Evaluation of Stiffness in Postmastectomy Lymphedema Using Acoustic Radiation Force Impulse Imaging

A Prospective Randomized Controlled Study for Identifying the Optimal Pneumatic Compression Pressure to Reduce Stiffness

Soo Kyung Bok, MD, PhD, Yumi Jeon, MD, MS, Jin A. Lee, PT, MS, and So Young Ahn, MD, PhD. Lymphatic Research And Biology Volume 00, Number 00, 2017

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Evaluation of Stiffness in Postmastectomy Lymphedema Using Acoustic Radiation Force Impulse Imaging: A Prospective Randomized Controlled Study for Identifying the Optimal Pneumatic Compression Pressure to Reduce Stiffness

Soo Kyung Bok, MD, PhD, Yumi Jeon, MD, MS, Jin A. Lee, PT, MS, and So Young Ahn, MD, PhD. Lymphatic Research And Biology, August, 2017

Purpose: We aimed to assess the improvement in stiffness in patients with postmastectomy lymphedema (PMLE) after intermittent pneumatic compression (IPC) using acoustic radiation force impulse (ARFI) imaging and evaluate the effects of different IPC pressures. Methods: We randomly assigned 45 patients with PMLE (stage II) to three groups based on the IPC pressure: 25, 35, and 45mmHg. Patients received a single session of IPC for 30 minutes. We recorded the subcutaneous tissue thickness of the proximal upper limbs using ultrasonography and circumference of the upper limbs and stiffness using ARFI before and immediately after IPC. Results: Arm circumference and subcutaneous tissue thickness were significantly decreased after IPC in all groups. The shear wave velocity (SWV) decreased after IPC in all groups, but significantly decreased only in the 35mmHg group. The subcutaneous tissue thickness and SWV in the 35mmHg group were significantly decreased compared to the other groups. Conclusion: IPC can reduce stiffness and subcutaneous tissue thickness of the proximal upper arm in patients with PMLE. A pressure of 35mmHg yields the largest improvement of stiffness; higher compression pressure did not yield any additional improvement.

Main findings

  • A total of 45 patients were randomly assigned to three groups based on the compression pressure used: Group A, 25mmHg; Group B, 35mmHg; and Group C, 45mmHg.
  • IPC was applied using Lympha Press Plus along with a 10-chamber sleeve used for applying the Lympha mode. The system delivered a sequential pressure along the limb, from the distal to the proximal end, without any deflation of the distal chambers to prevent backflow fluid and venous stasis. The overall pressure duration was 30 minutes, with alternate periods of inflation (18 seconds) and deflation (4 seconds).
  • Objective measurements included:
    • Circumference with a tape measure;
    • ARFI imaging via ultrasound which measures stiffness;
    • The thickness of the subcutaneous tissue was defined as the distance from the skin to the fascia.
  • All three groups showed a significant reduction in circumference and subcutaneous thickness but the shear wave velocity only significantly decreased in the 35mmHg group. Higher compression didn’t yield additional improvement.