The Effect of Complete Decongestive Therapy on Edema Volume Reduction and Pain in Women With Post Breast Surgery Lymph Edema
Identifieur interne : 000761 ( Pmc/Corpus ); précédent : 000760; suivant : 000762The Effect of Complete Decongestive Therapy on Edema Volume Reduction and Pain in Women With Post Breast Surgery Lymph Edema
Auteurs : Leila Angooti Oshnari ; Seyed Ali Hosseini ; Shahpar Haghighat ; Samaneh Hossein ZadehSource :
- Iranian Journal of Cancer Prevention [ 2008-2398 ] ; 2016.
Abstract
Upper extremity lymph edema is the most common side effect of breast cancer treatment that may produce significant physical and psychological morbidity. Pain is the frequent symptom of lymph edema that causes impairment of activities in daily life.
The aim of this study was assessment of the effect of complex decongestive therapy (CDT) on upper extremity lymph edema and pain in women with post breast surgery lymph edema.
In this quasi- experimental research with before- after design, 36 women with moderate lymph edema after breast surgery participated in the program. Edema volume was measured by water displacement method; pain values were evaluated by visual analog scale (VAS). Data were recorded before intervention and 2 and 4 weeks after it. CDT included the first phase (intensive phase) and the second phase (maintenance phase). Each phase lasted 2 weeks. After use of Shapiro Wilk test for normality, analysis of variances with GEE and repeated measurements were used to analyze the data.
After one month doing CDT program, significant decrease of edema was noticed (P < 0.0001), also pain decreased during 2 and 4 weeks after intervention (P < 0.0001).
This study indicated that CDT program is effective in reducing lymph edema volume and pain in women with moderate post breast surgery lymph edema. It seems that raising patients’ awareness and training healthcare professionals regarding lymph edema preventive strategies have an important role in earlier and better combating this complication.
Url:
DOI: 10.17795/ijcp-4209
PubMed: 27482330
PubMed Central: 4951770
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The Effect of Complete Decongestive Therapy on Edema Volume Reduction and Pain in Women With Post Breast Surgery Lymph Edema</title><author><name sortKey="Angooti Oshnari, Leila" sort="Angooti Oshnari, Leila" uniqKey="Angooti Oshnari L" first="Leila" last="Angooti Oshnari">Leila Angooti Oshnari</name><affiliation><nlm:aff id="aff1">Department of Occupational Therapy, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran</nlm:aff></affiliation></author><author><name sortKey="Hosseini, Seyed Ali" sort="Hosseini, Seyed Ali" uniqKey="Hosseini S" first="Seyed Ali" last="Hosseini">Seyed Ali Hosseini</name><affiliation><nlm:aff id="aff2">Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran</nlm:aff></affiliation></author><author><name sortKey="Haghighat, Shahpar" sort="Haghighat, Shahpar" uniqKey="Haghighat S" first="Shahpar" last="Haghighat">Shahpar Haghighat</name><affiliation><nlm:aff id="aff3">Department of Breast Cancer Research Center, Tehran University of Medical Sciences, Tehran, IR Iran</nlm:aff></affiliation></author><author><name sortKey="Hossein Zadeh, Samaneh" sort="Hossein Zadeh, Samaneh" uniqKey="Hossein Zadeh S" first="Samaneh" last="Hossein Zadeh">Samaneh Hossein Zadeh</name><affiliation><nlm:aff id="aff4">Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27482330</idno><idno type="pmc">4951770</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951770</idno><idno type="RBID">PMC:4951770</idno><idno type="doi">10.17795/ijcp-4209</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000761</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000761</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The Effect of Complete Decongestive Therapy on Edema Volume Reduction and Pain in Women With Post Breast Surgery Lymph Edema</title><author><name sortKey="Angooti Oshnari, Leila" sort="Angooti Oshnari, Leila" uniqKey="Angooti Oshnari L" first="Leila" last="Angooti Oshnari">Leila Angooti Oshnari</name><affiliation><nlm:aff id="aff1">Department of Occupational Therapy, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran</nlm:aff></affiliation></author><author><name sortKey="Hosseini, Seyed Ali" sort="Hosseini, Seyed Ali" uniqKey="Hosseini S" first="Seyed Ali" last="Hosseini">Seyed Ali Hosseini</name><affiliation><nlm:aff id="aff2">Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran</nlm:aff></affiliation></author><author><name sortKey="Haghighat, Shahpar" sort="Haghighat, Shahpar" uniqKey="Haghighat S" first="Shahpar" last="Haghighat">Shahpar Haghighat</name><affiliation><nlm:aff id="aff3">Department of Breast Cancer Research Center, Tehran University of Medical Sciences, Tehran, IR Iran</nlm:aff></affiliation></author><author><name sortKey="Hossein Zadeh, Samaneh" sort="Hossein Zadeh, Samaneh" uniqKey="Hossein Zadeh S" first="Samaneh" last="Hossein Zadeh">Samaneh Hossein Zadeh</name><affiliation><nlm:aff id="aff4">Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran</nlm:aff></affiliation></author></analytic><series><title level="j">Iranian Journal of Cancer Prevention</title><idno type="ISSN">2008-2398</idno><idno type="eISSN">2008-2401</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Upper extremity lymph edema is the most common side effect of breast cancer treatment that may produce significant physical and psychological morbidity. Pain is the frequent symptom of lymph edema that causes impairment of activities in daily life.</p></sec><sec><title>Objectives</title><p>The aim of this study was assessment of the effect of complex decongestive therapy (CDT) on upper extremity lymph edema and pain in women with post breast surgery lymph edema.</p></sec><sec><title>Patients and Methods</title><p>In this quasi- experimental research with before- after design, 36 women with moderate lymph edema after breast surgery participated in the program. Edema volume was measured by water displacement method; pain values were evaluated by visual analog scale (VAS). Data were recorded before intervention and 2 and 4 weeks after it. CDT included the first phase (intensive phase) and the second phase (maintenance phase). Each phase lasted 2 weeks. After use of Shapiro Wilk test for normality, analysis of variances with GEE and repeated measurements were used to analyze the data.</p></sec><sec><title>Results</title><p>After one month doing CDT program, significant decrease of edema was noticed (P < 0.0001), also pain decreased during 2 and 4 weeks after intervention (P < 0.0001).</p></sec><sec><title>Conclusions</title><p>This study indicated that CDT program is effective in reducing lymph edema volume and pain in women with moderate post breast surgery lymph edema. It seems that raising patients’ awareness and training healthcare professionals regarding lymph edema preventive strategies have an important role in earlier and better combating this complication.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Alizadeh Otaghvar, H" uniqKey="Alizadeh Otaghvar H">H Alizadeh Otaghvar</name></author><author><name sortKey="Hosseini, M" uniqKey="Hosseini M">M Hosseini</name></author><author><name sortKey="Tizmaghz, A" uniqKey="Tizmaghz A">A Tizmaghz</name></author><author><name sortKey="Shabestanipour, G" uniqKey="Shabestanipour G">G Shabestanipour</name></author><author><name sortKey="Noori, H" uniqKey="Noori H">H Noori</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kochaki Nejad, Z" uniqKey="Kochaki Nejad Z">Z Kochaki Nejad</name></author><author><name sortKey="Mohajjel Aghdam, A" uniqKey="Mohajjel Aghdam A">A Mohajjel Aghdam</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Iran J Cancer Prev</journal-id><journal-id journal-id-type="iso-abbrev">Iran J Cancer Prev</journal-id><journal-id journal-id-type="doi">10.17795/ijcp</journal-id><journal-id journal-id-type="publisher-id">Shahid Beheshti University of Medical Sciences</journal-id><journal-title-group><journal-title>Iranian Journal of Cancer Prevention</journal-title></journal-title-group><issn pub-type="ppub">2008-2398</issn><issn pub-type="epub">2008-2401</issn><publisher><publisher-name>Shahid Beheshti University of Medical Sciences</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27482330</article-id><article-id pub-id-type="pmc">4951770</article-id><article-id pub-id-type="doi">10.17795/ijcp-4209</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>The Effect of Complete Decongestive Therapy on Edema Volume Reduction and Pain in Women With Post Breast Surgery Lymph Edema</article-title></title-group><contrib-group><contrib id="idp216464" contrib-type="author"><name><surname>Angooti Oshnari</surname><given-names>Leila</given-names></name><xref ref-type="aff" rid="aff1">1</xref><xref ref-type="corresp" rid="idp2644704">*</xref></contrib><contrib id="idp215120" contrib-type="author"><name><surname>Hosseini</surname><given-names>Seyed Ali</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib id="idp218352" contrib-type="author"><name><surname>Haghighat</surname><given-names>Shahpar</given-names></name><xref ref-type="aff" rid="aff3">3</xref></contrib><contrib id="idp218992" contrib-type="author"><name><surname>Hossein Zadeh</surname><given-names>Samaneh</given-names></name><xref ref-type="aff" rid="aff4">4</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Department of Occupational Therapy, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran</aff><aff id="aff2"><label>2</label>Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran</aff><aff id="aff3"><label>3</label>Department of Breast Cancer Research Center, Tehran University of Medical Sciences, Tehran, IR Iran</aff><aff id="aff4"><label>4</label>Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran</aff><author-notes><corresp id="idp2644704"><label>*</label>Corresponding author: Leila Angooti Oshnari, Department of Occupational Therapy, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, P. O. Box: 198993414, Tehran, IR Iran. Tel/Fax: +98-2122721112, E-mail: <email>leylaa1768@yahoo.com</email></corresp></author-notes><pub-date pub-type="epub"><day>25</day><month>4</month><year>2016</year></pub-date><pub-date pub-type="collection"><month>4</month><year>2016</year></pub-date><volume>9</volume><issue>2</issue><elocation-id>e4209</elocation-id><history><date date-type="received"><day>01</day><month>10</month><year>2015</year></date><date date-type="rev-recd"><day>20</day><month>12</month><year>2015</year></date><date date-type="accepted"><day>14</day><month>3</month><year>2016</year></date></history><permissions><copyright-statement>Copyright © 2016, Iranian Journal of Cancer Prevention</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/"><license-p><pmc-comment>CREATIVE COMMONS</pmc-comment>This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</ext-link>) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.</license-p></license></permissions><abstract><sec><title>Background</title><p>Upper extremity lymph edema is the most common side effect of breast cancer treatment that may produce significant physical and psychological morbidity. Pain is the frequent symptom of lymph edema that causes impairment of activities in daily life.</p></sec><sec><title>Objectives</title><p>The aim of this study was assessment of the effect of complex decongestive therapy (CDT) on upper extremity lymph edema and pain in women with post breast surgery lymph edema.</p></sec><sec><title>Patients and Methods</title><p>In this quasi- experimental research with before- after design, 36 women with moderate lymph edema after breast surgery participated in the program. Edema volume was measured by water displacement method; pain values were evaluated by visual analog scale (VAS). Data were recorded before intervention and 2 and 4 weeks after it. CDT included the first phase (intensive phase) and the second phase (maintenance phase). Each phase lasted 2 weeks. After use of Shapiro Wilk test for normality, analysis of variances with GEE and repeated measurements were used to analyze the data.</p></sec><sec><title>Results</title><p>After one month doing CDT program, significant decrease of edema was noticed (P < 0.0001), also pain decreased during 2 and 4 weeks after intervention (P < 0.0001).</p></sec><sec><title>Conclusions</title><p>This study indicated that CDT program is effective in reducing lymph edema volume and pain in women with moderate post breast surgery lymph edema. It seems that raising patients’ awareness and training healthcare professionals regarding lymph edema preventive strategies have an important role in earlier and better combating this complication.</p></sec></abstract><kwd-group kwd-group-type="author"><kwd>Breast Cancer</kwd><kwd>Lymph Edema</kwd><kwd>Complex Decongestive Therapy</kwd><kwd>Pain</kwd></kwd-group></article-meta></front><body><sec><title>1. Background</title><p>Breast cancer, with the incidence of 2% annually (<xref rid="A4209REF1" ref-type="bibr">1</xref>), is one of the most common malignancies among Iranian women (<xref rid="A4209REF2" ref-type="bibr">2</xref>) and the lowest mean age in the middle east (<xref rid="A4209REF3" ref-type="bibr">3</xref>). Although its treatments such as surgery, radiotherapy, chemotherapy and hormonal therapy reduce mortality rates of breast cancer, each may lead to different side effects (<xref rid="A4209REF4" ref-type="bibr">4</xref>).</p><p>The secondary upper limb lymph edema related to breast cancer (<xref rid="A4209REF5" ref-type="bibr">5</xref>) is one of the most common morbidities and important consequences of treatment (<xref rid="A4209REF6" ref-type="bibr">6</xref>) that is usually unilateral (<xref rid="A4209REF5" ref-type="bibr">5</xref>), with mild to severe intensity at any time during the life (<xref rid="A4209REF7" ref-type="bibr">7</xref>). It is known as a chronic, incurable (<xref rid="A4209REF6" ref-type="bibr">6</xref>) visible and progressive disease (<xref rid="A4209REF8" ref-type="bibr">8</xref>). So it is causing physical and psychological disorders (<xref rid="A4209REF9" ref-type="bibr">9</xref>). Without intervention, lymph edema can lead to progressive swollen and larger in size of limb or localized fluid accumulation in other body areas, tightness, heaviness, limitation of mobility in upper limb and hand, numbness and tingling, pain, fatigue (<xref rid="A4209REF5" ref-type="bibr">5</xref>), skin changes (<xref rid="A4209REF10" ref-type="bibr">10</xref>), deformities (<xref rid="A4209REF11" ref-type="bibr">11</xref>), body image impairment, stress, depression, loss of confidence, lack of participation in social activities (9), and even death in advanced stages of lymph edema in these patients (<xref rid="A4209REF12" ref-type="bibr">12</xref>).</p><p>Despite the large studies for the treatment of lymphedema, there is not any certain cure (<xref rid="A4209REF8" ref-type="bibr">8</xref>). The gold standard treatment so far has been complex decongestive therapy (CDT). The international association of north America (LANA) has known CDT as common, standard, and an effective treatment. It is a two-phase program. The first phase (intensive phase) usually, depending on the degree of edema, lasts 2 to 4 weeks. The patient receives treatment 5 days per week and the second phase (maintenance phase) immediately begins after the first phase that is life-long self-care to maintain the size of the limb (<xref rid="A4209REF5" ref-type="bibr">5</xref>-<xref rid="A4209REF8" ref-type="bibr">8</xref>).</p></sec><sec><title>2. Objectives</title><p>Due to the increase of life expectancy in patients with breast cancer and lymph edema related to it as a chronic disease and also the lack of lymph therapist in our society, so in this research, CDT program with emphasis on raising awareness and education of the patients on early diagnosis, prevention, encouragement to continue long-time treatment by themselves and compatibility with the presence of lymph edema is used, in order to the patient is helped to reduce complications of this condition such as pain.</p></sec><sec><title>3. Patients and Methods</title><p>This quasi-experimental clinical trial with before- after design, after being confirmed by ethical committee of lymph edema clinic of Shohadaye Tajrish hospital, Tehran was performed in 2011. 36 women with breast carcinoma treatment and moderate lymph edema (> 200 - < 400 cc), were considered eligible to participate in this study. The criteria for excluding the patients from study were: breast cancer recurrence, malignancy, infection, bilateral lymph edema, history of trauma, previous treatment for lymph edema, heart and kidney insufficiency, hypertension, diabetic, thrombosis, unheard wound and skin diseases, fracture, neuromuscular diseases and any absolute contraindications for CDT (5,9,13).</p><p>Non-invasive CDT treatment was implemented in two phases for 4 weeks (6 days a week except for Fridays). The first phase (intensive phase) for 2 weeks consisted of 45 minutes Manual Lymph Drainage (MLD) massage slightly by therapist, the multi-layered low stretch bandages (Lohmann Rauscher bandage set) up to start the next session, five lymph exercises with the bandages and skin-nail care. The second phase (maintenance phase) with 2-week follow-up, included daily Self-Lymph Drainage (SLD) massage by the patient, the use of A-H sleeve (Sigvaris brand) with support straps in category 500 and class 2 pressure (23-32 mm hg in German standard pressure), the multi-layered low stretch bandages in nights, going on to do exercise and skin-nail care.</p><p>In addition to demographic questionnaire, the volume of edema was measured with water displacement volumetric by a blinded investigator not engaged in the treatment. This method is the gold standard, as mentioned earlier, 2 and 4 weeks after the intervention. The edema volume in texts explained as the volume difference between affected and unaffected arms. Then to calculate the percent of volume reduction (PVR) at the end of phase 1, the volume difference between before and 2 weeks after intervention is divided by before volume then multiplied by 100. Also, PVR at the end of phase 2 was calculated by the volume difference between 2 weeks after intervention and 2 weeks follow up divided by 2 weeks intervention volume multiplied by 100 (<xref rid="A4209REF5" ref-type="bibr">5</xref>, <xref rid="A4209REF9" ref-type="bibr">9</xref>, <xref rid="A4209REF13" ref-type="bibr">13</xref>, <xref rid="A4209REF14" ref-type="bibr">14</xref>).</p><p>Also, pain value was evaluated by visual analog scale (VAS) that is standard, valid, reliable and simple in use (<xref rid="A4209REF15" ref-type="bibr">15</xref>), in this study in order to express the amount of pain, patients were marked with a pencil on the line by themselves before, 2 and 4 weeks after the intervention.</p><p>After data gathering and coding, due to the fact that the pain variable did not follow the normal distribution in Shapiro Wilk test, generalized estimating equation (GEE) to determine the existence of differences and repeated measurement to identify disagreements in measurement modes were used by using statistical package SPSS 18.</p></sec><sec><title>4. Results</title><p><xref ref-type="table" rid="A4209TBL1">Tables 1</xref> and <xref ref-type="table" rid="A4209TBL2">2</xref> demonstrate some demographic data of participants. The average of age in participants was 53 years (± 10.28), the average of body mass index (BMI) was 28.84 kg/m<sup>2</sup> (± 4.55), the average of distance between surgery until the initial assessment was 35 months (± 45.65), the average of number of lymph nodes removed was 14 (± 9.51), and the average of number of lymph nodes involved was 3 (± 3.29).</p><table-wrap id="A4209TBL1" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Demographic Characteristics of Patients (N = 36)</title></caption><table frame="hsides" rules="groups"><thead><tr><th style="text-align: left;" rowspan="1" colspan="1">Variable</th><th rowspan="1" colspan="1">No. (%)</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Marital status</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Single</td><td style="text-align: center;" rowspan="1" colspan="1">2 (5.6)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Married</td><td style="text-align: center;" rowspan="1" colspan="1">31 (86.1)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Widowed/Divorced</td><td style="text-align: center;" rowspan="1" colspan="1">3 (8.3)</td></tr><tr><td rowspan="1" colspan="1"><bold>Education</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Illiterate</td><td style="text-align: center;" rowspan="1" colspan="1">5 (13.9)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Less than high school</td><td style="text-align: center;" rowspan="1" colspan="1">16 (44.4)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">High school</td><td style="text-align: center;" rowspan="1" colspan="1">10 (27.8)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Higher education</td><td style="text-align: center;" rowspan="1" colspan="1">5 (13.9)</td></tr><tr><td rowspan="1" colspan="1"><bold>Job</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Housewife</td><td style="text-align: center;" rowspan="1" colspan="1">33 (91.7)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Employed</td><td style="text-align: center;" rowspan="1" colspan="1">3 (8.3)</td></tr><tr><td rowspan="1" colspan="1"><bold>Dominant limb</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Right</td><td style="text-align: center;" rowspan="1" colspan="1">34 (94.4)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Left</td><td style="text-align: center;" rowspan="1" colspan="1">2 (5.6)</td></tr></tbody></table></table-wrap><table-wrap id="A4209TBL2" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Clinical Characteristics of Patients (N = 36)</title></caption><table frame="hsides" rules="groups"><thead><tr><th style="text-align: left;" rowspan="1" colspan="1">Variable</th><th rowspan="1" colspan="1">No. (%)</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Involved limb</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Right</td><td style="text-align: center;" rowspan="1" colspan="1">14 (38.9)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Left</td><td style="text-align: center;" rowspan="1" colspan="1">22 (61.1)</td></tr><tr><td rowspan="1" colspan="1"><bold>Breast surgery</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">MRM</td><td style="text-align: center;" rowspan="1" colspan="1">32 (88.9)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">BP</td><td style="text-align: center;" rowspan="1" colspan="1">4 (11.1)</td></tr><tr><td rowspan="1" colspan="1"><bold>Axillaries surgery</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Lymph nodes removal</td><td style="text-align: center;" rowspan="1" colspan="1">35 (97.2)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Sentinel node removal</td><td style="text-align: center;" rowspan="1" colspan="1">1 (2.8)</td></tr><tr><td rowspan="1" colspan="1"><bold>Radiation therapy</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Yes</td><td style="text-align: center;" rowspan="1" colspan="1">28 (77.8)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">No</td><td style="text-align: center;" rowspan="1" colspan="1">8 (22.2)</td></tr><tr><td rowspan="1" colspan="1"><bold>Chemotherapy</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Yes</td><td style="text-align: center;" rowspan="1" colspan="1">36 (100)</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">No</td><td style="text-align: center;" rowspan="1" colspan="1">0 (0)</td></tr></tbody></table></table-wrap><p>As shown in <xref ref-type="table" rid="A4209TBL3">Table 3</xref>, the mean of percent of volume reduction increased during both phases. Also, according to a paired t-test, the mean percent of volume reduction, during first two weeks 46.45 (± 18.67) and second two weeks 17.12 (± 22.35) were significant P < 0.0001) and it was observed that PVR in first two weeks was less than second two weeks. In addition, the average of pain score before treatment was 4.86 (± 2.82) and 2 and 4 weeks after treatment reduced to 1.97 (± 1.81) and 1.63 (± 1.95) respectively. According to GEE method, the average of pain in repeated measurements were significantly different (P < 0.0001).</p><table-wrap id="A4209TBL3" orientation="portrait" position="float"><label>Table 3.</label><caption><title>Average and Significant Variables in the Analysis of Repeated Measures (N = 36)</title></caption><table frame="hsides" rules="groups"><thead><tr><th style="text-align: left;" rowspan="1" colspan="1">Variable</th><th rowspan="1" colspan="1">Mean ± SD</th><th rowspan="1" colspan="1">P Value</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><bold>Percent of volume reduction</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td><td style="text-align: center;" rowspan="1" colspan="1">0.0001</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">First two weeks</td><td style="text-align: center;" rowspan="1" colspan="1">46.45 ± 18.67</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Second two weeks</td><td style="text-align: center;" rowspan="1" colspan="1">17.12 ± 22.35</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Pain</bold></td><td style="text-align: center;" rowspan="1" colspan="1"></td><td style="text-align: center;" rowspan="1" colspan="1">0.0001</td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Before</td><td style="text-align: center;" rowspan="1" colspan="1">4.86 ± 2.82</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Two weeks</td><td style="text-align: center;" rowspan="1" colspan="1">1.97 ± 1.81</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr><tr><td style="padding-left: 20pt;" rowspan="1" colspan="1">Four weeks</td><td style="text-align: center;" rowspan="1" colspan="1">1.63 ± 1.95</td><td style="text-align: center;" rowspan="1" colspan="1"></td></tr></tbody></table></table-wrap><p>In <xref ref-type="table" rid="A4209TBL4">Table 4</xref>, results of paired comparison test to determine the differences in measurements, the average of pain showed a significant difference between before and 2 weeks after the intervention (P < 0.0001), between before and 4 weeks after the intervention (P < 0.0001), and between 2 and 4 weeks after the intervention (P = 0.023).</p><table-wrap id="A4209TBL4" orientation="portrait" position="float"><label>Table 4.</label><caption><title>Paired Comparison of the Average Pain in Patients (N = 36)</title></caption><table frame="hsides" rules="groups"><thead><tr><th style="text-align: left;" rowspan="1" colspan="1">Pain</th><th rowspan="1" colspan="1">Difference of Mean (SE)</th><th rowspan="1" colspan="1">P Value</th><th colspan="2" rowspan="1">(95% CI)</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"></td><td style="text-align: center;" rowspan="1" colspan="1"></td><td style="text-align: center;" rowspan="1" colspan="1"></td><td style="text-align: center;" rowspan="1" colspan="1"><bold>Upper Limit</bold></td><td style="text-align: center;" rowspan="1" colspan="1"><bold>Lower Limit</bold></td></tr><tr><td rowspan="1" colspan="1"><bold>Before and 2 weeks</bold></td><td style="text-align: center;" rowspan="1" colspan="1">2.89 (0.37)</td><td style="text-align: center;" rowspan="1" colspan="1">< 0.0001</td><td style="text-align: center;" rowspan="1" colspan="1">2.17</td><td style="text-align: center;" rowspan="1" colspan="1">3.61</td></tr><tr><td rowspan="1" colspan="1"><bold>2 weeks and 4 weeks</bold></td><td style="text-align: center;" rowspan="1" colspan="1">0.33 (0.15)</td><td style="text-align: center;" rowspan="1" colspan="1">0.023</td><td style="text-align: center;" rowspan="1" colspan="1">0.05</td><td style="text-align: center;" rowspan="1" colspan="1">0.62</td></tr><tr><td rowspan="1" colspan="1"><bold>Before and 4 weeks</bold></td><td style="text-align: center;" rowspan="1" colspan="1">3.22 (0.41)</td><td style="text-align: center;" rowspan="1" colspan="1">< 0.0001</td><td style="text-align: center;" rowspan="1" colspan="1">2.18</td><td style="text-align: center;" rowspan="1" colspan="1">4.02</td></tr></tbody></table></table-wrap></sec><sec><title>5. Discussion</title><p>This study, to evaluate effect of CDT on upper extremity lymph edema and pain in women after breast cancer surgery, showed that CDT led to a significant increase in mean percentage of volume reduction in both phases, but in the first phase provided better results. Hamner et al. (2006) (<xref rid="A4209REF16" ref-type="bibr">16</xref>) and Haghighat et al. (2008) found that CDT had impressive results in lower volume too (<xref rid="A4209REF17" ref-type="bibr">17</xref>). Also, Morgan et al. found out Patients in the first phase more than 50% and in the second phase about 50% of lymph edema decreased (<xref rid="A4209REF18" ref-type="bibr">18</xref>). It seems that the multi-layered low stretch bandages to reduce lymph edema and sleeves to avoid presence of lymph edema are used (<xref rid="A4209REF9" ref-type="bibr">9</xref>). And the second phase immediately after the first phase is done to maintain the maximum results of the first phase (<xref rid="A4209REF13" ref-type="bibr">13</xref>). No studies were found to increase the volume of lymph edema due to breast cancer with CDT, but a study by Szuba et al. showed that CDT and pneumatic compression pump reduced the volume of edema more than CDT alone in patients (<xref rid="A4209REF19" ref-type="bibr">19</xref>).</p><p>Also in this study the average of pain scale in both phases reduced, but in the first phase was more than the second one. As mentioned in the sources, causes of pain in limb lymph edema can be due to muscles strain (<xref rid="A4209REF9" ref-type="bibr">9</xref>), elongation of nerve fibers in the skin, and pressure on the nerve trunk by excessive accumulation of fluid (<xref rid="A4209REF20" ref-type="bibr">20</xref>). Therefore, more evacuation of lymph edema causes less strain on vessels and peripheral nerves of the skin and muscles of the upper extremity and trunk. However, lymph edema causes pain (<xref rid="A4209REF9" ref-type="bibr">9</xref>), but massage can reduce pain (<xref rid="A4209REF21" ref-type="bibr">21</xref>), so there was reduction of pain in both phases. </p><p>Hammner et al. found CDT has effects on pain reduction (<xref rid="A4209REF16" ref-type="bibr">16</xref>). Mandery received pain reduction in VAS Score from 7 to 1 with CDT too (<xref rid="A4209REF22" ref-type="bibr">22</xref>). Khoshnazar also showed that the rehabilitation program led to a significant reduction in pain (<xref rid="A4209REF15" ref-type="bibr">15</xref>). As well, Cassileth found that manual lymph drainage massage reduced pain and discomfort in upper limb lymph edema caused by the removal of lymph nodes (<xref rid="A4209REF23" ref-type="bibr">23</xref>). It should be noted that no study was found to increase the pain of breast cancer treatment with CDT, but Haghighat et al. reported that the use of CDT alone and CDT with pneumatic compression pump pressure had the same significant reduction of pain (<xref rid="A4209REF24" ref-type="bibr">24</xref>).</p><p>Overall, this study showed that complex decongestive therapy rehabilitation program services is effective on reduction of lymph edema and pain in women with lymph edema after breast surgery.</p><p>Since breast cancer is an important problem in public health, is considered one of the most common malignancies in women (<xref rid="A4209REF25" ref-type="bibr">25</xref>), and unfortunately with regard to the lack of awareness of women in society not only on the role of the prophylactic factors of breast cancer and the examination (<xref rid="A4209REF26" ref-type="bibr">26</xref>), but also in treatment-related complications, including lymph edema, cause to the treatment centers will be late (<xref rid="A4209REF15" ref-type="bibr">15</xref>). As well , due to the fact that most of the experts thought that lymph edema is an inevitable and incurable complication, late referral of patients, lack of lymph edema treatment clinics and providing services in the field of educational planning cause treatment as CDT should be provided limited or very time-consuming and costly.</p><p>Due to the need to enhance or restore the ability and minimize disability to improve independence without pain in activities of daily living in these patients, this study can serve as an introduction to broader and more complete prevention of lymph edema research by researchers and therapists.</p></sec></body><back><ack><p>None declared.</p></ack><fn-group><fn fn-type="other" id="afn1"><p><bold>Authors’ Contributions:</bold>None declared.</p></fn><fn fn-type="financial-disclosure" id="afn2"><p><bold>Financial Disclosure:</bold>We have no financial interests related to the material in the manuscript.</p></fn><fn fn-type="conflict" 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