Effects of phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer related lymph edema
Identifieur interne : 004119 ( Pmc/Corpus ); précédent : 004118; suivant : 004120Effects of phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer related lymph edema
Auteurs : Orçin Telli Atalay ; An L Özkir ; Bilge Ba Akçi Çalik ; Emre Baskan ; Harun Ta KinSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2015.
Abstract
[Purpose] Breast cancer-related upper extremity lymph edema is known to cause physical, functional and psychological impairments in women after modified radical mastectomy. The aim of this study was to investigate the effects of phase I Complex Decongestive Physiotherapy (CDP) on physical functions and depression levels in women with breast cancer-related upper extremity lymph edema. [Subjects and Methods] Fifty-eight subjects with breast cancer-related upper extremity lymph edema were the subjects of this study. The arm circumference, shoulder range of motion (ROM), muscle strength and depression levels of the subjects were assessed before and after phase I CDP treatment. [Results] After phase I CDP, there was a statistically significant reduction in circumference measurements at all levels of the affected arm. There was not any statistically significant difference in muscle strength after CDP. The shoulder ROM improved after treatment. There was a significant reduction in the Beck Depression Inventory score. A significant positive correlation was found between depression levels and circumference measurement. [Conclusion] Based on the results we suggest that by reducing limb volume, beside improving physical functions, phase I CDP can affect psychological status, especially depression which is very common in women with breast cancer-related upper extremity lymph edema.
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DOI: 10.1589/jpts.27.865
PubMed: 25931748
PubMed Central: 4395732
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Effects of phase I complex decongestive physiotherapy on physical functions
and depression levels in breast cancer related lymph edema</title><author><name sortKey="Atalay, Orcin Telli" sort="Atalay, Orcin Telli" uniqKey="Atalay O" first="Orçin Telli" last="Atalay">Orçin Telli Atalay</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Ozkir, An L" sort="Ozkir, An L" uniqKey="Ozkir A" first="An L" last="Özkir">An L Özkir</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Calik, Bilge Ba Akci" sort="Calik, Bilge Ba Akci" uniqKey="Calik B" first="Bilge Ba Akçi" last="Çalik">Bilge Ba Akçi Çalik</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Baskan, Emre" sort="Baskan, Emre" uniqKey="Baskan E" first="Emre" last="Baskan">Emre Baskan</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Ta Kin, Harun" sort="Ta Kin, Harun" uniqKey="Ta Kin H" first="Harun" last="Ta Kin">Harun Ta Kin</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25931748</idno><idno type="pmc">4395732</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395732</idno><idno type="RBID">PMC:4395732</idno><idno type="doi">10.1589/jpts.27.865</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">004119</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">004119</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Effects of phase I complex decongestive physiotherapy on physical functions
and depression levels in breast cancer related lymph edema</title><author><name sortKey="Atalay, Orcin Telli" sort="Atalay, Orcin Telli" uniqKey="Atalay O" first="Orçin Telli" last="Atalay">Orçin Telli Atalay</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Ozkir, An L" sort="Ozkir, An L" uniqKey="Ozkir A" first="An L" last="Özkir">An L Özkir</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Calik, Bilge Ba Akci" sort="Calik, Bilge Ba Akci" uniqKey="Calik B" first="Bilge Ba Akçi" last="Çalik">Bilge Ba Akçi Çalik</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Baskan, Emre" sort="Baskan, Emre" uniqKey="Baskan E" first="Emre" last="Baskan">Emre Baskan</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Ta Kin, Harun" sort="Ta Kin, Harun" uniqKey="Ta Kin H" first="Harun" last="Ta Kin">Harun Ta Kin</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>[Purpose] Breast cancer-related upper extremity lymph edema is known to cause physical,
functional and psychological impairments in women after modified radical mastectomy. The
aim of this study was to investigate the effects of phase I Complex Decongestive
Physiotherapy (CDP) on physical functions and depression levels in women with breast
cancer-related upper extremity lymph edema. [Subjects and Methods] Fifty-eight subjects
with breast cancer-related upper extremity lymph edema were the subjects of this study.
The arm circumference, shoulder range of motion (ROM), muscle strength and depression
levels of the subjects were assessed before and after phase I CDP treatment. [Results]
After phase I CDP, there was a statistically significant reduction in circumference
measurements at all levels of the affected arm. There was not any statistically
significant difference in muscle strength after CDP. The shoulder ROM improved after
treatment. There was a significant reduction in the Beck Depression Inventory score. A
significant positive correlation was found between depression levels and circumference
measurement. [Conclusion] Based on the results we suggest that by reducing limb volume,
beside improving physical functions, phase I CDP can affect psychological status,
especially depression which is very common in women with breast cancer-related upper
extremity lymph edema.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Kocak, Z" uniqKey="Kocak Z">Z Kocak</name></author><author><name sortKey="Overgaard, J" uniqKey="Overgaard J">J Overgaard</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lawenda, Bd" uniqKey="Lawenda B">BD Lawenda</name></author><author><name sortKey="Mondry, Te" uniqKey="Mondry T">TE Mondry</name></author><author><name sortKey="Johnstone, Pa" uniqKey="Johnstone P">PA Johnstone</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="G Rtner, R" uniqKey="G Rtner R">R Gärtner</name></author><author><name sortKey="Jensen, Mb" uniqKey="Jensen M">MB Jensen</name></author><author><name sortKey="Kronborg, L" uniqKey="Kronborg L">L Kronborg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bergmann, A" uniqKey="Bergmann A">A Bergmann</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25931748</article-id><article-id pub-id-type="pmc">4395732</article-id><article-id pub-id-type="publisher-id">jpts-2014-617</article-id><article-id pub-id-type="doi">10.1589/jpts.27.865</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Effects of phase I complex decongestive physiotherapy on physical functions
and depression levels in breast cancer related lymph edema</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Atalay</surname><given-names>Orçin Telli</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Özkir</surname><given-names>Anıl</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Çalik</surname><given-names>Bilge Başakçi</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Baskan</surname><given-names>Emre</given-names></name><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Taşkin</surname><given-names>Harun</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physiotherapy and Rehabilitation, School of Physical Therapy and Rehabilitation, Pamukkale University, Turkey</aff><aff id="aff2"><label>2)</label> Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Pamukkale University, Turkey</aff><aff id="aff3"><label>3)</label> Department of Orthopedical Rehabilitation, School of Physical Therapy and Rehabilitation, Pamukkale University, Turkey</aff><aff id="aff4"><label>4)</label> Department of Neurological Rehabilitation, School of Physical Therapy and Rehabilitation, Pamukkale University, Turkey</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Orçin Telli Atalay, Department of Physiotherapy and Rehabilitation, School of
Physical Therapy and Rehabilitation, Pamukkale University: Denizli, Turkey. (E-mail: <email xlink:href="orcint@pau.edu.tr">orcint@pau.edu.tr</email>)</corresp></author-notes><pub-date pub-type="epub"><day>31</day><month>3</month><year>2015</year></pub-date><pub-date pub-type="ppub"><month>3</month><year>2015</year></pub-date><volume>27</volume><issue>3</issue><fpage>865</fpage><lpage>870</lpage><history><date date-type="received"><day>25</day><month>9</month><year>2014</year></date><date date-type="accepted"><day>07</day><month>11</month><year>2014</year></date></history><permissions><copyright-statement>2015©by the Society of Physical Therapy Science. Published by IPEC Inc.</copyright-statement><copyright-year>2015</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p>[Purpose] Breast cancer-related upper extremity lymph edema is known to cause physical,
functional and psychological impairments in women after modified radical mastectomy. The
aim of this study was to investigate the effects of phase I Complex Decongestive
Physiotherapy (CDP) on physical functions and depression levels in women with breast
cancer-related upper extremity lymph edema. [Subjects and Methods] Fifty-eight subjects
with breast cancer-related upper extremity lymph edema were the subjects of this study.
The arm circumference, shoulder range of motion (ROM), muscle strength and depression
levels of the subjects were assessed before and after phase I CDP treatment. [Results]
After phase I CDP, there was a statistically significant reduction in circumference
measurements at all levels of the affected arm. There was not any statistically
significant difference in muscle strength after CDP. The shoulder ROM improved after
treatment. There was a significant reduction in the Beck Depression Inventory score. A
significant positive correlation was found between depression levels and circumference
measurement. [Conclusion] Based on the results we suggest that by reducing limb volume,
beside improving physical functions, phase I CDP can affect psychological status,
especially depression which is very common in women with breast cancer-related upper
extremity lymph edema.</p></abstract><kwd-group><title>Key words</title><kwd>Lymph edema</kwd><kwd>Complex decongestive physiotherapy</kwd><kwd>Depression</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>Lymph edema is the accumulation of a high-protein edema fluid in the interstitial tissue as
a result of the functional overload of the lymphatic system in which lymph volume exceeds
transport capabilities and the lymphatic system becomes overwhelmed, causing lymphatic
insufficiency or failure<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>.</p><p>Primary lymph edema may be caused by the congenital and/or hereditary etiology. Secondary
lymph edema may occur as a result of obstruction or interruption of the lymph system due to
surgery. Also radiotherapy, trauma, infection, malignancy and chronic venous insufficiency.
The most common cause of secondary lymph edema in the upper extremity is breast cancer
treatment, especially with the combination of axillary surgery and radiation and lower
extremity lymph edema mostly occurs as a consequence of gynecological cancer (cervical,
endometrial, vulvar, head and neck cancers)<xref rid="r2" ref-type="bibr">2</xref><sup>)</sup>.</p><p>The prevalence of post breast cancer surgery upper limb lymph edema is between 8% and 65%
as described in the literature<xref rid="r3" ref-type="bibr">3</xref>, <xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>. The main reasons for this wide reported range of prevalence
of the upper extremity lymph edema are: the follow-up time, the number of patients included
in the studies, the classification and criteria used for its definition, the use of
different measuring methods, and the time elapsed after surgery.</p><p>The factors that contribute to the development of upper extremity lymph edema after breast
cancer surgery are classified in terms of extent of axillary surgery and mastectomy,
axillary lymph node dissection (ALND), the number of nodes removed, the presence of a
metastatic lymph node, use of axillary radiation therapy, chemotherapy, younger age at
diagnosis, older age (>55), weight, body mass index (BMI), injury or infection in the
ipsilateral arm, and trauma<xref rid="r3" ref-type="bibr">3</xref>,<xref rid="r4" ref-type="bibr">4</xref>,<xref rid="r5" ref-type="bibr">5</xref>,<xref rid="r6" ref-type="bibr">6</xref>,<xref rid="r7" ref-type="bibr">7</xref>,<xref rid="r8" ref-type="bibr">8</xref>,<xref rid="r9" ref-type="bibr">9</xref>,<xref rid="r10" ref-type="bibr">10</xref>,<xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>.</p><p>Except for lymph edema the other complications after breast cancer surgery are as follows:
pain in the affected shoulder and arm, restrictions of shoulder motions, decrease in the
muscle strength and functional capacity of the upper extremity, and difficulty with
activities of daily living<xref rid="r12" ref-type="bibr">12</xref>,<xref rid="r13" ref-type="bibr">13</xref>,<xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r15" ref-type="bibr">15</xref>,<xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. Development of
lymph edema after breast cancer surgery increases the upper extremity symptoms of pain,
numbness, stiffness, loss of strength and function<xref rid="r5" ref-type="bibr">5</xref>,
<xref rid="r17" ref-type="bibr">17</xref><sup>)</sup>.</p><p>Together with physical and functional inabilities, lymph edema is also associated with
psychological morbidity<xref rid="r13" ref-type="bibr">13</xref><sup>)</sup>. Psychological
impacts of lymph edema include anxiety, depression, loss of body self confidence, social
isolation and sexual dysfunction<xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>.
Moreover lymph edema and impaired upper extremity functions lead to deterioration in the
activities of daily living<xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. It is
reported that the functions of the arm decrease as the severity of lymph edema increases and
the levels of depression and anxiety increase as the symptoms of the upper extremity
increase<xref rid="r19" ref-type="bibr">19</xref>, <xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>. The severity and localization of lymph edema and pain are the
factors that aggravate psychological distress and anxiety<xref rid="r13" ref-type="bibr">13</xref><sup>)</sup>. There are several methods of treatment for breast cancer-related
lymph edema including physiotherapy, exercises, medical treatment with benzopyrones and a
variety of microsurgical techniques. Complex decongestive physiotherapy (CDP) is a
multimodality approach that consists of manual lymphatic drainage (MLD), skin care,
compression bandages, and exercise, and it is a promising form of treatment recently. CDP is
used to activate lymphatic vessels and move protein rich fluid from edematous to non
edematous areas. Although CDP was developed several decades ago, there are many studies that
show CDP can greatly reduce the volume and percentage volume of breast cancer-related lymph
edema. However, there are few studies about the effects of CDP on other physical aspects
such as pain, restriction of movements, and functions of the upper extremity or its effects
on psychological factors. Therefore the aim of this study was to investigate the effects of
phase I CDP on physical functions and depression levels of subjects with breast
cancer-related upper extremity lymph edema.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><p>This interventional clinical study was carried out at Pamukkale University School of
Physical Therapy and Rehabilitation. Approval for this study was granted by the non-invasive
clinical research ethics committee of Pamukkale University and the study was conducted in
accordance with the principles of the Declaration of Helsinki. All the subjects provided
their informed consent.</p><p>Among the 96 subjects having lymph edema and referred for physical therapy, 77 subjects
with secondary lymph edema after modified radical mastectomy were chosen. The subjects who
had metastasis, severe orthopedical or neurological deformity, acute infection, uncontrolled
hypertension, severe venous or arterial insufficiency, severe psychiatric symptoms or any
other contraindications to manual lymphatic drainage and compression were excluded.
Sixty-three subjects met the inclusion criteria of this study, but five of the subjects did
not attend to the decongestive physical therapy programme regularly and they were excluded
from the assessments. Therefore, the data of 58 subjects forms the basis of this study.</p><p>Circumference, range of motion (ROM) measurements of both upper extremities, muscle
strength of the ipsilateral extremity and depression level were assessed before and after
the phase I CDP treatment.</p><p>The circumferences of both extremities were measured at the metacarpophalengeal joints of
the hand, and styloid process of radius and 5, 10, and 15 cm above the styloid process of
radius of the forearm, the lateral epycondile and 5, 10, and 15 cm above the lateral
epycondile of the upper arm by using a standard one inch, retractable, fiber glass tape
measure. The measurements were done twice, each time by the same physiotherapist<xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>.</p><p>The shoulder range of motion was measured using standard techniques of goniometry as active
and passive measurements of shoulder flexion, extension, abduction and adduction, internal
and external rotation<xref rid="r21" ref-type="bibr">21</xref>, <xref rid="r22" ref-type="bibr">22</xref><sup>)</sup>. Muscle strength of the ipsilateral extremity was measured
by Lovett’s manual muscle testing<xref rid="r23" ref-type="bibr">23</xref><sup>)</sup>.</p><p>Depression levels of the subjects were evaluated using the Beck Depression Inventory (BDI)
which was first developed by Beck et al. in 1961<xref rid="r24" ref-type="bibr">24</xref><sup>)</sup>. There are 21 categories; each of which has four options.
Participants were asked to choose the suitable option that expressed their emotional status
in the last 1-week period. The maximum score is 63, and the cutoff value for the Turkish
version is 17 which indicates a need for help<xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>.</p><p>Phase I Complex Decongestive Physiotherapy consisting of MLD, multi layer compression
bandaging, remedial exercises in combination with respiratory exercises were performed by
all subjects five times in a week for four weeks (20 sessions in total) by a certified lymph
edema physiotherapist<xref rid="r21" ref-type="bibr">21</xref>, <xref rid="r26" ref-type="bibr">26</xref>,<xref rid="r27" ref-type="bibr">27</xref>,<xref rid="r28" ref-type="bibr">28</xref><sup>)</sup>. At the end of the phase I CDP treatment the subjects wore
compression garments. Self massage, home exercises for lymph edema and skin care were
prescribed for the subjects by the therapist for the phase II CDP.</p><p>Analyses of data were performed using SPSS for Windows version 16.00. Differences in
measurements circumference, shoulder range of motion and the Beck Depression Inventory were
assessed using the paired samples t test. Pearson’s correlation coefficient method was used
to assess the influence of changes in measurement of circumference and shoulder range of
motion on Beck Depression Inventory scores. P values < 0.05 were considered as
statistically significant.</p></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p>The physical characteristics and demographic data of subjects are presented in <xref rid="tbl_001" ref-type="table">Table 1</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Physical properties and demographic data of the subjects</title></caption><table frame="hsides" rules="groups"><thead><tr><th colspan="2" valign="top" align="center" rowspan="1">Physical properties</th><th valign="top" align="center" rowspan="1" colspan="1">X ± SD</th></tr></thead><tbody><tr><td align="left" valign="top" colspan="2" rowspan="1">Age (years)</td><td align="center" valign="top" rowspan="1" colspan="1">43.5 ± 5.3</td></tr><tr><td align="left" valign="top" colspan="2" rowspan="1">Height (cm)</td><td align="center" valign="top" rowspan="1" colspan="1">161.3 ± 6.7</td></tr><tr><td align="left" valign="top" colspan="2" rowspan="1">Weight (kg)</td><td align="center" valign="top" rowspan="1" colspan="1">78.4 ± 7.8</td></tr><tr><td align="left" valign="top" colspan="2" rowspan="1">BMI (kg/m<sup>2</sup>)</td><td align="center" valign="top" rowspan="1" colspan="1">26.3 ± 1.2</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" valign="top" colspan="2" rowspan="1">Demographic data</td><td align="center" valign="top" rowspan="1" colspan="1">N (%)</td></tr><tr><td align="left" valign="top" rowspan="3" colspan="1">Education level</td><td align="left" valign="top" rowspan="1" colspan="1">Illiterate</td><td align="center" valign="top" rowspan="1" colspan="1">15 (25.8)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><8 years</td><td align="center" valign="top" rowspan="1" colspan="1">27 (46.5)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">>8 years</td><td align="center" valign="top" rowspan="1" colspan="1">16 (27.5)</td></tr><tr><td align="left" valign="top" rowspan="3" colspan="1">Occupation</td><td align="left" valign="top" rowspan="1" colspan="1">Housewife</td><td align="center" valign="top" rowspan="1" colspan="1">35 (60,34)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Teacher</td><td align="center" valign="top" rowspan="1" colspan="1">13 (22.4)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Retired</td><td align="center" valign="top" rowspan="1" colspan="1">10 (17.2)</td></tr></tbody></table></table-wrap>. The dominant extremities of twenty-eight subjects were affected. Fifty-one of
the subjects had been given chemical therapy (CT), 43 of subjects had been given
radiotherapy (RT) and 38 of subjects had received endochirine therapy (<xref rid="tbl_002" ref-type="table">Table 2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Other therapies that subjects received after MRM</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" colspan="2" rowspan="1">Other therapies</th><th align="center" valign="top" rowspan="1" colspan="1">N (%)</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="2" colspan="1">Chemical therapy</td><td align="left" valign="top" rowspan="1" colspan="1">Yes</td><td align="center" valign="top" rowspan="1" colspan="1">51 (87.9)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">No</td><td align="center" valign="top" rowspan="1" colspan="1">7 (12.0)</td></tr><tr><td align="left" valign="top" rowspan="2" colspan="1">Radio therapy</td><td align="left" valign="top" rowspan="1" colspan="1">Yes</td><td align="center" valign="top" rowspan="1" colspan="1">43 (74.1)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">No</td><td align="center" valign="top" rowspan="1" colspan="1">15 (25.8)</td></tr><tr><td align="left" valign="top" rowspan="2" colspan="1">Endocrine therapy</td><td align="left" valign="top" rowspan="1" colspan="1">Yes</td><td align="center" valign="top" rowspan="1" colspan="1">38 (65.5)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">No</td><td align="center" valign="top" rowspan="1" colspan="1">20 (34.4)</td></tr></tbody></table></table-wrap>). The average duration of lymph edema was 32.0±5.5 months and the average time
since the operation was 38.5±2.1 months. The average number of dissected lymph nodes was
11.1±1.8. After modified radical mastectomy, the subjects were given on averagely 5.3 ±1.1
treatments of CT and 10.2 ±4.0 sessions of RT. A significant difference in the circumference
measurement was found when compared before and after complex decongestive physiotherapy
(CDP) at all levels of measurement (<xref rid="tbl_003" ref-type="table">Table
3</xref><table-wrap id="tbl_003" orientation="portrait" position="float"><label>Table 3.</label><caption><title>Comparison of upper extremity circumference measurements</title></caption><table frame="hsides" rules="groups"><thead><tr><th valign="top" align="center" rowspan="1" colspan="1">Circumference Measurement</th><th align="center" rowspan="1" colspan="1">B.CDP (cm)</th><th align="center" rowspan="1" colspan="1">A.CDP (cm)</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">MCP joint<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">21.3±0.8</td><td align="center" valign="top" rowspan="1" colspan="1">20.0±1.2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Styloideus Radius<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">22.5±4.3</td><td align="center" valign="top" rowspan="1" colspan="1">20.9±0.9</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">5 cm ↑<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">26.4±4.7</td><td align="center" valign="top" rowspan="1" colspan="1">23.6±2.5</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">10 cm ↑<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">27.0±5.1</td><td align="center" valign="top" rowspan="1" colspan="1">24.7±7.3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">15 cm ↑<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">29.2±4.7</td><td align="center" valign="top" rowspan="1" colspan="1">26.7±5.3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Lateral Epicondyles<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">30.9±3.9</td><td align="center" valign="top" rowspan="1" colspan="1">29.2±3.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">5 cm ↑<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">36.7±6.3</td><td align="center" valign="top" rowspan="1" colspan="1">32.3±6.8</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">10 cm ↑<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">37.0±7.7</td><td align="center" valign="top" rowspan="1" colspan="1">33.9±5.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">15 cm ↑<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">38.8±3.3</td><td align="center" valign="top" rowspan="1" colspan="1">34.0±2.9</td></tr></tbody></table><table-wrap-foot><p>* p < 0.05, MCP: metacarpophalengeal. B.CDP: Before Complex Decongestive
Physiotherapy. A.CDP: After Complex Decongestive Physiotherapy</p></table-wrap-foot></table-wrap>). We found that the muscle strength of the subjects was good (average 4.6±0.2
according to manual muscle testing) and decrease in muscle strength was not found before
CDP. The shoulder range of motions before and after CDP are shown in <xref rid="tbl_004" ref-type="table">Table 4</xref><table-wrap id="tbl_004" orientation="portrait" position="float"><label>Table 4.</label><caption><title>Comparison of upper extremity range of motions</title></caption><table frame="hsides" rules="groups"><thead><tr><th colspan="2" valign="top" align="center" rowspan="1">ROM</th><th valign="top" align="center" rowspan="1" colspan="1">B.CDP (º)</th><th valign="top" align="center" rowspan="1" colspan="1">A.CDP (º)</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="6" colspan="1">Shoulder joint</td><td align="left" valign="top" rowspan="1" colspan="1">Flexion<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">136.6±9.6</td><td align="center" valign="top" rowspan="1" colspan="1">171.3±8.2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Extension<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">54.6±5.7</td><td align="center" valign="top" rowspan="1" colspan="1">58.6±6.2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Abduction<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">128.3±16.4</td><td align="center" valign="top" rowspan="1" colspan="1">164.9±2.3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Adduction</td><td align="center" valign="top" rowspan="1" colspan="1">0.0±0.0</td><td align="center" valign="top" rowspan="1" colspan="1">0.0±0.1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Internal rotation<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">78.8±4.6</td><td align="center" valign="top" rowspan="1" colspan="1">85.5±1.0</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">External rotation<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">76.4±2.4</td><td align="center" valign="top" rowspan="1" colspan="1">84.2±3.6</td></tr><tr><td align="left" valign="top" rowspan="2" colspan="1">Elbow joint</td><td align="left" valign="top" rowspan="1" colspan="1">Flexion<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">142.6± 8.9</td><td align="center" valign="top" rowspan="1" colspan="1">146.0±9.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Extension</td><td align="center" valign="top" rowspan="1" colspan="1">0.0± 0.0</td><td align="center" valign="top" rowspan="1" colspan="1">0.0±0.0</td></tr><tr><td align="left" valign="top" rowspan="4" colspan="1">Wrist joint</td><td align="left" valign="top" rowspan="1" colspan="1">Flexion</td><td align="center" valign="top" rowspan="1" colspan="1">85.5± 2.5</td><td align="center" valign="top" rowspan="1" colspan="1">85.9± 3.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Extension</td><td align="center" valign="top" rowspan="1" colspan="1">84.8±0.8</td><td align="center" valign="top" rowspan="1" colspan="1">85.3± 3.8</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Ulnar deviation</td><td align="center" valign="top" rowspan="1" colspan="1">19.6±0.3</td><td align="center" valign="top" rowspan="1" colspan="1">21.0± 2.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Radial deviation</td><td align="center" valign="top" rowspan="1" colspan="1">14.4±1.9</td><td align="center" valign="top" rowspan="1" colspan="1">15.6± 2.3</td></tr></tbody></table><table-wrap-foot><p>*p<0.05, ROM: range of motion. B.CDP: Before Complex Decongestive Physiotherapy.
A.CDP: After Complex Decongestive Physiotherapy</p></table-wrap-foot></table-wrap>. According to this table, a significant difference was found in all shoulder
range of movements except from adduction. Although active shoulder range of movement did not
reach to normal levels, there was a significant increase after CDP. When we assessed the
average depression scores of the subjects before CDP a moderate level of depression was
found. The depression score improved to mild depression levels after CDP and there was a
significant difference in the scores of before and after treatment as shown in <xref rid="tbl_005" ref-type="table">Table 5</xref><table-wrap id="tbl_005" orientation="portrait" position="float"><label>Table 5.</label><caption><title>Comparison of depression scores</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" valign="top" rowspan="1" colspan="1">Depression score</th><th align="center" valign="top" rowspan="1" colspan="1">B.CDP</th><th align="center" valign="top" rowspan="1" colspan="1">A.CDP</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">BDI<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">24.5±5.4</td><td align="center" valign="top" rowspan="1" colspan="1">19.4±8.3</td></tr></tbody></table><table-wrap-foot><p>* p<0.05, B.CDP: Before Complex Decongestive Physiotherapy. A.CDP: After Complex
Decongestive Physiotherapy</p></table-wrap-foot></table-wrap>. There was a significant positive correlation between the changes in
circumference measurement of the affected arm and the depression level (<xref rid="tbl_006" ref-type="table">Table 6</xref><table-wrap id="tbl_006" orientation="portrait" position="float"><label>Table 6.</label><caption><title>Relation between average change in depression measurement and average change in
circumference measurements of the affected arm</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="middle" rowspan="1" colspan="1">The average change in depression scores ( X± SD)</th><th align="left" valign="middle" rowspan="1" colspan="1">The average change in circum ference measurements of
the affected arm ( X± SD) (cm)</th><th align="center" valign="middle" rowspan="1" colspan="1">r</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="9" colspan="1">∆ BDI score (5.6 ± 1.4)</td><td align="left" valign="top" rowspan="1" colspan="1">∆ MCP joint (1.0 ± 0.8)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ Styloideus radius (2.2 ± 0.7)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.7</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ 5 cm ↑ (3.4± 0.9)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ 10 cm ↑ (3.1 ±1.1)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.7</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ 15 cm ↑ (3.4 ± 1.2)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ Lateral epicondyles (1.0±0.5)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ 5 cm ↑ (4.2 ±1.2)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ 10 cm ↑ (2.9 ± 0.2)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">∆ 15 cm ↑ (4.0 ± 1.2)<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">0.7</td></tr></tbody></table><table-wrap-foot><p>*p<0.05, MCP: metacarpophalengeal</p></table-wrap-foot></table-wrap>). The depression levels decreased as the circumference measurement
decreased.</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>Psychological and psychosocial factors such as anxiety, depression, distress, altered
emotional reactions, sleep disturbances and social isolation are common in breast
cancer<xref rid="r29" ref-type="bibr">29</xref><sup>)</sup>. Increased prevalence of
depression among breast cancer patients has been shown in several studies<xref rid="r30" ref-type="bibr">30</xref>,<xref rid="r31" ref-type="bibr">31</xref>,<xref rid="r32" ref-type="bibr">32</xref>,<xref rid="r33" ref-type="bibr">33</xref><sup>)</sup>.
Fann et al. reported that the risk of major depression is 25% in women with breast cancer,
and within one year of diagnosis up to 30% of women with breast cancer may develop either
anxiety or depression, which may persist for more than 5 years after diagnosis and initial
treatment<xref rid="r34" ref-type="bibr">34</xref><sup>)</sup>. In one interesting study
it was found that those cases of mastectomy and hysterectomy had depressive symptoms and
problems regarding body image, spouse relationships and sexual satisfaction. When the
depressive state was compared between the cases with mastectomy and hysterectomy, it was
found that patients with mastectomy were more depressive than patients with
hysterectomy<xref rid="r35" ref-type="bibr">35</xref><sup>)</sup>.</p><p>The factors which are related to psychological distress include being diagnosed as having a
life-threatening illness, treatments and their side-effects, uncertainty of outcomes, role
changes as a result of activity limitation and restrictive participation, and issues related
to body image, especially unsatisfactory cosmetic results and lymph edema<xref rid="r36" ref-type="bibr">36</xref>, <xref rid="r37" ref-type="bibr">37</xref><sup>)</sup>. There are studies which report that psychological distress such as
depression, anxiety; hopelessness and helplessness are more common in breast cancer
survivors with lymph edema<xref rid="r31" ref-type="bibr">31</xref>,<xref rid="r32" ref-type="bibr">32</xref>,<xref rid="r33" ref-type="bibr">33</xref>, <xref rid="r38" ref-type="bibr">38</xref><sup>)</sup>. The study of Khan et al. they found that lymph edema was
associated with a higher impact score on the Perceived Impact Problem Profile<xref rid="r39" ref-type="bibr">39</xref><sup>)</sup>. In another study, Pyszel et al. reported
that breast cancer survivors with lymph edema had statistically significantly worse
psychological distress scores than survivors without lymph edema<xref rid="r40" ref-type="bibr">40</xref><sup>)</sup>.</p><p>In our study we assessed the depression levels of women with lymph edema after modified
radical mastectomy with BDI. In common with the previous studies, we found that women with
post mastectomy lymph edema had moderate levels of depression (average BDI score=24.5±5.4).
The most common symptoms associated with lymph edema are swelling, heaviness, tightness,
firmness, pain, numbness, stiffness, decreased mobility, and the physical disfigurement of
the condition. Women with post mastectomy lymph edema are unable to complete household
responsibilities, in severe cases they even need assistance with daily care activities, and
have difficulty in performing their jobs which leads to significant role changes in social
life. As a result untreated or occurance of lymph edema is a cause of serious psychological
disturbances, e.g. depression. Another reason for the occurance of depression is difficulty
with coping and adjusting to a chronic disease, which is for some of the subjects a surprise
because of inadequate information. Many of the subjects in our study had the idea that lymph
edema was an untreatable condition before complex decongestive therapy, which also might
have been a reason for their high levels of depression. Aesthetic concerns, which might
prevent women from wearing their usual clothing, might also be an important cause of
depression.</p><p>The shoulder ROM of women with post mastectomy lymph edema was significantly reduced in our
study. There are many studies which indicate that following breast cancer treatment, women
with lymph edema present with upper extremity impairments<xref rid="r3" ref-type="bibr">3</xref>, <xref rid="r4" ref-type="bibr">4</xref>, <xref rid="r13" ref-type="bibr">13</xref>, <xref rid="r17" ref-type="bibr">17</xref>, <xref rid="r27" ref-type="bibr">27</xref>, <xref rid="r28" ref-type="bibr">28</xref><sup>)</sup>. Women with lymph edema
more frequently demonstrate bilateral impairments in shoulder ROM and upper extremity
strength than women without lymph edema. Besides swelling of the arm, ROM limitation can
lead to reduced physical activity which may also be related to depression<xref rid="r41" ref-type="bibr">41</xref>, <xref rid="r42" ref-type="bibr">42</xref><sup>)</sup>.</p><p>The subjects of our study underwent intensive complex decongestive physiotherapy. Complex
physical therapy has been recommended as a primary treatment by consensus panels and is an
effective therapy for lymph edema<xref rid="r43" ref-type="bibr">43</xref>,<xref rid="r44" ref-type="bibr">44</xref>,<xref rid="r45" ref-type="bibr">45</xref>,<xref rid="r46" ref-type="bibr">46</xref>,<xref rid="r47" ref-type="bibr">47</xref><sup>)</sup>.
Complex physical therapy resulted in some volume reduction of the affected extremity in 95%
of 399 patients (50% reduction in 56% of patients, 25–49% reduction in 31%, and 1–24%
reduction in 8%), 54% of whom maintained the therapeutic result after 3 years<xref rid="r48" ref-type="bibr">48</xref><sup>)</sup>. In agreement with the literature, the
results of our study showed that after CDP, the shoulder ROM of the subjects increased and
the circumference measurement of the affected arm significantly decreased.</p><p>Several studies have shown the effects of CDP on physical functions and the quality of life
of lymph edema patients<xref rid="r14" ref-type="bibr">14</xref>, <xref rid="r15" ref-type="bibr">15</xref>, <xref rid="r26" ref-type="bibr">26</xref>,<xref rid="r27" ref-type="bibr">27</xref>,<xref rid="r28" ref-type="bibr">28</xref>, <xref rid="r47" ref-type="bibr">47</xref>,<xref rid="r48" ref-type="bibr">48</xref>,<xref rid="r49" ref-type="bibr">49</xref><sup>)</sup>. In one of the literature reviews, researchers concluded
that among the therapeutic modalities used for lymph edema treatment, CDP undoubtedly had
the strongest scientific support<xref rid="r50" ref-type="bibr">50</xref><sup>)</sup>. CDP
applied lymph edema patients effectively improved the quality of lymph edema patients
through the reduction in the volume and circumference of the affected limb, a decrease in
fear of movement, and increase in physical function<xref rid="r49" ref-type="bibr">49</xref><sup>)</sup>. As we discussed above, psychological distress such as depression
and anxiety, is also associated with lymph edema. Many studies have demonstrated the
effectiveness of CDP, however, not many studies have investigated the effects of CDP on
depression and other psychological issues. In present study we assessed the depression
levels of subjects before and after CDP. We found a significant decrease in the depression
score to mild-minimum levels. There was a positive correlation between circumference
reduction and depression levels and also a negative correlation between ROM and depression
levels. We think arm swelling and ROM limitation as a result of lymph edema after mastectomy
aggravate depression which is usually found in breast cancer survivors. CDP which is one
effective way of treating arm swelling and decrease in physical function can also contribute
treatments for psychological distress such as depression.</p><p>Reduction in limb volume and increase in range of motion reduces the fear of movement and
increase the physical function. The volume decrease in the affected extremity and increase
in ROM may lead to improvements in the social roles of subjects through increase of physical
function. The improvement in social participation may also be a factor that helps to
alleviate depression. Also, a decrease in aesthetic anxiety and becoming aware of that lymph
edema is treatable, are the other factors that may contribute to the alleviation of
depression.</p><p>Our study is important as there are not many studies of the psychological distress in
breast cancer and/or lymph edema related to breast cancer, especially secondary lymph edema
after mastectomy, and there are very few studies about the effects of CDP and other
treatment choices on the psychological distress such as depression<xref rid="r51" ref-type="bibr">51</xref>, <xref rid="r52" ref-type="bibr">52</xref><sup>)</sup>. The lack of a
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