Hot of the Press December 2020
We have collated some great articles and material published over the last month. Click on the links below to read the abstract or download the full paper.
Anatomy / Physiology /Pathophysiology
Inflammation Precedes Fat Deposition in an Experimental Model of Lymphedema - click for abstract
Inflammation Precedes Fat Deposition in an Experimental Model of Lymphedema
Chronic lymphedema is a common complication of lymphatic obstruction, particularly after cancer treatment, characterized by an increased volume of the affected extremity, partly caused by the accumulation of excessive adipose tissue. The relationship between lymph vessels’ obstruction and fat deposit is, however, poorly understood. Objective: Our central hypothesis was that the inflammatory process caused by lymph stasis precedes the adipocyte differentiation and fat deposition. Methods and Results: We used a modified mouse tail model to produce secondary lymphedema. Animals were treated with dexamethasone, or the procedure was performed in nitric oxide synthase 2 (NOS2)-deficient mice to evaluate the role of inflammation in lymphedema formation. Adipose tissue (Lipin) and inflammatory markers (IL-6, MCP-1, and F4-80) were analyzed in histological samples and by quantitative polymerase chain reaction. We observed an increased deposition of fat into the affected area that starts 3 weeks after lymph vessel ligation; it further increased after 6 weeks. Genes involved in the inflammatory process were upregulated before adipocyte maturation. Treatment with dexamethasone or the use of inducible nitric oxide synthase knockout mice blocked the inflammatory reaction and inhibited the accumulation of fat distal to the lymphatic obstruction. Conclusion: In the modified mouse tail lymphedema, inflammation precedes adipogenesis. Our data suggest that MCP-1 and nitric oxide may be potential targets for lymphedema management.
Prevalence and Risk Factors
Reduced lymphedema after sentinel lymph node biopsy versus lymphadenectomy for endometrial cancer - click for abstract
Reduced lymphedema after sentinel lymph node biopsy versus lymphadenectomy for endometrial cancer
OBJECTIVE: Endometrial cancer surgical staging includes lymph node assessment which can lead to lower extremity lymphedema. The aim of this study was to estimate prevalence after sentinel lymph node biopsy versus lymphadenectomy.
METHODS: Consecutive patients who underwent minimally invasive surgery at the Mayo Clinic, Rochester, Minnesota, USA, between January 2009 and June 2016 for newly diagnosed endometrial cancer were mailed our validated 13 item lower extremity lymphedema screening questionnaire. We also ascertained via questionnaire whether the patient was ever diagnosed with lower extremity lymphedema.
RESULTS: Among 378 patients included in the analysis, 127 (33.5%) had sentinel lymph node biopsy with or without side specific lymphadenectomy (sentinel lymph node cohort) and 251 (66.4%) underwent bilateral lymphadenectomy prior to sentinel lymph node biopsy implementation at our institution or as ‘backup’ after sentinel lymph node mapping (lymphadenectomy cohort). The prevalence of lower extremity lymphedema was 41.5% (157/378), with 69 patients (18.3%) self-reporting a lower extremity lymphedema diagnosis after their endometrial cancer surgery at a median of 54.3 months (interquartile range 31.2-70.1 months), and an additional 88 patients (23.3%) identified by the screening questionnaire. The prevalence of lower extremity lymphedema was significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node group (49.4% (124/251) vs 26.0% (33/127); p<0.001). When the cohorts were restricted to patients surgically managed after the introduction of sentinel lymph node, the prevalence of lower extremity lymphedema was still significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node cohort (39.0% (41/105) vs 26.0% (33/127); p=0.03). In a multivariable analysis adjusted for body mass index, receipt of adjuvant external beam radiation, diabetes, congestive heart failure, and International Federation of Gynecology and Obstetrics grade, the adjusted odds ratio for the association between type of nodal sampling (lymphadenectomy cohort vs sentinel lymph node cohort) and lower extremity lymphedema was 2.75 (95% confidence interval 1.69 to 4.47, p<0.001). CONCLUSIONS: Sentinel lymph node biopsy was associated with a decreased risk of post-treatment lymphedema compared with lymphadenectomy in patients who underwent surgical staging for endometrial carcinoma.
Assessment
Lymphedema Symptom Intensity and Distress Surveys-Truncal and Head and Neck, Version 2.0 - click for abstract
Lymphedema Symptom Intensity and Distress Surveys-Truncal and Head and Neck, Version 2.0
A comparison of symptom prevalence, intensity, and distress for participants with truncal lymphedema, head and neck lymphedema, and no lymphedema identified a need for a truncal-specific, lymphedema-related symptom assessment tool and a revision of the Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N). The purpose of this study was to institute the development of the Lymphedema Symptom Intensity and Distress Survey-Truncal (LSIDS-T) and revise the LSIDS-H&N. Methods and Results: A comprehensive midline measure and subsequent series of analyses were used to develop the LSIDS-T and revise the initial LSIDS-H&N. Participants included 97 without lymphedema, 82 with truncal lymphedema, and 72 with head and neck lymphedema. Cluster analysis for the LSIDS-T resulted in five clusters with a total of 21 items. Cluster analysis for the LSIDS-H&N resulted in seven clusters with a total of 31 items. Key correlations in expected directions were found with the validated measures for both surveys, and correlations with the Marlowe Crown Social Desirability Scale did not indicate issues with social desirability of response. Conclusion: The 24-item LSIDS-T and the 31-item revised LSIDS-H&N v.2 are promising additions to the suite of other LSIDS measures for use in clinical environments
Limb Volume Changes and Activities of Daily Living: A Prospective Study – Download full paper
Who Will Continuously Depend on Compression to Control Persistent or Progressive Breast Cancer-Related Lymphedema Despite 2 Years of Conservative Care? – Download full paper
The Correlation Between Fluid Distribution and Swelling or Subjective Symptoms of the Trunk in Lymphedema Patients: A Preliminary Observational Study click for abstract
The Correlation Between Fluid Distribution and Swelling or Subjective Symptoms of the Trunk in Lymphedema Patients: A Preliminary Observational Study
Manual lymph drainage (MLD) is one of the common treatments for breast cancer-related lymphedema (BCRL). Although the primary goal of MLD is to drain the excessive fluid accumulated in the affected upper limb and trunk to an area of the body that drains usually, the use of MLD is decided based on swelling and subjective symptoms, without assessing whether there is fluid accumulated in the affected region. The purpose of this study was to examine truncal fluid distribution in a sample of BCRL patients and investigate any correlation between such fluid distribution and swelling or subjective symptoms. Methods and Results: An observational study was conducted with 13 women who had unilateral, upper extremity BCRL. Fluid distribution was evaluated by using two magnetic resonance imaging (MRI) sequences: half-Fourier acquisition single-shot turbo spin echo and three-dimensional double-echo steady-state. The presence of swelling was determined by lymphedema therapists, and subjective symptoms were measured by using a visual analog scale. On MRI, no participants had any free water signals in the trunk. However, seven had swelling and all 13 had some kind of subjective symptoms on the affected side of their trunk. Conclusions: These results suggest that swelling and subjective symptoms do not correlate with the presence of truncal fluid. For such cases, a different approach than MLD may be needed to address truncal swelling and related subjective symptoms. Checking for the presence of fluid in the truncal region may help MLD be used more appropriately.
Comparison of Shoulder-Arm Complex Pain, Function, and Scapular Dyskinesia in Women With and Without Unilateral Lymphedema After Breast Cancer Surgery - click for abstract
Comparison of Shoulder-Arm Complex Pain, Function, and Scapular Dyskinesia in Women With and Without Unilateral Lymphedema After Breast Cancer Surgery
INTRODUCTION: Lymphedema is the most important complication seen after breast cancer surgery. The study aimed to evaluate pain, shoulder-arm complex function, and scapular function in women who developed lymphedema after breast cancer surgery and to compare these with women without lymphedema.
MATERIALS AND METHODS: Fifty women with lymphedema (age, 54.34 ± 9.08 years; body mass index, 30.10 ± 4.03 kg/cm2) and 57 women without lymphedema (age, 53.68 ± 9.41 years; body mass index, 29.0 ± 5.44 kg/cm2) after unilateral surgery for breast cancer were included. Clinical and demographic information was noted. The severity of lymphedema with perimeter measurements (Frustum model), level of heaviness discomfort sensation with a visual analog scale, pain threshold with a digital algometer, shoulder-arm complex functionality with the Disabilities of the Arm, Shoulder, Hand Problems Survey (DASH), and scapular function with observational scapular dyskinesia and lateral scapular sliding tests were assessed. The t test, χ2 test, and Mann-Whitney U test were used for analyses.
RESULTS: The follow-up duration after the surgery was 4.24 ± 2.97 years and 3.19 ± 1.76 years, and the upper extremity volume was 2106.65 ± 510.82 cm3 and 1725.92 ± 342.49 cm³ in the lymphedema group and in the no-lymphedema group, respectively. In the lymphedema group, arm-heaviness discomfort, pain threshold levels in the trapezius and deltoid muscles, and DASH scores were worse (P < .05). The rate of scapular dyskinesia (70.0%) and type 2 scapula (32%) in the surgical side was higher in patients with lymphedema. CONCLUSION: The pain pressure threshold in the trapezius and deltoid muscles, heaviness sensation level, and inadequate upper extremity function are significantly higher in patients with lymphedema, and the scapular dyskinesia rate was higher.
Extracellular Water Ratio as an Indicator of the Development and Severity of Leg Lymphedema Using Bioelectrical Impedance Analysis - click for abstract
Extracellular Water Ratio as an Indicator of the Development and Severity of Leg Lymphedema Using Bioelectrical Impedance Analysis
The role of ultrasonography in follow-up of effectiveness of Complex Decongestive Therapy (CDT) in different subgroups of patients with breast cancer-related lymphoedema - click for abstract
The role of ultrasonography in follow-up of effectiveness of Complex Decongestive Therapy (CDT) in different subgroups of patients with breast cancer-related lymphoedema
Cancer-related fatigue in head and neck cancer survivors: Energy and functional impacts - click for abstract
Cancer-related fatigue in head and neck cancer survivors: Energy and functional impacts
Patient-Reported Outcome Measures in Lymphedema: A Systematic Review and COSMIN Analysis - click for abstract
Patient-Reported Outcome Measures in Lymphedema: A Systematic Review and COSMIN Analysis
The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements - click for abstract
The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements
Personalizing Conservative Lymphedema Management Using Indocyanine Green-Guided Manual Lymphatic Drainage - click for abstract
Personalizing Conservative Lymphedema Management Using Indocyanine Green-Guided Manual Lymphatic Drainage
The Early Detection of Breast Cancer Treatment-Related Lymphedema of the Arm - click for abstract
The Early Detection of Breast Cancer Treatment-Related Lymphedema of the Arm
Management Strategies
A historical account of the role of exercise in the prevention and treatment of cancer-related lymphedema - click for abstract
A historical account of the role of exercise in the prevention and treatment of cancer-related lymphedema
Treatment of male genital lymphedema with non-elastic fabric – Download full paper
Compression Therapy Is Not Contraindicated in Diabetic Patients with Venous or Mixed Leg Ulcer – Download full paper
Fluid Shifts Induced by Physical Therapy in Lower Limb Lymphedema Patients – Download full paper
Physiotherapy and rehabilitation applications in lipedema management: A literature review - click for abstract
Physiotherapy and rehabilitation applications in lipedema management: A literature review
Lipedema is a chronic and progressive disease of adipose tissue caused by abnormal fat accumulation in subcutaneous tissue. Although there is no known cure for lipedema, possible complications can be prevented with conservative and surgical treatments. One of the conservative treatment options is physiotherapy and rehabilitation (PR). When the literature is examined, few studies focusing on the efficacy of PR were found for this patient group. The purpose of this review is to provide a better understanding of the effectiveness of PR applications by compiling existing studies. A bibliographic PubMed search was performed for published studies regarding PR in lipedema management in June 2019 including the last 58 years (1951-2019). Articles were chosen by reading the abstracts and subsequently data were analyzed by reading the entire text through full-text resources. A total of 15 studies met inclusion criteria. Results document how lipedema patients are benefited by PR and the effectiveness of different types of PR programs. The current review also showed that complex decongestive physiotherapy, gait training, hydrotherapy, aerobic exercise, and resistance exercise training each have value in the management of lipedema. The effects of PR for the treatment of lipedema are variable among studies, although overall PR seems to be effective in lipedema management. Although physiotherapy applications have a potentially important role in the management of lipedema, they should be used in combination with other treatment modalities. More studies with higher quality are needed to fully demonstrate the effect and efficacy of PR in lipedema patients.
Lymphatic treatments after orthopedic surgery or injury: A systematic review - click for abstract
Lymphatic treatments after orthopedic surgery or injury: A systematic review
BACKGROUND: Orthopedic injuries in conjunction with extensive damage to tissues, bones and blood vessels, usually require a long recovery. Associated consequences are pain, movement limitations, decreased function and occasionally, prolonged edema, which can delay or interfere with the healing process. Lymphatic and compression therapy have become increasingly common, intending to reduce edema and pain, thus, promoting the recovery process. AIMS: To examine the efficacy of methods commonly used to reduce edema after orthopedic injury or surgery, i.e. decongestive therapy, manual lymphatic drainage, and compression bandaging.
METHODS: English literature search was undertaken in January 2019, in the following databases: Cochrane Library, MEDLINE, PEDro.
INCLUSION CRITERIA: randomized controlled or quasi-controlled trials in adults who have edema or pain after recent limb trauma or surgery. Two independent assessors rated study quality and risk of bias using the PRISMA recommendations and PEDro score.
RESULTS: We evaluated 71 papers. After excluding duplicated and irrelevant papers, 15 met the eligibility criteria (6 on lymphatic treatment and 9 on compression). Quality of papers ranged from 3 to 7 on PEDro score; of them, 13 were 1b Level of Evidence and two were 1c.
CONCLUSION: After elective surgeries, when the significant edema appears or persists beyond recovery time, complex decongestive therapy and manual edema mobilization should be recommended in addition to conventional physical therapy. In acute injuries such as ankle or distal radius fractures, lymphatic treatments and compression bandaging should be considered as part of the therapeutic protocol. Nine studies evaluated different compression modalities found that only multilayer and long stretch compression significantly reduce edema.
Effect of Nonelastic Compression With an Adjustable Wrap After Total Knee Arthroplasty - click for abstract
Effect of Nonelastic Compression With an Adjustable Wrap After Total Knee Arthroplasty
Breast cancer-related lymphedema and its treatment: how big is the financial impact? - click for abstract
Breast cancer-related lymphedema and its treatment: how big is the financial impact?