Effects of the Manual Lymph Drainage on

Cardiac Autonomic Tone, Lymphedema,

and Quality of Life

Sungjoong Kim

The Graduate School

Yonsei University

Department of Rehabilitation Therapy

Effects of the Manual Lymph Drainage on

Cardiac Autonomic Tone, Lymphedema,

and Quality of Life

A Dissertation

Submitted to the Department of Rehabilitation Therapy

and the Graduate School of Yonsei University

in partial fulfillment of the

requirements for the degree of

Doctor of Philosophy

Sungjoong Kim

June 2008

This certifies that the dissertation of Sungjoong Kim

is approved.

Thesis Supervisor: Ohyun Kwon

Chunghwi Yi

Sanghyun Cho

Hyeseon Jeon

Sunghyun You

The Graduate School

Yonsei University

June 2008

Acknowledgements

This dissertation involved a series of stages towards its completion.

Without the support from many caring people it would not have been possible.

First of all, I thank my God for giving me the courage to purse my dreams, the

strength to endure the difficulties, and the sensitive to acknowledge my

blessings.

I would like to begin by saying how indebted, grateful, and appreciative I

am of my supervisor Professor Ohyun Kwon, who accepted me to study in the

doctorate course and has been a wonderful advisor and mentor. I would not

have been able to complete this dissertation without his thoughtful advice and

support. I am very grateful to Professor Chunghwi Yi for providing this topic,

and sincere advice to improve the quality of this study. I wish to acknowledge

Professor Sanghyun Cho who taught me the right way to get the scientific

method for systemic studies and to be a good scholar, Professor Hyeseon Jeon,

who gave me the warm encouragement and support whenever I was in trouble

and Professor Sunghyun You for always helping expand my knowledge and

complete this dissertation. I also thank Professor Boin Chung, Professor Minye

Jung, and Professor Eunyoung Yoo for providing encouragement.

Furthermore, this dissertation would not have been completed without the

love and support of my family. I cannot fully articulate in words the deep sense

of love I continue to receive from my parents, parents-in-law, and brother. I

dedicate this to them. I especially would like to thank my two daughters,

Sooah and Goeun for being my inspiration and for their patience and

confidence. I sent my heart felt appreciation to grandmother-in-law who took

care of my children for a long time.

Finally, my special gratitude goes to my wife Jungmyo, Shim for giving

me spiritual and moral support in every endeavor. She made sacrifices so that I

could pursue this vision. She was a constant source of encouragement. Thank

you.

- i -

Table of Contents

List of Figures ·····························································································ⅳ

List of Tables ······························································································ⅴ

Abstract ·······································································································ⅵ

ChapterⅠ ········································································································1

Introduction ·······························································································1

Chapter Ⅱ ·······································································································3

Effects of Manual Lymph Drainage on Cardiac Autonomic Tone in

Healthy Subjects (Experiment 1) ······························································3

Introduction ·······························································································3

Method ······································································································6

1. Subjects ·····························································································6

2. Experimental Protocol ·······································································7

3. MLD Procedure ·················································································9

4. ECG Recording and Analysis ·························································10

5. Measuring the PPT ··········································································12

6. Statistical Analysis ··········································································13

Results ·····································································································14

1. Descriptive Characteristics ·····························································14

2. ECG Measure ··················································································16

- ii -

3. PPT Measure ···················································································18

Discussion ·······························································································19

Conclusion ·······························································································23

Chapter Ⅲ ···································································································24

The Long-Term Effects of Manual Lymph Drainage-Based

Complex Decongestive Physical Therapy on Edema and the

Quality of Life in Breast Cancer Patients With Unilateral

Lymphedema (Experiment 2) ··································································24

Introduction ·····························································································24

Method ····································································································28

1. Subjects ···························································································28

2. Experimental Protocol ·····································································30

3. Edema Measurement and Analysis ·················································32

4. Statistical Analysis ··········································································34

Results ·····································································································35

1. Descriptive Characteristics ·····························································35

2. PCEV ·······························································································36

3. Measurement of QOL ······································································38

4. Relationship Between PCEV and QOL ··········································42

Discussion ·······························································································44

Conclusion ·······························································································49

Chapter Ⅳ ···································································································50

- iii -

Summary and Conclusion ·······································································50

References ···································································································51

Abstract in Korean ······················································································64

- iv -

List of Figures

Figure 1. Experimental 1 procedure for the determination of

manual lymph drainage effects on the heart rate

variability and pressure pain threshold ·········································· 8

Figure 2. Pictures before and after treatment ··············································· 37

Figure 3. Mean quality of life scores at baseline, 1 month, and

6 months in the physical functioning, social functioning,

role-physical, and role-emotional domains ·································· 40

Figure 4. Mean quality of life scores at baseline, 1 month, and

6 months in the mental health, vitality, bodily pain,

and general health domains ·························································· 41

- v -

List of Tables

Table 1. Homogeneity test for general characteristics and time-

and frequency-domain parameters of the subjects at baseline ······15

Table 2. Postintervention time-and frequency-domain results in

the experimental and control groups ·············································17

Table 3. Baseline, 1 month, and 6 months quality of life values

assessing functional status and well-being attributes of

patients with unilateral arm lymphedema ·····································39

Table 4. Pearson’s correlations between the percentage excess

volume and quality of life ·····························································43

- vi -

ABSTRACT

Effects of the Manual Lymph Drainage on Cardiac

Autonomic Tone, Lymphedema, and Quality of Life

Sungjoong Kim

Dept. of Rehabilitation Therapy

(Physical Therapy Major)

The Graduate School

Yonsei University

The purpose of this study was to investigate the effects of manual lymph

drainage (MLD) on the cardiac autonomic tone and the long-term physical and

psychological conditions in patients with breast cancer unilateral arm

lymphedema. The study was divided into two experiments. Experiment 1 was

done to investigate the effects of MLD on the cardiac autonomic tone. Thirty-

two healthy male subjects with no drug intake, musculoskeletal disorders,

- vii -

infection, pain, or history of treatment for thrombosis were randomly assigned

to experimental (MLD) and control (rest) group. MLD was applied with a

comfortable pressure for 40 minutes on the neck and abdomen in the

experimental group and the rest was allowed for 40 minutes for the control

group. Autonomic function was determined by time and frequency domain

analysis of heart rate variability (HRV). Data of HRV were recorded with

bipolar electrocardiography (ECG) using standard limb lead. The pressure pain

threshold (PPT) was quantitatively measured using a pressure algometer.

Unpaired t-tests were used to compare the cardiac autonomic tone and the PPT

between experimental and control group. Heart rate variability differed

significantly between the experimental and control group (p<0.05), but the

PPT in the upper trapezius muscle did not (p>0.05). These findings indicate

that the application of MLD was effective in reducing the activity of the

sympathetic nervous system. Experiment 2 was done to ascertain whether

MLD-based complex decongestive physiotherapy (CDP) for upper arm

lymphedema results in long-term changes in edema and quality of life (QOL),

using the SF-36 questionnaire and to determine the whether the treatment-

induced change in the percentage excess volume (PCEV) is correlated with

any changes in QOL. Fifty-three breast cancer patients who had unilateral

lymphedema were treated with MLD-based CDP. PECV and QOL was

- viii -

recorded before and 1 month after MLD-based CDP, and at a 6 months follow-

up visit. One-way analysis of variance (ANOVA) with repeated measures was

used to detect any significant effect of MLD-based CDP on the lymphedema

and QOL. Pearson’s correlation was calculated to examine the relationships

between PCEV and QOL. PCEV in breast cancer patients with lymphedema

was decreased significantly (p<0.05) at 1 month after MLD-based CDP, but it

increased significantly (p<0.05) at 6 months. The QOL scores at 1 and 6

months after MLD-based CDP were significantly higher than the baseline

scores, indicating an improvement in the QOL. Significant changes were also

evident in the single domains of physical functioning, role-physical, mental

health, and general health. The change in PCEV was associated with the

changes in physical functioning, vitality, bodily pain, and general health at 1

and 6 months after MLD-based CDP (p<0.05). Therefore, this study suggests

that QOL significantly improved with upper-arm lymphedema during the

maintenance phase, which was correlated with the reduction in limb volume.

- ix -

Key Words: Cardiac autonomic tone, Complex decongestive physiotherapy,

Lymphedema, Manual lymph drainage, Quality of life.

- 1 -

Chapter ⅠⅠⅠⅠ

Introduction

Manual lymph drainage (MLD), which was developed by a physical

therapist (Dr. Vodder), is a type of skin massage involving a range of

specialized hand movements designed to increase lymph flow and reabsorption

without increasing filtration (Kasseroller 1998; Wittlinger, and Wittlinger

1998). Gentle skin massage is thought to cause superficial lymphatic

contractions, thereby increasing lymph drainage. MLD generally forms the

main part of an intensive treatment regime (Chikly 2001).

The actual techniques of MLD are well documented and firmly established

as a preferred first-line treatment throughout Europe, North America, and

Australia. MLD is commonly prescribed by physicians, who recognize that the

removal of excess fluid expedites the healing process, and can be used in as

many as 60 different indications (Pollot 2001).

Numerous observational ‘before and after’ case studies and case series

published over many years have demonstrated that MLD is effective at

reducing the size of edematous limbs (Boris, Weindorf, and Lasinski 1997;

Foldi, and Foldi 1993; Ko et al. 1998; Olszewski 1991; Sitzia, and Sobrido

- 2 -

1997). MLD can be beneficial in the treatment of both lymphedema and

various other ailments. However, very few reported studies have actually

investigated the various effects of MLD on the body. Despite the increasing

popularity and availability of MLD, most studies into its efficacy have focused

on the physical reduction of edema, and hence the other effects of MLD

remain to be demonstrated.

The purposes of the present study were to elucidate the immediate effects of

MLD on the autonomic nervous system (ANS) in healthy subjects (experiment

1), and the long-term volumetric reductions in unilateral arm lymphedema and

the changes in the quality of life (QOL) after a intensive treatment course of

MLD-based complex decongestive physiotherapy (CDP) (experiment 2).

We hypothesized that in experiment 1 the MLD would (1) change the time-

and frequency-domain parameters of heart-rate variability, (2) decrease the

activities of the ANS and thereby affect the cardiac autonomic tone, and (3)

immediately increase the pressure pain threshold, and that in experiment 2 the

MLD-based CDP would (4) decrease edema and improve the QOL in the

maintenance phase and (5) reveal in a negative correlation between the QOL

and edema.

- 3 -

Chapter ⅡⅡⅡⅡ

Effects of Manual Lymph Drainage on Cardiac

Autonomic Tone in Healthy Subjects

(Experiment 1)

Introduction

Lymphedema is defined as a swelling of the extremity caused by insufficient

lymph drainage. There are two kinds of lymphedema, primary and secondary.

Primary lymphedema results from defects in the lymphatic system and is often

occurred at birth. Secondary can be associated with surgery, trauma, infection,

inflammation, cancer, and radiation (Brennan, DePompolo, and Garden 1996;

Olszewski 1991; Smeltzer, Stickler, and Schirger 1985). Although the exact

pathogenesis of lymphedema is often unclear, in most cases, it is caused by a

failure of the lymph pump (Mortimer 1998).

Lymphedema is not rare and troublesome complication in various medical

conditions such as cancer, trauma and infection. The deformity in body shape

can not be disguised with an ordinary dress; physically uncomfortable activity

- 4 -

and limbs disability are associated with expansion of edema and recurrent

episodes of cellulitis. Because of theses physical symptoms and its nonfetal

nature, patients may experience distress throughout life (Petrek, Pressman, and

Smith 2000). In this situation the sympathetic nervous system arousal is never

“turned off”, which makes the individual more vulnerable to infection (Selye

1978).

The methods for the treatment are debulking or reduction surgery, drug

therapy, MLD-based CDP, compression garments, pneumatic pump, mercury

compression, mesotherapy, ultrasound, elevation, and microwave and laser

therapies (Brennan, and Weitz 1992; Bunce et al. 1994; Cartier, Guilhem, and

Andrieu 1985). The best one of them is MLD-based CDP, which especially

includes MLD (Kasseroller 1998), even in the most advanced stages of

lymphostatic edema. Because it is a gentle, effective, cost-effective, safe, non-

invasive and reliable method that shows good long term results in both primary

and secondary lymphedema (Foldi, and Foldi 1993; Kasseroller 1998;

Olszewski 1991; Wittlinger, and Wittlinger 1998).

MLD affects the treatment of edema and acts on the body in various ways

(Chikly 2001), especially a calming effects on the sympathetic hyperactivity

that results from daily stress, the environment, and other factors (Wittlinger,

and Wittlinger 1998). This means that the appropriate application of MLD to

- 5 -

patients makes them calmer and more relaxed, with MLD having a tonic effect

on the smooth muscle of blood and lymph vessels that possess numerous nerve

endings with connections to the ANS (Foldi, and Foldi 1993; Kasseroller

1998; Weissleder, and Schuchhardt 2001; Wittlinger, and Wittlinger 1998).

That is, MLD is one of the therapies useful for treating lymphedema patients

with stress that result from autonomic-function imbalance. However, no

previous study has investigated the impact of MLD on ANS.

In recent years, noninvasive and sensitive indirect techniques have used

HRV as a marker of changes in the activity of the ANS (Kay 1987; Pagani, and

Malliani 2000; Stein 1994; Zefferino et al. 2003; Zhong et al. 2006). Analysis

of HRV can be used to identify cardiac autonomic disturbances (Kleiger et al.

1987; Pagani et al. 1988) and assess changes in sympathovagal tone in various

psychological (Carney et al. 1995) and emotional (McCraty et al. 1995;

Rechlin et al. 1994) states.

We are not aware of any reports on the effects of MLD on ANS using power

spectral analysis (PSA). In this study we investigated the effects of MLD on

the cardiac autonomic tone and evaluated the PPT as an index of psychological

outcomes of the treatment.

- 6 -

Method

1. Subjects

The sample comprised 32 normal, healthy male volunteers of Young-Dong

University, Republic of Korea. The participants were randomly assigned to an

experimental group (17 subjects) and a control group (15 subjects).

Participants were screened for inclusion/exclusion criteria. The inclusion

criteria were (1) normal skin with no preexisting skin conditions, (2) giving

informed consent, and (3) agreeing to adhere strictly to instructions. The

exclusion criteria included (1) history of treatment for thrombosis, (2)

compromised skin, such as irritation, excessive dryness, known presence of

eczema or psoriasis, or visible adverse condition (rash or infection), and (3)

taking any prescription drugs known to affect the cardiovascular system and

pain relief.

- 7 -

2. Experimental Protocol

Subjects were allowed to rest comfortably for at least 5 minutes prior to the

baseline recording procedure. Brief psychological stress (Kuriyama et al. 2005)

was induced to change the sympathetic activity by performing a serial

subtraction task (100 minus 7) for 2 minutes. Electrocardiography (ECG) was

recorded for 5 minutes, and PPT data were acquired prior to performing MLD.

Subjects in the experimental group received MLD to the neck and abdomen for

40 minutes, while the subjects in the control group relaxed by lying quietly for

the same time period. Data acquisition and MLD took place in a quiet

temperature-controlled environment (22~24℃). Conversation, phone calls,

and noise that could increase the activity of the SNS were minimized, and the

subject’s body was covered with a soft and thin sheet so as to avoid discomfort

from body exposure. ECG and PPT data were acquired immediately following

MLD in the experimental group and in the control group (Figure 1).

- 8 -

Figure 1. Experimental 1 procedure for the determination of manual lymph

drainage (MLD) effects on the heart rate variability and pressure

pain threshold (PPT).

- 9 -

3. MLD Procedure

Subjects were required to undress for MLD. Following baseline recordings,

they remained supine on the massage table. In order to maintain consistency,

an MLD therapist certified by Dr. Vodder’s school and physical therapist with

10 years of experience in the treatment of lymphedema performed MLD by

applying the same standardized procedures to the neck and abdomen. MLD

procedure, which took 40 minutes, employed the technique as described by Dr.

Vodder. The technique was applied in the areas of the neck and abdomen.

MLD procedure used in this study can be found in detail in the Textbook of Dr.

Vodder's Manual Lymph Drainage (Wittlinger, and Wittlinger 1998).

- 10 -

4. ECG Recording and Analysis

HRV was used to assess quantitatively the effect of MLD on cardiac

autonomic tone, since this is an objective index of the emotional responses to

stimuli (Pomeranz et al. 1985; Schumacher 2004; Task force of the European

Society of Cardiology and the North American Society of Pacing and

Elecrophysiology 1996). Heart rate data were acquired with bipolar

electrocardiography using standard limb lead positions for 5 minutes at

baseline and for 5 minutes immediately following MLD in a supine position.

The ECG electrodes were connected to a four-channel monitoring system

(QECG-3, LAXTHA, Korea) that satisfied the standard of the European

Society of Cardiology and the North American Society of Pacing and

Electrophysiology. A notebook computer was used for controlling the

experiments and storing the output data.

The ECG signals were digitized by a 12-bit analog-to-digital converter at

256 ㎐ and processed on a personal computer with a software peak detection

algorithm that located the R waves. This consisted of an automatic default

filtering procedure contained within the TeleScan software package

(LAXTHA) and also a careful inspection of the R-R-interval tachogram. The

- 11 -

tachogram was visually scanned to ensure the complete removal of abnormal

data.

The assessed time-domain indices were the mean heart rate, R-R interval,

the standard deviation of normal-to-normal cardiac interbeat (R-R) intervals

(SDNN), the root mean square of successive differences (RMSSD), and

pNN50%, and the frequency-domain indices were the total power, low

frequency (LF) power, high frequency (HF) power and the LF/HF ratio. Data

were computed off-line using TeleScan software.

- 12 -

5. Measuring the PPT

A pressure algometer was used (Algometer Commander, JTECH Medical,

USA) to determine the changes in muscle tension associated with changes in

ANS. Before the measurements, the subjects were asked to relax in a chair in

an upright position as the investigator explained the procedure to them. To

determine a baseline value, the investigator applied pressure to the upper

trapezius muscle on the dominant side which has received considerable

attention in clinical fields due to the high prevalence of work-related shoulder

and neck disorders (Madeleine et al. 2002; Maeda 1977; Schnoz, Laubli, and

Krueger 2000) until the subject experienced that the sensation of pressure

changed to pain. The pressure was increased at a constant rate of

approximately 0.5 kg/s. The recording was stopped immediately when the

subject reported the sensation change. The entire procedure was repeated three

times, with the mean value calculated for each muscle. Following MLD being

performed for 40 minutes, the PPT of the upper trapezius muscle was

immediately reassessed in the same manner as described above.

- 13 -

6. Statistical Analysis

Descriptive data are expressed here as mean and standard deviation (SD)

values. Testing of all variables using the one-sample Kolmogorov-Smirnov

test revealed that they were normally distributed. An unpaired t-test was used

to test for homogeneity and to compare the experimental group and control

groups for differences in HRV. The collected data were analyzed using

standard statistics software (SPSS ver. 12.0), and a probability of p<0.05 was

considered statistically significant.

- 14 -

Results

1. Descriptive Characteristics

The general characteristics and the time- and frequency-domain parameters

in the study of MLD on the cardiac tone did not differ statistically between the

two groups at baseline (p>0.05) (Table 1).

- 15 -

Table 1. Homogeneity test (mean ±SD) for general characteristics and time-

and frequency-domain parameters of the subjects at baseline

Variable Experimental

group (n1=17)

Control group

(n2=15) t p

Age (years) 21.16±1.24 20.95±1.37 0.46 0.65

Height (cm) 176.10±2.80 175.99±2.43 0.11 0.91

Weight (kg) 73.78±4.61 74.51±3.96 –0.48 0.63

Pressure Pain Threshold (kg) 9.97±2.01 10.15±1.62 –0.27 0.79

Time-domain parameters

Heart rate (beats/minute) 72.71±1.39 72.77±2.03 –0.11 0.91

R-R interval (ms) 834.29±40.69 827.75±17.58 0.58 0.57

Standard deviation of

interbeat intervals (ms) 62.30±2.77 60.50±4.65 1.35 0.19

Root mean square of

successive differences (ms) 38.97±1.43 37.47±9.35 0.65 0.52

pNN50 (%) 5.94±0.50 5.93±0.88 0.06 0.95

Frequency-domain

parameters

Total power (ms2) 2912.59±344.63 2824.20±317.44 0.75 0.45

Low frequency power (ms2) 1512.94±157.52 1555.87±136.91 –0.82 0.42

High frequency power (ms2) 633.47±162.60 656.53±173.61 –0.39 0.70

Low frequency to high

frequency ratio 2.81±0.39 3.01±0.51 –1.32 0.19

- 16 -

2. ECG Measures

The postintervention R-R interval, SDNN, RMSSD, and pNN50 (%) value

were significantly higher in the experimental group than in the control group

(Table 2) (p<0.05). Moreover, the heart rate was significantly reduced in the

experimental group, as indicated by an increase in the average R-R-interval

length (p<0.05). The postintervention total power and LF/HF ratio differed

significantly between the groups (p<0.05), with the latter being significantly

lower in the experimental group.

- 17 -

Table 2. Postintervention time- and frequency-domain results in the

experimental and control groups

Variables Experimental

group (n1=17)

Control group

(n2=15) t p

Time-domain parameters

Heart rate (beats/minute) 68.39±2.11* 71.15±1.45 4.24 0.00

R-R interval (ms) 879.88±51.41 830.35±42.07 2.96 0.01

Standard deviation of interbeat intervals (ms)

70.72±7.52 65.02±4.74 2.53 0.02

Root mean square of successive differences (ms)

50.58±6.31 38.77±10.90 3.81 0.00

pNN50 (%) 7.54±1.27 5.93±0.98 3.98 0.00 Frequency-domain

parameters

Total power (ms2) 3771.47±538.37 3168.07±443.94 3.43 0.00

Low frequency power (ms2) 1844.00±279.50 1817.20±300.77 0.26 0.79

High frequency power (ms2) 1459.18±258.74 1268.73±222.43 2.22 0.03

Low frequency to high frequency ratio

1.28±0.17 1.46±0.28 –2.28 0.03

*mean ±SD.

- 18 -

3. PPT Measures

Pain threshold responses to treatment were assessed as changes in muscle

tension as a result of changes to the ANS according to pressure algometer

results. The mean (±SD) PPT were 11.14±2.32 kg for the experimental group

and 10.18±1.72 kg for the control group. There were no significant differences

between the groups after intervention (p>0.05).

- 19 -

Discussion

This is the first study to examine the effects of MLD using HRV analysis to

measure cardiac autonomic tone in healthy college students. It has been

reported that physical and psychological stress can change HRV; heart rate

being reduced and stabilized during relaxation or proper stimulation (Haker,

Egekvist, and Bjerring 2000). We found that R-R interval, SDNN, RMSSD,

and pNN50 (%) value in time domain were higher in the experimental group,

and heart rate and the LF/HF ratio were lower following MLD application. The

results of the study suggest that MLD for 40 minutes is highly effective in

increasing HRV and cardiac parasympathetic activity in normal subjects. Lee

et al. (2004) have demonstrated that physical and psychological stresses can

reduce the heart rate during experimental measurements. Delaney et al. (2002)

reported a significant increase in HF power following trigger-point massage.

Haker, Egekvist, and Bjerring (2000) also reported that a significant decrease

in the heart rate frequency and increase in the HF component of HRV at the

end of the post-stimulation period by acupuncture. Possibly, these explain the

relaxation, calmness and reduced feelings of distress commonly experienced

- 20 -

by the patients with the increase in PNS activity (Benson, Beary, and Carol

1974).

Not only has massage such as MLD to be used in this study recently become

popular as part of the conservative treatment, but it also received nonobjective

support for reducing pain and alleviating stress, depression, and anxiety in the

context of various physical and psychiatric disorders. The PSA of HRV has

been used as a sensitive index of autonomic nervous activity that provides

quantitative information on autonomic control mechanisms (Malliani et al.

1991; Pagani et al. 1986; Pomeranz et al. 1985; Task force of the European

Society of Cardiology and the North American Society of Pacing and

Elecrophysiology 1996). There are two approaches to measurement of HRV:

analysis in the time (Kleiger et al. 1992) or in the frequency domain (Malliani

et al. 1991; Malliani, Lombardi, and Pagani 1994). These measures are based

on the analysis of interbeat intervals of normal beats. Time domain based on

interbeat intervals includes SDNN, RMSSD and pNN 50 (%). Frequency

domain includes total power, HF, LF and the LF/HF ratio (Malliani et al. 1991;

Schumacher 2004; Stein et al. 1994). HF component of HRV visualize the

component of parasympathetic activity on HRV (between 0.15 and 0.4 Hz),

and LF component of HRV may be considered as a marker sympathetic

activity associated with components around 0.1 Hz on HRV (Benson, Beary,

- 21 -

and Carol 1974; Kay 1987; Stein et al. 1994; Sztajzel 2004). The lower LF/HF

ratios measured in experimental group suggests that vagal drive is increased

when compared to control sessions (p<0.05), this results suggests a shift

toward cardiac parasympathetic activity. MLD may be able to decrease

sympathetic responses and increase parasympathetic responses in the

neuromuscular system (sympathicolytic action).

By stimulating parasympathetic tone, MLD can cause relaxation, antispastic,

and antalgic effects. Light rhythmic stimulation such as MLD of the skin

nonnociceptive receptors may have a pain-inhibiting effect (Pagani et al. 1988).

In the gate control theory of pain, Wall, and Melzack (1994) explain how

nonnoxious sensory stimulation can help to reduce the intensity of pain.

Many clinical applications of the pressure algometer have been documented,

including evaluation (Fischer 1988) and identification of trigger points, and

evaluation of pain sensitivity (Fischer 1987). The PPT of a muscle is the

pressure level at which the patient reports that the feeling of pressure changes

into a painful sensation (Fischer 1987). Autonomic nerves extend to all parts

of the skin; blood vessels, lymphatic vessels, and soft connective tissue ground

substance. Inputs from the special senses acting via the limbic system and

hypothalamus have an effect on the responses of the ANS (Ebner 1985;

Wittlinger, and Wittlinger 1998). Although the PPT was not differed

- 22 -

significantly between the experimental and the control group, there was

increased in pain threshold in the experimental group following MLD from

9.97±2.01 kg to 11.14±2.32 kg.

The present results indicate that sensory stimulation during MLD is

associated with change of various components in the time and frequency

domain of HRV reflecting changed from the sympathetic activity to

parasympathetic activity.

MLD seemed to make the experimental group more comfortable than the

control group. Light, soft, and rhythmical massage can reduce stress in

experimental group, thereby improving their psychological state. These

relaxation factors reduced the HR and stabilized the sympathetic nervous

system, with a corresponding decrease in LF/HF in experimental group

compare to control group. Our study reveals that MLD reduces negative

psychological factors, such as stress, depression, anxiety, compared to the rest.

These effects may induce stabilization of the SNS and cardiac autonomic tone.

Under correct physical therapist’s instruction, MLD could be taught to the

caregivers of lymphedema patients for reducing the physical problems that are

caused by the physical and psychological harmful stress and decreasing the

lymphedema by stimulating the lymphangiomotoricity.

- 23 -

Conclusion

The data presented here suggest that MLD is highly effective in increasing

HRV and cardiac parasympathetic activity in normal subjects, as demonstrated

in the time domain by a decrease in heart rate and increases in SDNN and

RMSSD, and in the frequency domain by an increase in the total power and a

decrease in the LF/HF ratio. These results suggest that MLD could help reduce

stress and improve autonomic function by increasing HRV and

parasympathetic activity. Further study is needed to identify the effects of

MLD on the edema.

- 24 -

Chapter ⅢⅢⅢⅢ

The Long-Term Effects of Manual Lymph Drainage -

Based Complex Decongestive Physical Therapy on

Edema and the Quality of Life in Breast Cancer

Patients With Unilateral Lymphedema

(Experiment 2)

Introduction

The incidence of breast cancer continues to rise in South Korea (Kim 2005).

However, improvements to disease management have led to a well-publicized

recent decline in breast cancer deaths (Peto et al. 2000) and a concomitant

greater emphasis on the side effects of treatment (Pain, Vowler, and

Purushotham 2003). Breast-cancer-related lymphedema due to impaired

lymphatic drainage from the arm secondary to axillary surgery and/or

radiotherapy is one of the common side effects, occurring in 12~28% of cases

(Clark, Sitzia, and Harlow 2005; Meric et al. 2002). Lymphedema is a chronic

- 25 -

condition because it is not possible to reverse the damage responsible for the

swelling. Affected patients have an unsightly, uncomfortable arm that is prone

to repeated episodes of infections, with the rare – but potentially fatal –

complications of secondary lymphangiosarcoma (Foldi 1998). Several physical

and emotional factors are related to lymphedema (MacWayne, and Heiney

2005; Passik, and McDonald 1998), including increased weight of the

edematous limb with restricted motion aggravated by fibrosis and joint

contracture, and altered sensitivity and embarrassment during social

interactions (Didem et al. 2005; Liao et al. 2004).

The main aim of treatment is not cure but to reduce the limb size, usually

via MLD, skin care, remedial exercise, compression garments, pneumatic

pump, mercury compression, elevation, and microwave and laser therapies

(Brennan, and Weitz 1992; Bunce et al. 1994; Cartier, Guilhem, and Andrieu

1985). Treatment involving combined therapies was developed in Europe in

the 1930s and was introduced to South Korea in the 1990s (Kim 2002). One

such treatment, MLD-based CDP is now recognized as an effective

nonsurgical technique for managing lymphedema, and is recommended by the

International Society of Lymphology (Lymphology Executive Committee

1995). Most studies into upper-arm lymphedema have focused on the physical

aspects using volumetric measurements of the limb as the primary tool (Sitzia,

- 26 -

Stanton, and Badger 1997). Since patients with lymphedema experience a wide

range of psychological and physical difficulties, including depression,

embarrassment, resentment, poor body image, impaired limb movement,

impaired physical mobility, and pain (Sitzia, and Sobrido 1997), they would

probably benefit from treatment being assessed using a broader clinical

approach based on the QOL (Pereira de Godoy et al. 2002). Evaluating the

QOL is becoming an increasingly important issue in breast cancer patients

with lymphedema, and the emotional, social, psychological, and sexual effects

of breast cancer treatment have been studied (Ganz 1997; Lee 1997; Moyer

1997).

The SF-36 (Medical Outcome Study 36–Short Form) is a potentially useful

instrument used for evaluating the QOL in cancer patients with lymphedema

(Jager, Doller, and Roth 2006; McKenzie, and Kalda 2003; Pereira de Godoy

et al. 2002; Velanovich, and Szymanski 1999). The SF-36 is potentially useful

instrument to evaluate the QOL and its reliability and validity are well

established (Ware, Kosinski, and Gandek 2004). This measure contains eight

subscales relevant to the health of the individual: physical functioning (PF),

role-physical (RP), role-emotional (RE), mental health (MH), bodily pain (BP),

general health (GH), vitality (VT), and social functioning (SF). The responses

to the SF-36 are transformed into the concepts to provide a scale from zero

- 27 -

(worst possible score) to 100 (i.e., the optimal level of health in that domain)

(Ware, Kosinski, and Gandek 2004). Though a great deal of research has

aimed at understanding the QOL of breast cancer patients with lymphedema,

such interventional studies with MLD-based CDP have generally been

undertaken in small number of patients (Moffatt et al. 2003; Pereira de Godoy

et al. 2002; Sitzia, and Sobrido 1997; Weiss, and Spray 2002), typically less

than 50 in subjects, using nonvalidated QOL tools (McKenzie, and Kalda

2003), or have used a combination of patients with arm and leg edema (Pereira

de Godoy et al. 2002; Sitzia, and Sobrido 1997; Weiss, and Spray 2002). Also,

few papers have reported follow-up assessments of arm lymphedema and QOL

after MLD-based CDP.

The purpose of this study was to ascertain the long-term physical and

psychological impacts of MLD-based CDP treatment for arm lymphedema,

and to determine whether limb volume changes resulting from of MLD-based

CDP treatment are associated with changes in the QOL.

- 28 -

Method

1. Subjects

Data were collected from breast cancer patients who had experienced

lymphedema and who had been referred by a physician for lymphedema

treatment to three outpatient physical therapy clinics in South Korea from

March 1, 2003, through October 30, 2005. The inclusion criteria were as

follows: (1) being female, (2) aged at least 19 years, (3) no known neurological

disorder that would interfere with completion of the measures, (4) able to

complete a questionnaire, (5) no history of treatment for other types of cancer,

(6) no known untreated or unstable medical conditions, (7) no edema in lower

limbs, (8) completed adjuvant chemotherapy, radiation, and surgical treatments

for breast cancer at least 3 months and a most 5 years previously, (9)

agreement to fully receive decongestive treatment five times per week, and

(10) unilateral upper-arm lymphedema. Seventy-eight patients met all of these

eligibility criteria, of which seven refused to participate and three were

excluded since they had active disease and/or were receiving treatment for

recurrent cancer. Five patients did not visit the clinic during the follow-up

- 29 -

period, one patient died, nine patients refused to complete the SF-36 and

volume measurements in follow-up assessments (five patients became too ill

or physically or mentally tired to respond, and four patients declined to

participate due to their personal reasons). The total number of subjects who

successfully complete this study was 53 (N=53, 67.9%).

- 30 -

2. Experimental Protocol

Informed consent was obtained before performing a clinical examination

and documenting general characteristics. Each patient received of MLD-based

CDP treatment, which consisted of a “decongestive phase” that lasted 2–4

weeks, during which the patients received treatment daily. The patients then

followed a “maintenance phase” of self-care for the rest of their lives. The

decongestive phase programs consisted of MLD, compression bandaging,

remedial exercise, and skin care, with each MLD session lasting 45~60

minutes. Treatments were performed by physical therapists certified in

Vodder’s technique of MLD who had at least 5 years of experience of treating

lymphedema. A low-pH skin lotion (Eucerin, Beiersdorf, Norwalk, CT) was

applied prior to bandaging the limb using padding (Artiflex, Beiersdorf) and

low-stretch bandages (Rosidal K, Lohmann, Neuwied, Germany). The protocol

also included teaching the patients to perform self-edema-control activities

(e.g., self-administered MLD, exercise, self-applied bandages or compression

bandage, and skin care) that were to be continued at home in the maintenance

phase. Patients were issued with compression garments as a final component

of the treatment. The protocol in the maintenance phase consisted of wearing

compression bandages or hosiery at all times, a daily session of self-

- 31 -

administered MLD, skin care, and an exercise program. The use of daytime

bandages on at least three days per week was recommended during the

maintenance phase. During the maintenance phase, follow-up visits were

scheduled at 1 month and 6 months after treatment.

- 32 -

3. Edema Measurement and Analysis

A trained physical therapist measured the arm circumference at six locations

(hand, wrist, forearm, elbow, and two locations on the upper arm) using a tape

measure along the lateral aspect in each upper arm (Kim, Yang, and Yi 2000)

before treatment (baseline) and at 1 and 6 months after treatment.

Lymphedema volume was calculated using the truncated cone formula:

volume=H(C2+Cc+c2)/12π, where H=height, C=circumference of the top of

the cone, and c=circumference of the base of the cone (Boris, Weindorf, and

Lasinski 1997; Ko et al. 1998; Weiss, and Spray 2002). This method

demonstrated excellent inter- and intraexaminar reproducibility in comparison

to water displacement, which is considered the gold standard (Galland et al.

2002; Megens et al. 2001).

Each segment was measured three times, and the average reduction in arm

circumference was calculated by the following formula with the unaffected

limb used as a normal control for the affected limb (percentage excess volume;

PCEV): PCEV = [(affected volume – unaffected volume)/unaffected volume]

× 100.

Patients also completed the SF-36 questionnaire (Korean version,

QualityMetric Incorporated, Lincoln, RI) at the initial visit and 1 month after

- 33 -

completion of the decongestive phase, and then at 6 months after treatment in

the clinic.

- 34 -

4. Statistical Analysis

Descriptive data are expressed here as mean and SD values. Testing of all

variables using the one-sample Kolmogorov-Smirnov test revealed that they

were normally distributed. One-way analysis of variance (ANOVA) with

repeated measures was used to detect significant effects of MLD-based CDP

on the lymphedema and QOL. All was three time points: baseline, one-month

post-treatment and 6 months post-treatment. In the event of significant values

of F in the ANOVA, the Bonferroni’s correction test of critical differences was

used to detect significant differences between means. Pearson’s correlation

coefficients were calculated to examine the relationships between the PCEV

and QOL. The collected data were analyzed using standard statistics software

(SPSS ver. 12.0), and a probability of p<0.05 was considered statistically

significant.

- 35 -

Results

1. Descriptive Characteristics

The fifty-three patients in the study of MLD-based CDP on the lymphedema

and QOL were aged 51.0±6.7 years, and their body mass index was 19.0~30.7

(23.9±3.3) kg/m2. Forty-six patients (86.7%) were educated to at least high

school level, and 28 patients (52.8%) were not currently working. The majority

(92.4%) of patients reported a high or moderate economic status, and 44

patients (83.0%) were married. Thirty-four patients (64.2%) had received both

surgery and radiotherapy for cancer, with the length of time since

surgery/radiotherapy being 0.3~4.7 (2.5±1.5) years.

- 36 -

2. PCEV

The PCEV differences between the abnormal and normal arms at baseline, 1

month, and 6 months after treatment were 49.28±21.98%, 28.66±11.29%, and

41.64±17.31%, respectively. The PCEV was higher at baseline than at 1 and 6

months, and was higher at 6 months than at 1 month. However, it generally

decreased significantly during the decongestive and maintenance phases

(p<0.05). Figure 2 is an example of edema reduction in upper lymphedema

after MLD-based CDP.

- 37 -

Figure 2. Pictures before and after treatment. A, lymphedema after

mastectomy before manual lymph drainage - based complex

decongestive physiotherapy. B, The same patient after 1 month of

treatment.

- 38 -

3. Measurement of QOL

Table 3 presents the mean scores of all domains of the SF-36 for the patients.

The scores for the PF (p=0.004), RP (p=0.001), MH (p=0.004), and GH

(p=0.020) domains differed significantly among baseline, 1 month, and 6

months after treatment. Figures 3 and 4 illustrate the differences between the

mean scores after post-hoc test. The scores in the PF, RP, and GH domains

were significantly higher at 6 months after treatment than at baseline,

indicating an improved QOL in these domains at 6 months after treatment. The

score in the MH domain was significantly higher at 1 month after treatment

than at baseline.

- 39 -

Table 3. Baseline, 1 month, and 6 months quality of life values assessing

functional status and well-being attributes of patients with unilateral

arm lymphedema

Baseline 1 month 6 months p

Functional status

Physical functioning 61.25±16.10* 64.68±15.87 67.30±13.51 0.004

Social functioning 64.30±21.83 63.54±18.26 69.59±16.98 0.098

Role-physical 52.34±16.97 54.76±17.18 55.55±14.73 0.001

Role-emotional 52.53±24.90 55.10±16.41 57.81±17.76 0.184

Well-being

Mental health 54.11±16.84 59.47±20.09 58.79±14.79 0.004

Vitality 57.83±18.31 59.53±20.02 59.86±17.70 0.250

Bodily pain 61.28±22.00 63.13±23.53 66.20±22.63 0.782

General health 64.36±16.76 66.85±16.52 71.91±19.29 0.020

* mean ±SD.

- 40 -

Figure 3. Mean quality of life (QOL) scores at baseline, 1 month, and 6 months

in the physical functioning (PF), social functioning (SF), role-

physical (RP), and role-emotional (RE) domains.

- 41 -

Figure 4. Mean quality of life (QOL) scores at baseline, 1 month, and 6 months

in the mental health (MH), vitality (VT), bodily pain (BP), and

general health (GH) domains.

- 42 -

4. Relationship Between PCEV and QOL

The PCEV of edema was negatively correlated with SF-36 subscales (Table

4), including functioning at baseline (r=–0.55, p<0.01), 1 month after

treatment (r=0.46, p<0.01), and 6 months after treatment (r=–0.50, p<0.01),

VT at 1 month (r=–0.27, p<0.05) and 6 months after treatment (r=–0.42,

p<0.05), BP at 1 month (r=–0.28, p<0.015) and 6 months after treatment (r=–

0.51, p<0.01), and GH at 1 month (r=–0.30, p<0.05) and 6 months after

treatment (r=–0.55, p<0.01).

- 43 -

Table 4. Pearson’s correlations between the percentage excess volume and

quality of life

Before (baseline) 1 month 6 months

Functional status

Physical functioning –0.55** –0.46** –0.50**

Social functioning –0.18 –0.25 –0.18

Role-physical –0.19 –0.10 –0.16

Role-emotional –0.26 –0.15 –0.11

Well-being

Mental health –0.22 –0.23 –0.50

Vitality –0.15 –0.27* –0.42*

Bodily pain –0.19 –0.28* –0.51**

General health –0.19 –0.30* –0.55** *p<0.05; ** p<0.01.

- 44 -

Discussion

Lymphedema can be viewed as a QOL issue due to the difficulties in causes

in functioning at work or at home, altered body image, low self-esteem,

difficulty dressing, and a loss of interest in social activities (Carter 1997; Sitzia,

and Sobrido 1997; Wood, Tobin, and Mortimor 1995). This study was

undertaken to examine whether the QOL at long-term follow-up was improved

in breast cancer patients with lymphedema following MLD-based CDP, and

whether limb volume changes were associated with any detected changes in

the QOL.

During the decongestive phase, we noted that the PCEV decreased from

49.29±21.98% at baseline to 28.66±11.29% at 1 month after treatment. The

percentage reduction in the lymphedema volume has varied from 20% to 80%

in previously published series, but these have employed diverse calculation

formulas (e.g., in terms of the perimeter measures used and different intervals

between the two measures) (Boris, Weindorf, and Lasinski 1994; Casley-Smith,

and Casley-Smith 1992; Foldi, Foldi, and Clodius 1989; Ko et al. 1998). There

was a small increase in the lymphedema volume during the maintenance phase.

Boris, Weindorf, and Lasinski (1997) reported that the maintenance of reduced

- 45 -

lymphedema volume depend on the compliance. Foldi, Foldi, and Clodius

(1989) found in a 3-year follow-up that more than 50% of the patients

maintained the initial reduction in lymphedema obtained after the decongestive

phase.

We found that the self-reported PF, RP, MH, and GH scores were

significantly changed by MLD-based CDP treatment. Sitzia, and Sobrido

(1997) reported similar improvements in the QOL of patients following MLD

with multilayered bandaging or simple massage with multilayered bandaging.

Based on the Nottingham Health Profile Part 1 (NHP-1), they reported that

patients had the greatest improvement in physical attributes. They also

concluded that the NHP-1 was useful in assessing physical aspects of the QOL,

but less helpful with regard to psychological and emotional attributes. In

contrast, we found that using the SF-36 resulted in the detection of significant

changes in physical, functional, and psychosocial posttreatment measures.

Weiss, and Spray (2002) also reported the MLD-based CDP improved the

QOL of patients with peripheral lymphedema due to various causes. The trend

toward increases in PF scores in the study participants supports the theory that

MLD-based CDP is beneficial for women with secondary lymphedema after

breast cancer treatment. Subjects expressed greater confidence in using their

affected arm for activities of daily living, and some mentioned that they were

- 46 -

again able to lift objects with the affected arm after the decongestive phase.

This may explain the trend toward increased RP, MH, and GH scores, in as

much as the subjects were less aware of their disease, were confident that

MLD-based CDP prevents the edema from increasing, and therefore felt

healthier overall. Although the lymphedema volume was increased at 6 months,

the data showed trends toward increases in almost all domains of the SF-36. A

recent similar study (Mondry, Riffenburgh, and Johnstone 2004) investigated

the long-term effects of MLD-based CDP in 20 patients with breast-cancer-

related lymphedema, and found similar results for QOL: there was no

significant change in QOL immediately after treatment, but QOL scores had

consistently increased by 6 months. These observations suggest that MLD-

based CDP programs improve the QOL .

The study reported here differs from previous evaluations (Pereira de Godoy

et al. 2002; Weiss, and Spray 2002) of changes in the QOL in lymphedema

patients following MLD-based CDP, in that it included only breast cancer

patients with lymphedema and reported follow-up assessments of QOL after

MLD-based CDP. In contrast, the studies of Pereira de Godoy et al. (2002) and

Weiss, and Spray (2002) involved patients with multiple diseases (and only a

small number of breast cancer patients with lymphedema) and reported only

short-term results.

- 47 -

Despite MLD-based CDP inducing significant edema volume reductions,

the results from this study did not support an association between limb volume

reduction and scores in any of the domains of the SF-36 except for the PF

score at baseline, an association between limb volume reduction and scores

that is supported by Mondry, Riffenburgh, and Johnstone (2004), Sitzia,

Stanton, and Badger (1997), and Weiss, and Spray (2002). But the significant

correlations at 1 and 6 months after treatment (i.e., in the maintenance phase)

support an association with PF, VT, BP, and GH. The lack of association

suggests that a reduction in the edema volume is only partly responsible for an

improvement in the QOL. It is therefore reasonable to postulate that education

programs for edema control influence the association between limb volume

reduction and the QOL. These data highlight the importance of broadening

care to treat these patients beyond the physical aspect of lymphedema, and they

also suggest that more-effective treatment of the physical condition increases

the likelihood of the emotional and social statuses also improving. Nonetheless,

a multidisciplinary approach is desirable for optimizing the QOL of a patient

with lymphedema.

The main strengths of our study were to deal only with patients with

lymphedema after breast cancer. The treatment was homogeneous and

provided by physiotherapists who specialized in lymphology. The intensive

- 48 -

treatment program allowed education, giving advice about avoiding infection

such as cellulitis, and learning self-bandaging and self-administered MLD.

However, the limitations of this study mean that its results must be interpreted

cautiously. These included the absence of a nontreatment control group, which

meant that the effects of MLD-based CDP on the QOL could not be

distinguished from the effects of simply participating in a clinical research

study. Moreover, the extent to which improvements in edema volume and the

QOL are attributable to poor internal validity factors such as measurement

errors, testing effects, and statistical regression could not be determined.

Twenty-five (32.0%) of the original sample of 78 patients were missed during

follow-up, of whom 9 withdrew due to recurrent cancer, death, illness, or

fatigue, and the others did not complete the study due to poor motivation. We

consider this to be an acceptable attrition rate for a sample of mostly older

women who had received treatment for breast cancer. In such populations the

persuasive power of the researchers may be very important to ensuring active

participation by patients. Although the loss to follow-up might have introduced

bias, our findings suggest that the MLD-based CDP program induced

lymphedema management that had a substantial impact on the QOL.

- 49 -

Conclusion

The data presented here suggest that MLD-based CDP reduce the

lymphedema in breast cancer patients with unilateral lymphedema. PF, RP,

MH, and GH scores in the maintenance phase were significantly higher than

the pre-treatment scores and QOL correlated with the reduction in limb

volume in the domain of PF, VT, BP, and GH. The findings reported here

emphasize the effect of MLD-based CDP to reduce the edema and the need to

evaluate the long-term QOL in patients with lymphedema, and not merely to

measure the limb volume. Further studies are needed to compare the effects of

different modalities of treatment on the QOL of patients with various

characteristics and clinical symptoms.

- 50 -

Chapter ⅣⅣⅣⅣ

Summary and Conclusion

MLD can increase parasympathetic activity and decrease sympathetic

activity through stabilization of the autonomic system. Therefore, it can reduce

the physical problems that are caused by the physical and psychological

harmful stress and decrease the lymphedema by stimulating the contraction of

lymphatic vessels whose activities are regulated by the ANS.

- 51 -

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국문 요약

MLD 가가가가 심장심장심장심장 자율신경자율신경자율신경자율신경 긴장도긴장도긴장도긴장도, 림프부종림프부종림프부종림프부종, 그리고그리고그리고그리고

삶의삶의삶의삶의 질에질에질에질에 미치는미치는미치는미치는 영향영향영향영향

연세대학교 대학원

재활학과(물리치료학 전공)

김 성 중

본 연구의 목적은 MLD 가 심장 자율신경 긴장도와 편측 상지

림프부종이 있는 유방암 환자의 장기적 신체적, 정신적 상태에 미치는

영향을 알아보는 것이었다. 연구는 두 단계로 나뉘어 실시되었다. 연구

1 은 MLD 가 심장 자율신경 긴장도에 미치는 영향을 조사하는 것이었다.

약 복용, 근골격계 질환, 감염, 통증, 또는 혈전 치료에 대한 병력이 없는

32 명의 건강한 성인 남자를 무작위로 실험(MLD)군과 대조(휴식)군에

무작위로 할당하였다. 실험군에는 MLD 를 40 분 동안 목과 복부에 편안한

압력으로 적용하였고 대조군은 40 분간 안정을 취하도록 하였다. 자율신경

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기능을 심박수 변이도의 시간과 주기 영역 분석을 이용하여 측정하였으며

자료는 표준 사지유도법을 이용하여 심전도로 기록 되었다. 압통역치는

통각측정기를 이용하여 정량적으로 측정하였다. 실험군과 대조군의 심장

자율신경 긴장과 압통역치를 비교하기 위해 독립 t 검정을 사용하였다.

심박수 변이도는 실험군과 대조군에서 통계적으로 유의한 차이를

보였으나(p<0.05), 상부 승모근에서의 압통 역치는 유의한 차이를 보이지

않았다 (p>0.05). 이런 결과는 MLD 적용이 자율신경계 활동성을

감소시키는데 효과가 있다는 것을 의미한다. 연구 2 는 MLD-기반 복합적

부종 감소 물리치료가 상지 림프부종에 장기적으로 부종과 SF-36

설문지를 이용한 삶의 질 평가에 어떠한 영향이 있는지를 알아보고

치료로 인한 부종 과용적률의 변화와 삶의 질 변화가 어떤 상관성이

있는지를 알아보았다. 53 명의 편측 림프부종을 가지고 있는 유방암

환자에게 MLD-기반 복합적 부종 감소 물리치료를 실시하였다. 부종

과용적률과 삶의 질을 치료 전, 치료 후 1 달, 그리고 6 개월 후에

측정하였다. MLD-기반 복합적 부종 감소 물리치료가 림프부종과 삶의

질에 어떤 유의한 효과가 있는지를 반복 측정된 일요인 분산분석으로

알아보았고 부종 과용적률과 삶의 질과의 상관성은 피어슨 상관계수를

이용하였다. 림프부종이 있는 유방암 환자의 부종 과용적률은 치료 한달

후에는 유의하게 감소하였으나 (p<0.05) 6 개월 후에는 유의하게

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증가하였다 (p<0.05). 삶의 질 점수는 치료 시작 전보다 치료 후 한달

그리고 6 개월 후에 유의하게 향상되어 삶의 질이 개선되었음을 알 수

있었다. 신체적 기능, 신체적 역할, 정신 건강, 그리고 일반적 건강의 개별

영역에서 유의한 변화를 보였다. 부종 과용적률의 변화는 치료 후 한 달과

6 개월 후에서 신체적 기능, 활력, 신체 통증, 그리고 일반적 건강과

상관관계가 있는 것으로 나타났다. 결국, 본 연구는 상지 림프부종이 있는

환자의 부종 유지기 동안에 체지 용적 감소와 상관관계가 있는 삶의 질이

MLD-기반의 치료를 통해 개선이 되었다는 것을 보여 주었다.

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핵심되는 말: 림프부종, 복합적 부종감소 물리치료, 삶의 질, 심장

자율신경 긴장도, MLD.