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Across these 12 studies, 1 study compared the effects of low-level laser therapy with MLD, [ 22 ] 1 study compared the effects of electrotherapy with MLD, [ 9 ] 1 study compared the effects of sequential pneumatic compression with MLD, [ 24 ] and 2 studies compared the effects of SLD with MLD [ 10 , 27 ] on reducing arm volume in the affected arm.

Five studies investigated the effect of MLD on the prevention of the incidence of lymphedema in patients after breast cancer surgery.

Of the 17 included studies, the methods of randomization for 8 studies were sufficient, the method of allocation concealment for 7 studies was acceptable, 6 studies used the assessor blinded method, and 1 study used the patient blinded method. In general, 12 eligible RCTs demonstrating the effect of MLD on treating lymphedema were published between and and had sample sizes ranging from 24 to 73 subjects.

Among the 12 eligible RCTs, 8 RCTs were examined by carrying out a meta-analysis including patients that used the same result evaluation indexes. Several subgroup analyses were carried out to explore the potential sources of interstudy heterogeneity on the estimated effect size.

Although substantial statistical heterogeneity was noted in this meta-analysis, almost all of the 8 included studies showed a similar direction of effect, thus demonstrating that some of the heterogeneity was mainly attributed to a variation in the magnitude of the estimated risk instead of the direction.

However, due to the limited number of included studies, we should interpret this finding with caution. Trim and fill methods were conducted to analyse the sensitivity analysis and the results indicated 1 missing study in the funnel plot Fig. Therefore, the results of this study were eligible and seemed to not be affected by publication bias. Moreover, we carried out a sensitivity analysis by excluding 1 trial each time and then recalculating the pooled SMD for the remaining trials to test the effect of each study on the overall estimates, which did not show an alteration of estimate when any one of the included trials was excluded Fig.

Duval's nonparametric trim and fill procedure for the effect of MLD on the reduction of post-mastectomy lymphedema in 8 RCTs. With regard to the remaining 4 studies, patients demonstrating the effect of MLD on the treatment of lymphedema were not pooled in the meta-analysis. The data reported by Ridner et al and Szolnoky et al were not pooled because the method used to measure the change in lymphedema volume was a circumferential measurement.

Five RCTs including patients reported the effect of MLD on the prevention of lymphedema in patients after breast cancer surgery. Zimmermann et al demonstrated that MLD applied immediately after breast cancer surgery prevented secondary lymphedema of the arm regardless of the surgery type at 6 months.

In fact, we found that MLD could significantly prevent the risk of lymphedema in patients after breast cancer surgery within a 1-month period RR 0.

The results, however, should be interpreted with caution due to the limited number of studies. We also conducted a sensitivity analysis by excluding 1 RCT each time and then recalculating the pooled RRs for the remaining RCTs to test the effect of each study on the overall estimates. We did not find an alteration of the estimate when any one of the included RCTs was excluded Fig. The current systematic review and meta-analysis were conducted to assess the effectiveness of MLD on lymphedema after breast cancer surgery.

The results of 8 RCTs that compared the effect of MLD with other therapies on the treatment of lymphedema related to breast cancer were summarized, which showed that MLD added no benefit in reducing the arm volume of the affected side. This estimated effect persisted in the analysis stratified by research region, publication year, sample size, type of surgery, statistical analysis method, mean age, and intervention time. The robustness effect was also confirmed by the trim and fill method and sensitivity analysis.

Meanwhile, 4 RCTs comparing the effects of MLD with standard therapy on the prevention of lymphedema after breast cancer surgery were included in our meta-analysis, which showed that MLD adds no benefit to the prevention of lymphedema compared to other interventions. This was because previous published reports of the effectiveness of preventing lymphedema were conflicting.

On the one hand, in the studies by Cho et al and Zhang et al, the use of MLD had been related to a lower risk of developing lymphedema for breast cancer patients. MLD is about pace, tension, and muscle as well as connective tissue compression, by means of the therapist's touch, which helps to improve circulation.

MLD stimulates lymphatic and venous flow, enhances metabolism muscle tissue elasticity, and promotes relaxation by increasing parasympathetic nervous system activity and decreasing sympathetic nervous system activity.

Such benefits, which were not assessed in the current study, can contribute to reducing anxiety and improving sleep and treatment adherence. However, multiple risk factors, including age, lymphedema onset, volume excess, number of infections, and obesity, can contribute to the failure of reducing limb volume after the treatment of breast cancer-related lymphedema. We noted moderate interstudy heterogeneity in our meta-analysis, which might result from variable clinical factors and clinical parameters.

First, the technique, duration and frequency of MLD were not the same among the included studies. Second, the characteristics of the participants differed across the studies.

For example, participants in the study by Sitzia et al were older than those in other trials. Fourth, the assessments used for detecting the reduction of arm volume also differed among the studies, which might affect the comparison of the clinical outcomes. This updated meta-analysis of 17 studies provided consistent evidence of the equal effect of MLD and other treatments, which further confirmed and extended the preliminary findings of the 2 previous published meta-analyses.

The first one published by Huang et al reported the addition of MLD to a standard treatment procedure, producing a non-significant effect on reducing arm volume for lymphedema related to breast cancer. The other study performed by Ezzo et al found that MLD with or without compression therapy showed no significant improvement from baseline and no significant between-group differences for percent reduction.

To our knowledge, our study is the most comprehensive study with the largest sample size and without language limitations to evaluate the effectiveness of MLD in the treatment and prevention of lymphedema. Moreover, comprehensive and systematic search strategies were used to ensure the inclusion of almost all of the relevant RCTs and enabled us to minimize bias for conducting this meta-analysis and generate 17 studies and data from participants.

The largest sample size of this study allowed a detailed subgroup analysis to be conducted, and this subgroup analysis, such as research region, publication year, sample size, type of surgery, statistical analysis method, mean age, and the intervention time of association between MLD treatment and the development of lymphedema, was examined. Moreover, the careful estimation of methodological quality and a rigorous analysis method contributed to more strengthened and precise evidence concerning the effectiveness of MLD in the treatment and prevention of lymphedema after breast cancer surgery.

Nevertheless, a few limitations of our meta-analysis should be considered. First, only half of the studies included in our analysis reported adequate randomization in the study-group allocation, which could affect the treatment effect. Second, in 11 of the studies, the assessment staffs were not blinded to the measurement of the outcomes, which would lead to a certain bias of the pooled estimate. Third, some of the authors could not be contacted for retrieving the necessary data, and grey literature was not included in this meta-analysis, which could also lead to inaccurate results.

Although there were several limitations in this meta-analysis, the clinical implication lied in that for breast cancer patients undergoing surgery, clinicians should consider the most effective treatment to minimize the development of lymphedema and improve the quality of life after breast cancer surgery.

In conclusion, our findings of this systematic review and meta-analysis provided evidence that MLD might not add any effect to the treatment and prevention of lymphedema after breast cancer surgery.

However, it remains unclear whether MLD should be part of the treatment plan for breast cancer patients. Therefore, whether clinicians consider MLD for females with breast cancer in post-acute and long-term care requires further investigation because of the lack of solid supportive findings. Therefore, further well-designed and large-scale RCTs providing the highest level of evidence should be implemented to further test the evidence, especially in patients below the age of 60 years old or with an intervention time of 1 month.

Critical revision of the manuscript for important intellectual content: all authors. Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials.

ML and QC contributed equally to this work and should be considered co-first authors. C to ML. The authors have no conflicts of interest to disclose. Supplemental digital content is available for this article. Medicine Baltimore. Published online Dec 4. Find articles by Lezhi Li. Author information Article notes Copyright and License information Disclaimer. Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4.

This article has been cited by other articles in PMC. Abstract Background: Studies have shown that manual lymphatic drainage MLD has a beneficial effect on lymphedema related to breast cancer surgery. Results: A total of 17 RCTs involving patients were included. Conclusions: Overall, this meta-analysis of 12 RCTs showed that MLD cannot significantly reduce or prevent lymphedema in patients after breast cancer surgery.

Keywords: breast cancer, lymphedema, manual lymph drainage, meta-analysis, randomized controlled trial. Introduction Lymphedema is a common complication after breast cancer surgery.

Study selection Two reviewers ML and QC independently screened and identified all retrieved records by reading the titles and abstracts for potential eligible articles. The RCTs were included in this systematic review and meta-analysis if they satisfied the following criteria: 1.

Study methods: RCTs enrol breast cancer patients who are receiving MLD, describe the definition of lymphedema, and provide the inclusion and exclusion criteria for enrolling participants;. Intervention: The experimental group received MLD, while the control group received compression bandaging and other methods such as physical therapy, simple lymphatic drainage SLD , etc for treatment;.

Main outcomes: RCTs evaluate the severity of lymphedema or the incidence of lymphedema. The quality of the studies was evaluated by the following criteria: 1. Outcomes assessments and definition of lymphedema The effect of MLD on the prevention of lymphedema was evaluated by the incidence of lymphedema, and the efficacy of MLD in the treatment of lymphedema was assessed by the percentage reduction in total of lymphedema from baseline to follow-up period.

Statistical synthesis and analysis Statistical analysis was conducted using Stata Statistical Software Version Results 3. Search and selection of studies Of the initial eligible articles, 27 were considered to be potentially relevant studies for further review. Table 1 Characteristics of the included studies on the effect of MLD on preventing or managing breast cancer-related lymphedema.

Author Year Region Inclusion criteria No. Open in a separate window. Table 2 Quality assessment of the included studies. The effect of MLD on the treatment of lymphedema In general, 12 eligible RCTs demonstrating the effect of MLD on treating lymphedema were published between and and had sample sizes ranging from 24 to 73 subjects. Figure 1. Publication bias and sensitivity analysis Although substantial statistical heterogeneity was noted in this meta-analysis, almost all of the 8 included studies showed a similar direction of effect, thus demonstrating that some of the heterogeneity was mainly attributed to a variation in the magnitude of the estimated risk instead of the direction.

Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Discussion 4. Principal findings The current systematic review and meta-analysis were conducted to assess the effectiveness of MLD on lymphedema after breast cancer surgery. Potential mechanisms MLD is about pace, tension, and muscle as well as connective tissue compression, by means of the therapist's touch, which helps to improve circulation.

Strengths and limitations This updated meta-analysis of 17 studies provided consistent evidence of the equal effect of MLD and other treatments, which further confirmed and extended the preliminary findings of the 2 previous published meta-analyses. Conclusion In conclusion, our findings of this systematic review and meta-analysis provided evidence that MLD might not add any effect to the treatment and prevention of lymphedema after breast cancer surgery.

Formal analysis: Mining liang. Methodology: Yongchao Hou. Software: Mining Liang, Yongchao Hou. Manual lymphatic drainage for lymphedema following breast cancer treatment. The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast Cancer Tokyo, Japan ; 25 — Incidence and risk factors of lymphedema after breast cancer treatment: 10 years of follow-up. BNStory adsk forindex techguide TheKooksInsideIn index numpy UserGuide DC13 index people1 psyops TheBeatlesAbbeyRoad alertcon foldern hsas X W3C index hal homesec strategicplan b19 b17 PaoloNutiniTheseStreets b16 workinggroups effects integrate A3 3dsmax memberreviews acord ube techblast wpp PCGames househome endorse fakemail amy post!

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