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BreastOriginal Article

Comprehensive decongestive therapy in

postmastectomy lymphedema: An Indian
Randheer S, Kadambari D, Srinivasan K, Bhuvaneswari V1, Bhanumathy M2,
Salaja R2
Departments of Surgery, 1Radiodiagnosis, 2Physiotherapy, JIPMER, Puducherry, India
Correspondence to: Dr. Randheer Aiswaria, E-mail:

BACKGROUND: Lymphedema following breast cancer treatment is one of the most morbid conditions affecting breast
cancer survivors. Currently, no therapy completely cures this condition. Comprehensive Decongestive Therapy (CDT),
a novel physiotherapeutic method offers promising results in managing this condition. This therapy is being widely
used in the West. Till date, there are no studies evaluating the effectiveness and feasibility of this therapy in the east.
MATERIALS AND METHODS: The therapeutic responses of 25 patients with postmastectomy lymphedema were analyzed
prospectively in this study. Each patient received an intensive phase of therapy for eight days from trained physiotherapists,
which included manual lymphatic drainage, multi layered compression bandaging, exercises, and skin care. Instruction in
self management techniques were given to the patients on completion of intensive therapy. The patients were followed up
for three months. Changes in the volume of the edematous limb were assessed with a geometric approximation derived
from serial circumference measurements of the limb and by water displacement volumetry. Changes in skin and sub cutis
thickness were assessed using high frequency ultrasound. RESULTS: The reduction in limb volume observed after therapy
was 32.3% and 42% of the excess, by measurement and volumetry, respectively. The maximum reduction was obtained
after the intensive phase. The reduction in skin and subcutis thickness of the edematous limb followed the same pattern as
volume reduction. Patients could maintain the reduction obtained by strictly following the protocols of the maintenance phase.
CONCLUSIONS: CDT combined with long-term self management is effective in treating post mastectomy lymphedema.
The tropical climate is a major factor limiting the regular use of bandages by the patients.
Key words: Comprehensive decongestive therapy, manual lymphatic drainage, volumetry

Postmastectomy lymphedema is one of the most morbid
conditions occurring after breast cancer therapy, causing
severe physical, functional, and psychological distress to
the patient. With improvements in breast cancer therapy,
more women become long time survivors and hence
the long term postoperative complications and their
management become an increasingly important issue.[1]
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Indian Journal of Cancer | October-December 2011 | Volume 48 | Issue 4

Postmastectomy lymphedema is a treatment

related complication resulting from axillary surgery
and radiotherapy. Even with less extensive axillary
surgery and improved radiotherapy techniques, the
literature reported incidence of this condition is about
Though not life threatening, it causes high
morbidity with functional impairment and cosmetic
disfigurement and has psychological effect on the
patient, thus downgrading quality of life. Treatment
of this condition poses a great challenge to physicians.
Physical therapy is the mainstay of management.
Pharmacotherapy and surgery give disappointing
results. [6] A novel form of physiotherapy called
Comprehensive Decongestive Therapy (CDT), which
combines various physiotherapeutic modalities like

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Randheer, et al.: CDT in postmastectomy lymphedema

massage, compression bandaging and exercises, is the

standard therapy in some Western countries.[7] With over
150 mastectomies conducted every year in our institute,
postmastectomy lymphedema is a major problem that
many of our breast cancer survivors are facing. This
study was undertaken to evaluate the efficacy of CDT
in our patients.
Patients and Methods
This was a prospective study conducted on patients
with post mastectomy lymphedema, attending the
Cancer follow-up Clinic of our hospital from November
2006 to June 2008. A total of 35 patients presented
with clinical evidence of lymphedema during the study
period. Women with symptomatic or asymptomatic
lymphedema that developed after a period of at least
four months after completion of breast cancer treatment
were enrolled in the study. Edema occurring within the
first few months of therapy tends to be temporary and
may subside without therapy. Those with a difference
in volume between the two arms of less than 200 ml
and a difference in circumference between the two arms
of less than 2 cm were excluded. Women with evidence
of locoregional recurrence of carcinoma, bilateral breast
cancer and edema due to other causes (filariasis, primary
lymphedema, and deep vein thrombosis) were also not
eligible. Seven patients were excluded two with local
recurrence, one who had carcinoma in the opposite
breast, two with metastatic disease, one due to recurrent
cellulitis following bandaging, and one who had edema
less than 200 ml; three patients were lost to follow-up.
Lymphedema was staged using parameters such as
pitting and dermal changes (skin thickening, skin folds,
and papillomas) [Table 1].[8] The scar was examined for
evidence of dense fibrosis and puckering indicative of
severe postoperative infection or postradiation reaction.
Objective assessment of lymphedema was done by
measuring limb volume using multiple circumference
measurements of the upper limb and by water
displacement volumetry. The limb volumes of
both upper limbs were measured. In circumference
measurement method, the upper limb was divided into
four segments. The upper limit of measurement, known
as the 65% point, was a point marked on the upper

arm, which is 65% of the distance from the olecranon

to the acromion tip. The four segments were: (a) Wrist
(at the level of ulnar styloid) to mid forearm, (b) Mid
forearm to elbow (at the level of olecranon), (c) Elbow
to mid arm and (d) Mid arm to the 65% point. Each
of these segments was assumed to be a truncated cone
(frustum). As the shape of upper limb is not exactly
cylindrical, studies have shown that calculations using
the frustum assumption produce the least standard error
of measurement. [9] The volume of each segment was
calculated using the formula, h (C12+C22+C1C2) / 12,
where h is the length of each segment, C1 and C2 are
the circumference of each segment at both ends. The
sum of these volumes gives the volume of the limb.
In water displacement volumetry, the patients upper
limb was immersed in a graduated steel cylinder up
to the 65% point. The volume of water displaced was
calculated using the formula r2h; where r is the radius
of the cylinder and h is the height of water displaced.
A graduated steel cylinder with an inner diameter of 38
cm was used in this study.
Following this, the skin and subcutis, thickness of
the upper limb were measured using high frequency
ultrasound probes (10 MHZ). The measurement was
made with the patient in sitting position with arms
extended and measurements were made at anterior,
posterior, medial and lateral aspects of mid arm and
mid forearm and the average taken. Compressibility of
axillary veins of both sides was assessed, to rule out
axillary vein thrombosis.
Following the initial assessment patients were
started on the intensive phase of CDT, in the
Physiotherapy Department. The intensive therapy
was given four times a week (on alternate days),
for two weeks. The patients were given Manual
Lymphatic Drainage (MLD) for a period of 45
minutes, as per the Vodder technique. This was
followed by multilayered compression bandaging of
the upper limb, which includes finger bandaging,
a gauze layer, a layer of foam, cotton wool pad,
and an outer layer of low stretch elastic bandage
(Top Grip) of size 15 cm(w) 4 m(L). The bandage
was applied from the hand to the upper arm. The
patients were also advised on skin and nail care and

Table 1: Stages of lymphedema

Stage I
Reversible lymphedema
Stage II
Spontaneously irreversible
Stage III
Lymphostatic elephantiasis

Reduces on elevation and pits to pressure

Swelling does not reduce on elevation and does not pits on pressure.
Progressive skin hardening and frequent infections.
Progressive fibrosclerosis with papillomas and large hanging skin folds.

Indian Journal of Cancer | October-December 2011 | Volume 48 | Issue 4

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Randheer, et al.: CDT in postmastectomy lymphedema

isotonic exercises to be performed with the bandages

on. They were also advised to re-apply the bandages
on the next day.
After completion of intensive phase, the patients
were assessed for reduction in limb volume using
circumference measurements, displacement volumetry
and sonographic measurement of skin and subcutis
thickness. They were advised to massage themselves
twice a day after performing deep breathing exercises.
Other measures included isotonic limb exercises thrice
a day, skin and nail care and application of low stretch
compression bandages throughout the day and limb
elevation at night. The patients were followed up
monthly over a period of three months for assessment
of reduction in limb volume.
For each patient, the therapeutic response was calculated
as the change in absolute limb volume (in millilitres)
and as the change in excess volume of the treated limb
before and after the intensive phase and at each month
of follow up. The volume of edema was calculated as
the difference in limb volume between the edematous
and normal limb. Results were expressed as the
percentage reduction in edema of the diseased limb,
which was calculated as:
Volume of edema before therapy Volume of edema
after therapy
Volume of edema before therapy
(Volume of edema = Volume of edematous limb
Volume of normal limb)

This study was approved by the Institute Ethics

Repeated measures ANOVA was used to test the
significance of difference in the absolute limb volume
changes, the reduction in the amount of edema and the
changes in skin and subcutis thickness before intensive
phase, after intensive phase, at 1st, 2nd, and 3rd months of
follow up. A P value of less than 0.05 was considered
significant. Correlation of the limb volumes assessed
by measurement and volumetry was calculated using
Pearson correlation. Statistical analysis of the data was
done using GraphPad Instat 3 and SPSS 16.0 software.
The mean age of the study group was 52 years; the
range being 3076 years. Majority of patients (72%),
had T2 or T3 disease and 60% of patients had nodal
involvement. All patients underwent total mastectomy
Indian Journal of Cancer | October-December 2011 | Volume 48 | Issue 4

with level II axillary dissection. About 92% of patients

received neoadjuvant and adjuvant chemotherapy and
post operative radiotherapy. Two patients did not
receive radiotherapy of which one defaulted and the
other was not given radiotherapy or chemotherapy in
view of advanced age and early stage of disease. As
much as 28% of patients had history of postoperative
wound infection and 24% of patients had a puckered
scar on examination, indicative of a severe postoperative
infection or radio dermatitis.
The median time for development of lymphedema was
six months following surgery or radiotherapy. The two
patients who did not receive radiotherapy developed
lymphedema two months and 26 months after
surgery. Majority of the patients presented with stage I
lymphedema (92%). The most common symptom was
heaviness of the affected limb (76%). 76% had rightsided lymphedema, as majority of patients had right
sided breast cancer. All patients were right handed.
The mean volume of the edematous limb in the
study group, before treatment, was 2603687 ml,
by circumference measurement and 3296988 ml by
volumetry vs 1848.3320 ml, by measurement and
2144.4430 ml, by volumetry in the normal limb. The
mean skin thickness at the mid arm and mid forearm
levels for the edematous limb was 2.80.9 mm and
3.041.2 mm ,respectively, and for the normal limb
was 1.50.3 mm and 1.40.28 mm, respectively.
The mean subcutis thickness at the mid arm and mid
forearm levels for the edematous limb was 14.94.4
mm and 11.95.4 mm, respectively, and that for
the normal limb was 9.63 mm and 51.5 mm,
During analysis of data, it was observed that on
applying the tests of normality (Kolmogorov- Smirnof
test) the data were not normally distributed (positively
skewed). Hence, log transformation of the data was
done before analysis.
With CDT, the mean reduction in absolute limb
volume of the edematous limb was 224.7 ml by
measurement and 485 ml by volumetry (P<0.001). The
maximum reduction in volume was observed after the
intensive phase of therapy [Table 2]. The percentage of
lymphedema, which is the amount of edema expressed
as a percentage of the normal limb volume, reduced
from 55.7% to 31% (P<0.01) after the therapy. The
reduction in limb volume observed after therapy was
32.3% and 42% of the excess, by measurement and
volumetry, respectively
However, two patients did not show any improvement

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Randheer, et al.: CDT in postmastectomy lymphedema

with therapy and had an increase in volume of 320 ml

and 146 ml by measurement. No change in volume
was recorded by volumetry. One of them had fungal
infection of the skin and was less compliant to therapy,
and the other patient was non compliant to the
maintenance therapy and was on irregular follow up.

like preoperative nodal status, presence of post operative

infection, puckered scar or the side of involvement.

In the maintenance phase, it was observed that there

was a mean increase in limb volume by 20.3 ml, which
was not statistically significant (P>0.05). Even though
there was a reduction in limb volume on subsequent
follow ups at second and third months, the reductions
were not statistically significant (P>0.05). However,
the overall reduction in limb volume before and after
therapy was found to be significant; P<0.001 [Table 2].

Two patients developed skin irritation and blistering

following application of multilayered bandaging. Of this,
one patient responded to conservative management and
continued the therapy without further complications,
while the second patient had severe blistering and was
excluded from the study when she developed distant
metastasis. One patient developed recurrent episodes of
cellulitis following bandaging, during the maintenance
phase and hence was excluded from the study. One
patient presented with recurrence of lymphedema
one year after therapy, due to non compliance to the
maintenance therapy.

The reduction in skin and subcutis thickness of

edematous limb during therapy followed almost the
same pattern as the volume reduction. [Tables 3,4]

It was also observed in the study that the measurements

by volumetry and circumference measurements had a
correlation coefficient of 0.98.

There were no significant changes in the volume or skin

and subcutis thickness of the normal limb, before and
after therapy.


The response to therapy was not influenced by factors

Postmastectomy lymphedema is a significant long

term problem for breast cancer survivors. Although
the incidence of this condition has decreased recently

Table 2: Absolute limb volume reduction obtained following CDT- for edematous limb
Time period

Mean reduction
(ml)- By measurement

Mean Reduction
(ml)-By volumetry

P value




Mean reduction
(mm) at Mid forearm

P value

Before and after intensive therapy

Between Intensive therapy and 1st month
Between 1st month and 2nd month
Between 2nd month and 3rd month
Before and after CDT

Table 3: Reduction in skin thickness of edematous limb during CDT

Time period
Before and after intensive therapy
Between Intensive therapy and 1st month
Between 1st month and 2nd month
Between 2nd month and 3rd month
Before and after CDT

Mean reduction
(mm) at Mid arm


Table 4: Reduction in subcutis thickness of edematous limb during CDT

Mean reduction
(mm) at Mid arm

Mean reduction
(mm) at Mid forearm

P value

Before and after intensive therapy



Between Intensive therapy and 1st month

Between 1st month and 2nd month
Between 2nd month and 3rd month
Before and after CDT




Time period


Indian Journal of Cancer | October-December 2011 | Volume 48 | Issue 4

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Randheer, et al.: CDT in postmastectomy lymphedema

with the advent of more conservative approaches in

surgery like breast conservation surgery and sentinel
lymph node biopsy, literature reports an incidence of
1254% for this condition.[2-6] As there is no treatment
that can offer cure for this condition, management is
challenging. Treatment for lymphedema can only aim
to control rather than to cure.[7]At present, multimodal
physical therapy is the standard of care.[10] The goals of
lymphedema management are to prevent the progression
of the disease, to reduce and maintain the limb size,
to alleviate symptoms, to improve mobility and ability
to perform daily activities, and to improve overall
psychological well being.
Comprehensive Decongestive Therapy (CDT), a
multimodal therapy, comprising of manual lymphatic
drainage (MLD),compression bandaging, exercise, skin
and nail care, is a promising way to treat all forms of
lymphedema. Irrespective of the stage of lymphedema,
etiology, or medical co morbidities, most lymphedema
patients are treated in a comparable fashion by CDT.[11]
Relatively few studies exist evaluating the effectiveness
of this therapy. Till date, no studies on CDT have been
reported from the Indian sub continent.
This study showed a reduction in the absolute volume of
the edematous limb by 485 ml. The maximum reduction
was obtained after the intensive phase of therapy. The
lymphedema reduction averaged 34% after the intensive
phase of therapy and 42% at the end of three months.
The amount of edema reduced by 244 ml after three
months of therapy. The results obtained in this study are
comparable to the results of other studies.[12-15] Andersen
and Hamner et al. reported an average reduction of
edema by 298 ml and 237 ml after the intensive phase,
respectively.[13,14] The percentage reduction of edema
obtained in these studies was 44% and 42%.
As observed by Andersen, [13] though the volume
reduction could be maintained during the follow-up
period, there was some loss of the initial lymphedema
reduction obtained after the intensive phase. This loss
of the initial reduction can be attributed to the non
compliance of the patients to the maintenance phase.
In our study, it was observed that in the first month
of follow-up, nineteen patients had some loss of the
edema reduction achieved after the intensive phase. It
was found that these patients did not strictly follow
the bandaging and simple lymphatic drainage protocols.
Nearly eighty percent patients were non compliant to
bandages, owing to the discomfort of using them in
the hot climate, and due to interference with their dayto-day activities. Most of the patients were found to
have forgotten the sequence of massage to be followed
in simple lymphatic drainage, during the maintenance
Indian Journal of Cancer | October-December 2011 | Volume 48 | Issue 4

phase. During each follow-up, patients were motivated

to continue their bandaging and the steps of simple
lymphatic drainage revised. It was observed that patients
followed the maintenance phase protocols better on
motivation, which was reflected by small reductions
in edema during further follow-ups. However, the
overall compliance to bandaging was less owing to the
discomfort the patients experienced while wearing them
in the hot climate and in doing their daily routine.
Although compression sleeves are more user friendly,
due to the ease of application and less discomfort,
they are too expensive. Thus, compliance to bandaging
and massage during the maintenance phase was a very
important factor in maintaining the reduction obtained
during the intensive phase and for further reductions
thereafter. [15,16] Boris reported that non compliant
patients had their reductions worsened from 63% to
Mellor reported that skin thickness measurement using
high frequency ultrasound was a simple and reliable
method to assess lymphedema and to investigate
therapeutic interventions. [17] However, there are no
studies on the use of ultrasound measurement in
assessing the response to CDT. It was observed in
this study that changes in skin and subcutis thickness
followed the same trend as volume changes, during the
course of CDT.
The volumes assessed by volumetry and circumference
measurement showed a mean difference of 690 ml for
the edematous limb and 298 ml for the normal limb.
This discrepancy can be explained by the fact that
in volumetric measurement the volume of the entire
upper limb was calculated, including that of the hand,
as the whole upper limb was immersed in the cylinder
of water. In circumference measurement method, the
volume of the hand was excluded, as the measurement
started at the level of the wrist. Sander et al. reported
a difference of 479 ml to 665 ml between volumetric
and geometric measurements of the arm. [18] Karges
reported a mean difference of 96 ml between these two
methods, when the volume of fingers was excluded from
the volumetric measurements.[19] Both studies reported
a high correlation between the volumes calculated by
geometric measurements and volumetry, which was
also demonstrated in our study (r=0.98). However,
studies have shown that the differences between the two
methods are too large to substitute measurements made
with one method for the other. One of the methods can
be reliably used for assessing the volume for clinical and
research purposes.[18]
The limitations of the study were the small sample size
and shorter duration of follow up, when compared

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to similar studies. Another drawback was that the

improvement in the quality of life of patients was
not assessed. A standard volumeter was not used in
the study, and hence the hand volumes could not be
measured accurately, so as to exclude them from the
limb volumes measured by volumetry.
This study showed that comprehensive decongestive
therapy can effectively promote acute limb volume
reduction in patients with post mastectomy
lymphedema, and when combined with self care results
in long term control of lymphedema. One of the
problems faced by patients in a tropical country like
India is the discomfort due to bandages. The hot
climate and the associated perspiration might be
the cause for intolerance to bandaging seen in some
patients, manifested by repeated episodes of cellulitis,
blistering, and exacerbation of fungal infection.
However, literature, which is mostly from the Western
world, has not reported any such complications
associated with this therapy. The climatic conditions
in the tropics are thus an important factor that
adds to the non compliance to this therapy in our
population. Emphasis on proper skin care and devising
an alternative component to continuous bandaging
like Intermittent Pneumatic Compression may be
helpful to combat the complications as well as the
non compliance to bandaging, especially for patients in
tropical countries.
CDT, when combined with long-term self management
proves effective in controlling postmastectomy
lymphedema. Patient compliance to treatment protocols
like regular manual lymphatic drainage, compression
bandaging, skin, and nail care is very important in
achieving and maintaining reduction in limb volume
following therapy. The hot climate in tropics is a factor
that limits the regular use of compression bandages by
the patients and may be responsible for the intolerance
to bandages as evidenced by recurrent cellulitis,
blistering, and exacerbation of fungal infections seen in
some patients.


Beaulac SM, Mc Nair LA, Scott TE, LaMorte WW, Kavanah MT.
Lymphedema and quality of life in survivors of early stage breast
cancer. Arch Surg 2002;137:1253-7.







Paskett ED, Naughton JM, McCoy TP, Case LD, Abbott JM. The
epidemiology of arm and hand swelling in premenopausal breast
cancer survivors. Cancer Epidemiol Biomarkers Prev 2007;
Clark B, Sitzia J, Harlow W. Incidence and risk of arm oedema
following treatment for breast cancer: A three year follow up study.
QJM 2005;98:343-8.
Kwan W, Jackson J, Weir LM, Dingee C, Mc Gregor G, Olivotto IA.
Chronic arm morbidity after curative breast cancer treatment:
Prevalence and impact on quality of life. J clin oncol 2002;
Deo SV,. Prevalence and risk factors for development of lymphedema
following breast cancer treatment. Indian J cancer 2004;41:8-12.
Soran A, D Angelo G, Begovic M, Ardic F, Harlak A, Wieand HS,l.
Breast cancer-related lymphedema-What are the significant
predictors and how they affect the severity of lymphedema? Breast
J 2006;12:536-43.
Gary DE. Lymphedema diagnosis and management. J Am Acad
Nurse Pract 2007;19:72-8.
Morrel RM, Halyard MY, Schild SE, Ali MS, Gunderson LL, Pockaj BA.
Breast Cancer related lymphedema. Mayo clin proc 2005;80:1480-4.
Taylor R, Jayasinghe UW, Koelmeyer L, Ung O, Boyages J. Reliability
and validity of arm volume measurements for assessment for
lymphedema. Phys Ther 2006;86:205-14.
Moseley Al, Carati CJ, Piller NB. A Systematic review of common
conservative therapies for arm lymphedema secondary to breast
cancer treatment. Ann Oncol 2007:639-46.
Cheville AL, Mc Garvey CL, Petrek JA, Russo SA, Taylor ME, Thiadens
SR. Lymphedema management. Semin Radiat Oncol 2003;13:290301.
Ko DS, Lerner R, Klose G, Cosimi AB. Effective treatment of
lymphedema of the extremities. Arch Surg 1998;133:452-8.
Andersen L, Hojris I, Erlandsen M, Andersen J. Treatment of breast
cancer- related lymphedema with or without manual lymphatic
drainage. Acta Oncol 2000;39:399-405.
Hamner JB, Fleming MD. Lymphedema therapy reduces the volume
of edema and pain in patients with breast cancer. Ann Surg Oncol
Boris M, Weindorf S, Lasinski B. Persistence of lymphedema
reduction after non invasive complex lymphedema therapy.
Oncology 1997;11:99-109.
Vignes S, Porcher R, Arrault M, Dupuy A. Long term management
of breast cancer related lymphedema after intensive decongestive
physiotherapy. Breast cancer Res Treat 2007;101:285-90.
Mellor RH, Bush NL, Stanton AW, Bamber JC, Levick JR, Mortimer
PS. Dual-Frequency ultrasound examination of skin and subcutis
thickness in breast cancer related lymphedema. Breast J
Sander AP, Hajer NM, Hemenway K, Miller AC. Upper extremity
volume measurements in women with lymphedema: A Comparison of
measurements obtained via water displacement with geometrically
determined volume. Phys Ther 2002;82:1201-12.
Karges JR, Marks BR, Stikeleather SJ, Worrell TW. Concurrent validity
of upper extremity volume estimates: Comparison of calculated
volume derived from girth measurements and water displacement
volume. Phys Ther 2003;83:134-45.

How to site this article: Randheer S, Kadambari D, Srinivasan K,

Bhuvaneswari V, Bhanumathy M, Salaja R. Comprehensive decongestive
therapy in postmastectomy lymphedema: An Indian perspective. Indian J
Cancer 2011;48:397-402.
Source of Support: Nil, Conflict of Interest: None Declared

Indian Journal of Cancer | October-December 2011 | Volume 48 | Issue 4