Table 1.

Overview of Practice Recommendations^a

Interventions by Stage	Practice Recommendations
Early Postoperative Care/Early Preventive Intervention	Postoperative exercise and resumption of activity should be coordinated with the interprofessional team and an individualized exercise program should be gradually increased while monitoring for adverse events. (Best Practice) Individually tailored exercises should be included postoperatively and gradually progressed. (Grade B) In individuals who have undergone axillary lymph node dissection: • The addition of therapist-provided manual lymphatic drainage (MLD) to the postoperative care plan may not reduce the risk of developing BCRL. (Grade C) • Provision of a fitted compression garment to patients at high risk of developing lymphedema, when paired with upper extremity exercise and diaphragmatic breathing, may reduce development of lymphedema. (Grade B)
Prospective Surveillance Model and Identified Subclinical (ISL Stage 0) Lymphedema	Early identification of subclinical lymphedema in high-risk groups through prospective surveillance may improve outcomes. (Grade C) • Monitoring with bioelectric impedance spectroscopy or volume measures may begin with a preoperative assessment, repeated every 3 months for the first year postoperatively, and then biannually for up to 5 years. (Grade C) Intervention for subclinical lymphedema may include education, self-massage, and use of compression garments. (Grade C) If early subclinical lymphedema persists or progresses after initial conservative intervention, individuals may benefit from more intensive interventions, such as complete decongestive therapy (CDT). (Grade C)
Exercise for Individuals at Risk for or With Subclinical (ISL Stage 0) BCRL	Progressive resistance training is safe when an individualized program is supervised beginning at least 1 month postsurgery. (Grade A) Individualized aerobic exercise programs should be provided. (Grade A) Monitoring for exercise tolerance and adverse effects should initially occur at least weekly and then taper according to clinical presentation. (Grade A)
Interventions Recommended for Individuals Diagnosed With BCRL	Early Lymphedema (ISL Stage I):   If early signs and/or symptoms of lymphedema are noted, the patient should be individually fitted with a compression garment, instructed in an exercise program, and provided education as first-line treatment. (Grade A) • If first-line treatment is not successful for early lymphedema, then CDT may be recommended. (Grade B) • Compression (garment or bandaging) should be tailored for the individual’s lymphedema stage and impairments, in consultation with the patient. (Grade A) Moderate and Late Lymphedema (ISL Stages II and III): CDT should be used to reduce limb volume in those diagnosed with moderate and late BCRL. (Grade B) • Compression bandaging and exercise are key components of CDT and should be used. (Grade A) • Modifying CDT, specifically shortening or omitting the MLD component, may yield similar results on long-term volume reduction. (Grade B) • In all treatment phases, compression interventions should be tailored for the individual’s lymphedema stage, impairments, and preferences. (Grade A) • Kinesiotape may reduce volume but cannot be recommended to replace short-stretch compression bandaging in stage II and III BCRL. (Grade B) If kinesiotape is used in BCRL, clinicians should closely monitor for adverse events. (Grade B) • Once a stable volume reduction is achieved with phase I clinical treatment, a program of home care including self-MLD, individually fitted compression garment, appropriate nightly compression if indicated, and exercise should be recommended. (Grade B) • Use of a standard or advanced intermittent pneumatic compression device may be considered in phase II home care treatment. (Grade C) • Monitoring for volume changes with follow-up care may be an important component for optimal long-term volume reduction. (Grade C) Low-level laser therapy may be considered either in combination with compression or CDT in patients with established lymphedema of the upper extremity. (Grade B) For All Stages (ISL Stages 0–III) in Relation to Other Therapeutic Modalities: The addition of myofascial therapy to stretching, exercise, and scar massage may be safe in patients greater than 3 months post–radiation therapy who are at risk for BCRL. (Grade C) Acupuncture has insufficient evidence to support use for volume reduction. (Grade C)

^a BCRL = breast cancer-related lymphedema; ISL = International Lymphology Society.