the experiential group and 42.3% in control group before treatment. Shoulder flexion and abduction movements in both groups were increased after treatment (p < 0.05). No significant difference was found in shoulder external rotation in both groups (p > 0.05). No difference was found between groups in shoulder mobility.

Patients were similarly classified using circumferential and volumetric measurements; therefore, either of the methods can be used.

• The sample size was small, with less than 100 patients.
• Patients had extensive disease of more than three years duration.
• The tissue was not described.
• Lymphedema was not staged.

The study included an experimental group and a control group. The experimental group received complete decongestive therapy (CDT) that included lymph drainage (Foldi method), multilayer compression bandage, elevation, remedial exercises, and skin care. The control group received standard physical therapy that included compression bandages, elevation, head and neck and shoulder exercises, and skin care. Both groups had a home program of bandaging, skin care, and walking. Therapy was three times per week for four weeks.

• The study sample (N = 53) included 27 experimental group patients and 26 control group patients who were randomly assigned and blinded to the intervention.
• All patients had mild (n = 32) or moderate (n = 21) lymphedema post-breast cancer treatment (2 cm circumference difference was defined as mild lymphedema, and 2–5 cm circumference difference was defined as moderate).
• Average duration of lymphedema at the time of treatment was three years; all patients had experienced lymphedema for more than one year. 
• Patients measuring 2–5 cm were excluded from the study based on obvious psychiatric illness, severe pain in axillary region, severe cardiac disease, uncontrolled hypertension, or malignancy.
• The average mean volume was 580 ml. 
• Patients were assessed for type of breast cancer procedures, but the sample was not characterized by them.
• Of the 53 patients who were post-breast cancer treatment, 24.4% had lumpectomies, 64.2% modified radical mastectomies, and 11.3% radical mastectomies. In addition, 13.2% received chemotherapy and 49.1% hormonal therapy. 
• All patients had axillary dissection with a range of 2–35 nodes removed and a mean of 24.2.

The study took place at a school of physical therapy.

A prospective trial design was used.

• Range of motion, circumference measurement, and volumetric measurement were assessed before and after treatment.
• Circumference was measured using a standard one-inch, retractable, fiberglass tape measure.
• Measurements were taken from 10, 15, and 20 cm above and below the olecranon process, at wrist, and at metacorpophalangial joints.
• Measurements always were taken twice.
• The same procedure was used for the unaffected arm of each participant.
• To measure volume, the arm was placed in a water-filled container and displaced water was measured.
• Goniometry was used to determine shoulder mobility. 
• Function was measured as the active mobility with extension-flexion, abduction-adduction, and external rotation.

• Mean percentage reduction in edema was 55.7% in the experimental group and 36% in the control group (p < 0.05).
• Only 45% of patients had limited of range of motion to start. Reduction in shoulder mobility was 48.1% in the experimental group and 42.3% in control group before treatment.
• Shoulder flexion, abduction movements in both groups were increased after treatment (p < 0.05).
• No significant difference was found in shoulder external rotation in both groups (p > 0.05).
• No difference between groups in shoulder mobility was found.
• Similar patient classification was found using circumferential and volumetric measurements.

Either of the methods can be used.

• Patients had extensive disease of more than three years' duration.
• No description of the tissue (pitting fibrotic) was provided.
• Lymphedema was not staged.
• The sample size was small.

To compare the differences in chemotherapy-induced nausea and vomiting (CINV) in women receiving chemotherapy for breast cancer among three groups: acupressure, acupressure placebo, and usual care

Subjects were randomized to one of three groups: acupressure to P6 point (active), acupressure to S13 point (placebo), or usual care. Participants in the acupressure groups were taught to apply acupressure wrist devices by research assistants unaware of the active pressure point. All participants completed daily logs for 21 days. Patients measured nausea and vomiting and recorded methods for controlling the symptoms, including antiemetics and acupressure. Research assistants, who had received two hours of training on the study protocol, instructed participants. In an examination or private room, the participants were taught to find a quiet place each morning to perform the acupressure treatment to both P6 points sequentially either as treatment or practice. During the day, participants in the acupressure groups were encouraged to apply digital pressure to one of the points whenever nausea occurred regardless of where they were. Each session was six minutes in the morning and three minutes each during the rest of the day. Self-ratings were completed on a daily basis prior to bedtime. All participants were called or seen on day eight for review of the log and coaching, if needed.

• The study consisted of 160 women beginning their second or third cycle of chemotherapy for breast cancer.
• Participants had experienced moderate nausea intensity scores with previous cycles of chemotherapy, based on a score of at least 3 on the Morrow Assessment of Nausea and Emesis.
• Participants were able to read and write in English.

The study was conducted in community oncology programs associated with M.D. Anderson Cancer Center and nine independent sites.

This was a multicenter, longitudinal, randomized controlled trial.

• The Rhodes Index of Nausea and Vomiting (three-item nausea; single-item vomiting subscales) was used.
• Nausea intensity also was rated with a descriptive, numeric rating scale, ranging from 0–10.
• The State-Trait Anxiety Index also was used.

• No significant differences were found in demographic data, disease, or treatment variables among the groups.
• No significant differences were identified in acute nausea and vomiting among the treatment groups.
• With delayed nausea and vomiting, the acupressure group demonstrated a statistically significant reduction in the amount of vomiting and intensity of nausea over time when compared with the placebo or usual care groups.
• No significant differences were found between the placebo and usual care groups.

In conjunction with pharmaceutical management, acupressure at P6 was  found to reduce the amount and intensity of delayed CINV in women undergoing treatment for breast cancer.

• The same research assistants and nurses taught both pressure points. Although most did not know which pressure point was active, a few referenced the Internet for the information.
• Some patients with uncontrolled nausea also broke the blind by pursuing more information online.
• Some participants had challenges finding the location consistently; some needed markings on their wrist. Two participants found application of pressure difficult because of long fingernails.
• Staff training on the technique and return demonstration were not specifically described.
• No men or children were included in the study population.

Acupressure is a safe and effective tool to be offered to women undergoing breast cancer chemotherapy treatment.

To compare the effects of usual care (regular antiemetics) versus usual care plus acupressure training on nausea and its intensity in women receiving chemotherapy for breast cancer

The intervention involved finger acupressure bilaterally at the P6 and ST36 acupressure points located on the forearm and knee for a maximum of three minutes for each point every morning or as needed for nausea. Baseline and poststudy questionnaires and a daily log were used to collect data.

• The study consisted of 17 adult women undergoing chemotherapy for breast cancer (cyclophosphamide, methotrexate, and fluorouracil or doxorubicin-containing regimens). The control group had nine patients, and the experimental group had eight patients.
• The mean age of both groups was 49 years old.
• More than half (59%) of participants were Caucasian.

The study was conducted in two sites located in urban areas in the western United States: an outpatient oncology clinic in a major teaching medical center and a private outpatient oncology practice.

• Nausea was measured at baseline and poststudy via questionnaires and daily logs.
• Nausea experience and its intensity were measured with the Rhodes Inventory of Nausea, Vomiting, and Retching.

Significant differences existed between the two groups in regard to nausea experience (p < 0.01) and nausea intensity (p < 0.04) during the first 10 days of the chemotherapy cycle, with the acupressure group reporting less intensity and experience of nausea.

• The study only looked at a single cycle of treatment.
• The sample size was small.
• The sample was limited to women with breast cancer.
• The ST36 acupressure point was difficult to reach.

To evaluate the efficacy and safety of a single dose of palonosetron, a second-generation serotonin type 3 (5-HT₃) receptor antagonist, in patients with aggressive non-Hodgkin lymphoma receiving moderately emetogenic chemotherapy (MEC)-containing steroids

Patients received a single IV bolus of palonosetron (0.25 mg) over 30 minutes before administration of chemotherapy (day 1), and patients were assessed from day 1 through day 5. The antiemetic response was evaluated during the acute, delayed, and overall phases, as well on each day.

• The study reported on 86 participants.
• Median age was 65 years, with a range of 20–87.
• The sample was 55% male and 45% female.
• Patients had aggressive, stage I–IV, non-Hodgkin lymphoma (diffuse large B cell lymphoma = 78%).
• Patients had European Cooperative Oncology Group (ECOG) status of 0–2, were receiving R-CHOP, CHOP, R-COMP, and other chemotherapy regimens. Dexamethasone or metoclopramide as rescue medication were available upon patient request.

This multisite was conducted in Italy.

• All patients were in active treatment.
• This study has application for late effects and survivorship.

This was a prospective, open label, nonrandomized, phase II study.

• Complete response (CR) was defined as no vomiting and no rescue therapy during overall phase (0–120 hours).    
• Complete control was defined as CR and only mild nausea.
• The percentage of patients experiencing emesis and nausea was recorded.
• Patients completed diaries on days 1–5, recording the nausea occurrence; nausea severity on a 3-point, Likert-type scale; and use of rescue medication.
• Patient global satisfaction with antiemetic therapy was measured using a visual analog scale (VAS).

• CR was observed in 86% of patients during the overall phase. CR during the acute phase was 90.7%, and CR during the delayed phase was 88.4%.
• CC was 82.6% overall, 89.5% during the acute phase, and 82.6% in the delayed phase. During the overall study period, the emesis-free rate was 74.4%, the nausea-free rate was 74.4%, and no patients experienced severe nausea. The median global satisfaction with antiemetic therapy was 8.0 out of 10.
• The treatment was well tolerated, and no patients experienced severe adverse events.
• The most common, grade 1–2 adverse events were constipation (7.0%), headache (5.8%), asthenia (7.0%), and dizziness (1.2%). No grade 3–4 adverse events or significant changes in lab tests or vital signs were recorded during the study period.

A single dose of palonosetron is effective, tolerable, and safe in control of CINV in patients receiving MEC-regimen-containing steroids.

• No appropriate control group was included.
• No control for risk factors for CINV other than gender and age. Although antiemetic regimen did not include dexamethasone, the chemotherapy regimen included prednisone.

A single dose palonosetron infusion is a tolerable and safe option for patients receiving MEC-containing steroids. A single-dose palonosetron infusion could be less expensive in comparison to multiple administration of IV infusions of the first generation 5-HT₃ RAs, which also could save time and required workforce.

To assess the feasibility and effects of pranayama (regulation and expansion of breath) among patients receiving chemotherapy. To test the efficacy of pranayama in alleviating common chemotherapy-associated symptoms (fatigue, sleep disturbance, stress, anxiety, and depression) and improving quality of life (QOL). To evaluate patients' responses to the use of pranayama in alleviating common chemotherapy-associated symptoms affecting QOL.

Participants were randomized 1:1 in blocks of four. The allocation sequence was generated by the study statistician and then transferred to sealed numbered envelopes. The study staff enrolled participants and implemented the allocation sequence, which was concealed from the study staff until study assignment. Blinding of participants was impossible due to the intervention, which consisted of a 60-minute class once per week taught by yoga instructors and twice daily home practice that totaled 20 to 30 minutes per day, along with usual care during two cycles of chemotherapy. The control group received only usual care during the initial cycle of chemotherapy, and the pranayama intervention along with usual care during the second cycle of chemotherapy.

• The sample was comprised of 16 patients.
• Mean age was 56 years (standard deviation [SD] = 11.9 years) in the control group and 52.4 years (SD = 14.6 years) in the treatment group.
• The treatment group was 75% female and 25% male; the control group was 100% female.
• Patients were receiving intravenous chemotherapy for cancer (50% of participants had breast cancer, 50% had some other type of cancer).
• Patients were included in the study if they had a visual analog scale (VAS) score for fatigue of at least 4 out of 10 and a Karnofsky Performance Status (KPS) of 60 or higher.
• Patients were excluded from the study if they participated in ongoing yoga practice; had severe chronic obstructive pulmonary disease (COPD), class III or IV heart failure, child class C cirrhosis, or end-stage renal disease; or had received more than three prior chemotherapy regimens.
• The sample was 62.5% white, and 7 out of 16 were employed.

• Single site
• Outpatient
• University medical center

Patients were undergoing the active treatment phase of care.

The study was a randomized, controlled trial.

• Participants kept a daily diary in which they recorded the amount of time spent practicing pranayama.
• At baseline, between the first and second cycle, and at the end of the study, the investigators took measures according to these instruments:
  • Piper Fatigue Scale (PFS)
  • General Sleep Disturbance Scale (GSDS)
  • Hospital Anxiety and Depression Scale (HADS)
  • Perceived Stress Scale (PSS)
  • Short Form 12 (SF-12 v1), to measure QOL.

Sixteen of 18 participants completed all study measures:  eight from the control group and eight from the treatment group. The study intervention had no adverse effects. Increased yoga practice was associated with statistically significant reductions in sleep disturbance (p = 0.04) and anxiety (p = 0.04). The mental component of QOL approached statistical significance (p = 0.05).

This was the first study of a pure pranayama intervention for patients with cancer, and it demonstrated that yoga breathing is a feasible and safe intervention for this patient population. Any increase in the yoga breathing practice correlated with improvements of chemotherapy-associated symptoms and QOL. Researchers should confirm these findings by means of a larger study.

• The study had a small sample size, with less than 30 participants.
• The study had risks of bias due to lack of an attentional control and due to selection bias:  those who would elect to participate in a study of this kind may be more likely than others to benefit from it. In addition, the study included self-reported outcomes.

Among patients with cancer who are undergoing chemotherapy, pranayama breathing techniques may help decrease sleep disturbance and anxiety and increase the mental component of QOL. Pranayama breathing, supplemented with reminders during and between treatments, seems to be an intervention that is feasible for this group of patients.

To identify the long-term effect of complete decongestive therapy (CDT) to decrease lymphedema and enhance quality of life in patients after radical mastectomy with unilateral upper extremity lymphedema

• N = 45   
• AGE = 48.44 (SD = 6.5 years)
• FEMALES: 100%
• CURRENT TREATMENT: Immunotherapy
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors after radical mastectomy
• OTHER KEY SAMPLE CHARACTERISTICS: History of unilateral post mastectomy lymphedema with more than 2 cm circumference than the normal side, aged older than 19 years, no neurological disorders, no untreated or unstable medical conditions, no edema in lower extremities

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: India

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Palliative care

• Pre-post design

• Modified truncated cone method
• European Organization of Research and Treatment of Cancer Core Quality of Life (EORTC QLQ-C30) questionnaire
• Upper limb lymphedema quality of life (ULL-QOL) questionnaire

Volume of the affected limb was decreased by 80.22 (95% confidence interval [CI] [–96.71, –63.73]) from baseline to the third month (p < 0.0001). Mean change in quality of life at the second month as compared to baseline was significant (69.95, 95% CI [66.49, 73.42], p < 0.0001).

CDT may be effective in reducing the volume in the lymphedema limb and in enhancing breast cancer survivors’ quality of life.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement validity/reliability questionable
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Single-site study

More rigorously designed studies are needed to examine the effectiveness of CDT in patients with lymphedema. Note that patients who underwent lumpectomy also developed lymphedema.

PHASE OF CARE: End of life care, various stages of diseases (dementia, advanced disease including cancer, children chronic illness) care  
 
APPLICATIONS: Pediatrics, Elder care, Palliative care

• Reported only on the arm that involved informal caregivers
• Eight of 15 ICG studies provided self-reported data on stress and anxiety. Seven of the 15 studies reported statistically significant improvements with informal caregiver use of meditative interventions. 
• Twelve of 15 studies measured ICGs' mood or mental health. Eight of those reported statistically significant improvements in caregiver mental health after a mindfulness intervention.
• Heterogeneity Q statistics were statistically significant for controlled trials of anxiety and for pre- and postintervention studies of ICG depression. 
• The combined effect for controlled trial studies involving ICGs on depression, anxiety, stress, self-reported efficacy, and quality of life and mental health showed benefits from meditation. 
• The combined effect for pre- and postintervention studies on depression, anxiety, stress, and caregiver burden showed meditation benefits.
• An insufficient number of studies existed to examine combined effect for caregiver fatigue, sleep quality, confusion and grief, personal growth, hope, energy, and life satisfaction was included.  
• Three out of the six studies that examined self-efficacy (a positive outcome) showed significant caregiver improvement, but the combined effect of the controlled trials suggested a meditation benefit but not for a reduction of caregiver burden. 
• Six of the seven studies of ICGs that assessed physiological measures of stress showed a statistically significant change postintervention. 

Focusing on the outcomes for ICGs, the combined evidence from the controlled trials supports use of meditative interventions to minimize ICG’s depression, anxiety, and stress. Combined evidence from the pre- and postmeditative intervention studies supported their use in alleviating ICG burden. However, the insufficient study rigor and number prevent ed conclusions about the meditative interventions' effects on caregiver energy, fatigue, hope, confusion, and grief or life satisfaction. The insufficient number of studies prevents assessment of effect of meditation on caregivers’ capacity for decision making, patient advocacy, or resilience.

• Review of the ICGs of mostly patients without cancer limits the applicability for patients with cancer and their caregivers  
• Insufficient studies exist to make conclusions about several caregiver-related outcomes (e.g., energy, fatigue, hope, confusion, grief or life satisfaction, capacity for decision making, patient advocacy or resilience).
• The majority of female study participants minimized the generalizability of findings to male ICGs.
• Many studies relied on self-report with a wide variability of assessed study qualities (Downs and Black criteria).
• Study reviewed only English language studies

The effect of a meditative intervention on caregivers of patients with cancer should be explored with more studies using rigorous designs possessing higher statistical power. The initial data from this study indicate that a meditative intervention may benefit the ICGs of patients with various illnesses.

To determine the effect of manual lymph drainage (MLD) in addition to exercise compared to exercise alone for management of lymphedema in patients with breast cancer

After surgery, patients with axillary node dissection were recruited to the study and randomized to receive exercise, guidelines for self-care and MLD, or exercise and guidelines alone. MLD was begun one week after removal of axillary drains and 5 weeks after surgery and was provided for 20 weeks. All patients received the same guidelines and 30-minute individual exercise sessions. Standardized MLD sessions took half an hour, and patients received 40 treatments during the study period. Patient assessments were done at 1, 3, 6, and 12 months after surgery.

• The study sample was comprised of 158 patients who followed for the first six months and 154 who completed the study after 12 months.
• Most patients in the study were female (99%).
• Mean age was 55.15 years.
• Sixty-eight percent of the sample had breast conserving surgery, 85% also had radiotherapy, 67% had chemotherapy, and 76% had endocrine treatment.
• Median increase in arm volume before allocated treatment was 8 ml in both study groups.

The study took place at a singe outpatient site in the Netherlands.

Patients were undergoing multiple phases of care.

The study used a single-blind randomized controlled trial design.

• Arm volume was measured using water displacement.
• Arm circumference was measured.
• Lymphedema was defined as increase of 200 ml or more.
   

There were no differences between groups in incidence of arm lymphedema, time to lymphedema development, or maximal increase in arm circumference.

 The addition of MLD to a program of patient guidelines and education and exercise did not have an effect on prevention of arm lymphedema in patients with breast cancer after axillary node dissection.

• Key sample group differences could influence results.
• No analysis of group baseline differences was provided, and patients in the intervention group had higher percentage with level 1–3 axillary surgery. 
• The maximum percentage of patients who developed lymphedema by month 12 was 24%, so not all patients were at risk in the sample. 
• It is not known if there were substantial differences in surgeries performed that could have affected results.

Findings show that the addition of MLD to a program of exercise and patient guidelines for self-management had no benefit to prevent lymphedema development.

To obtain estimates of the effect of selected psychoeducational interventions on pain in patients with cancer

• Databases searched were PubMed, CINAHL, Dissertation Abstracts, PsycLIT, and the Cochrane Database of Systematic Reviews.
• Keywords searched were cancer, neoplasms, patient education, counseling, behavioral therapy, guided imagery, hypnosis, relaxation therapy, music, and pain.
• Studies were included if they
  • Were experimental, quasi-experimental, or employed a pre/post-test single-group design.
  • Included outcome measurement for which an effect size could be calculated.
• Studies were excluded if they compared psychoeducational therapy to pharmacologic treatment for pain, involved fewer than five subjects in each treatment condition, and included treatment and control groups from different settings.

The search retrieved 50 studies. Authors eliminated 25 studies on the basis of inclusion and exclusion criteria. Authors did not describe the method of evaluation.

• Across all studies, the sample included 1,354 patients with various types of cancer. The sample range was 7–206 patients.
• Authors included 25 studies in meta-analysis. 

• Types of interventions: Interventions included listening to music, hypnosis, progressive muscle relaxation and imagery, cognitive-behavioral counseling, distraction, and support groups.
• Effects on pain:
  • Relaxation, guided imagery music, or hypnosis interventions: Twelve studies used an intervention of this type, demonstrating an average weighted effect size of 0.65 (p < 0.05).
  • Education interventions: Six studies included this type of intervention.  Overall average effect size was 0.36 (p < 0.05).
  • Support plus other content: Five studies were included in this group.  Average effect size was 0.44 (p < 0.05).
  • Relaxation plus other content: Six studies showed an effect size of 0.07.

Most studies demonstrated that psychoeducational interventions had at least a small positive effect on pain in patients with cancer.

• This analysis included a broad variety of interventions, a fact that raises questions about the generalizability of conclusions from the analysis.
• Authors identified a number of methodologic and reporting issues, which raises concerns about the validity and utility of study findings.
• Several studies had very small sample sizes and reported very high attrition rates.
• Differences among educational interventions, cognitive behavioral therapy interventions, and usual care are unclear.
• Most of the education studied in this research was aimed at enhancing patient use of prescribed analgesic regimens.

Further well-designed research in this area is needed. The complexity of cancer-related pain presents a number of challenges inherent in this research; authors outline these challenges. Psychoeducational interventions may be more acceptable to some patients than others, as high attrition rates suggest. In addition, rating pain is a subjective activity. The efficacy of an intervention may differ with cancer phase and with different pain severity. These factors should affect selection of intervention type.