Table 2.
Main characteristics of the studies included.
| Author Year Country |
Design | Participants | Time from Surgery | Breast Cancer Treatment | Intervention Modality | Frequency, Volume, Intensity, Protocol Duration | Control | Outcomes | Main Findings | |
|---|---|---|---|---|---|---|---|---|---|---|
| Sample Size (Dropouts) |
Mean age (years) BMI (kg/m2) |
|||||||||
| Cho et al., 2015 [31] South Korea |
RCT | 48 (7) PTMLD: n = 21 PT: n = 20 |
PTMLD: 46.6 ± 6.8 PT: 50.7 ± 9.6 PTMLD: ≥25: n = 6; <25: n = 15 PT: ≥25: n = 9; <25: n = 11 |
At least 4 weeks | PTMLD: mastectomy (n = 12), lumpectomy (n = 7), breast reconstruction (n = 2). Chemotherapy (n = 9), radiotherapy (n = 21), hormone therapy (n = 14). PT: mastectomy (n = 16), lumpectomy (n = 3), breast reconstruction (n = 1). Chemotherapy (n = 11), radiotherapy (n = 19), hormone therapy (n = 12). |
PTMLD: PT consisting of 10 min warm-up (stretching); shoulder flexor, shoulder abductor, and elbow flexor strengthening exercises; 30 min of manual therapy: soft tissue mobilization techniques and stretching for tight tissue cords, shoulder abduction, elbow extension, and wrist supination and extension stretching exercises, shoulder girdle mobilization; and PROM exercises; 10 min cooldown (stretching) + MLD Vodder method 30 min for session. Supervised. |
PTMLD: PT 3 times/week (50 min per session) for 4 weeks + MLD 5 times/week (30 min per session) for 4 weeks. PT: PT 3 times/week (50 min per session) for 4 weeks. PT intensity: 60–80% 1RM. MLD intensity: from comfortable to mild discomfort. |
PT consisting of 10 min warm-up (stretching); shoulder flexor, shoulder abductor, and elbow flexor strengthening exercises; 30 min of manual therapy: soft tissue mobilization techniques and stretching for tight tissue cords, shoulder abduction, elbow extension, and wrist supination and extension stretching exercises, shoulder girdle mobilization; and PROM exercises; 10 min cooldown (stretching). | Arm volume: circumference measurements; muscular strength: hand-held dynamometer; AROM: digital inclinometer; DASH; EORTC QLQ-C30; EORTC QLQ-BR23; NRS. | This study reports about 48 post-surgical BC AWS patients (mean age PTMLD: 46.6 ± 6.8, PT: 50.7 ± 9.6). They were treated 4 weeks after surgery. The main finding is represented by the improvement observed in QOL (both EORTC QLQ-C30; EORTC QLQ-BR23) including functional and symptom aspects, shoulder flexor strength, and AROM, DASH, and NRS scores that were significantly improved in both groups after the 4-week intervention (p < 0.05). NRS score and arm volume were significantly lower in the PTMLD group than in the PT group (p < 0.05). No lymphedema was observed in the PTMLD group but was observed in the PT group (p < 0.05). Visible cords percentage was not significantly different between the two groups (28.5% PTMLD, 35% PT, p = 0.658). |
| Ibrahim et al., 2018 [32] Egypt |
RCT | 60 (NA) Group A: n = 20 Group B: n = 20 Group C: n = 20 |
40–50 NA |
3 months | ALND | Group A: direct myofascial release (in shoulder abduction) and Kinesio tape (in shoulder abduction). Supervised. |
All groups: 2 sessions/week for 4 weeks Volume: NR Intensity: NR |
Group B: direct myofascial release (in shoulder abduction). Group C: Kinesio tape (in shoulder abduction). |
VAS, ultrasound for assessment of AWS cord thickness and disorganization. | This study reports about 60 post-surgical BC AWS patients (aged between 40 and 50 years). They were treated 3 months after surgery. The main finding is represented by the improvement observed in VAS (each group had a significant decrease post-treatment, p = 0.0001, but there was no significant difference between the three groups, p = 0.31); in decrease thickness of the cords (each group had a significant decrease post-treatment, p < 0.05, but there was no significant difference between the three groups, p = 0.39); and in cord disorganization (each group had a significant improvement post-treatment, p < 0.05, and there was a significant difference between groups A and B, p = 0.03, and A and C, p = 0.009, while there was no significant difference between B and C, p = 0.08). |
| Moreau et al., 2010 [33] Belgium |
Non-RCT | 28 (NA) Group 1: n = NA Group 2: n = NA |
NA NA |
NA | BC surgery with axillary clearing in 82.14% of cases (n = 23), and only sentinel node removal in 17.85% of cases (n = 5). | Group 1: MLD (Leduc method) + light adherence stretch (according to ROM, with no pain). Group 2: soft tissue work + adherence stretch (petrissage method, pain could be elicited) + upper extremity mobilization. Supervised. |
All groups: at least 13 sessions. Frequency: NR Volume: NR Intensity: NR |
NR | Adherence evaluation, upper extremities ROM, VAS. | This study reports about 28 post-surgical BC AWS patients (mean age not specified). The main finding is represented by the improvement observed in adherences, upper extremities ROM, and VAS, which resulted in being significant after 13 sessions of treatment (p < 0.05), while no significant difference was present between groups. |
| Wyrick et al., 2006 [34] United States |
Retrospective observational study | 31 (6) | NA NA |
From 14 days to 5.8 years; 17% of patients > 1 year. | Lumpectomy (n = 7), double lumpectomy (n = 1), lumpectomy followed by mastectomy (n = 4), mastectomy (n = 8), mastectomy followed by later breast reconstruction (n = 4), mastectomy followed by immediate breast reconstruction (n = 6). One patient was seen twice but had only one surgical procedure. Concomitant cancer therapy (chemotherapy or radiation, n = 12). |
Home exercises program with active mobilization; therapeutic exercise, including soft tissue stretching, progressive resistance exercises, Airdyne Bicycle training; if patients had lymphedema or persistent swelling, manual therapy, compression bandages, and intermitting pneumatic compression were also used. Supervision not specified. |
Average duration of treatment: 10.1 ± 9.5 weeks. Frequency: NR Volume: NR Intensity: NR |
NR | Cording severity (mild, mild to moderate, moderate, moderate to severe, severe), ROM, length of care. | This study reports about 31 post-surgical BC AWS patients (mean age not specified). They were treated from 14 days to 5.8 years after surgery. The main finding is represented by the resolution in lymphatic cording, which was faster with physical therapy. Shoulder ROM improved after 4 weeks of treatment (abduction improved by 52 ± 21° and flexion improved by 39 ± 20°). The difference in treatment duration between regular and irregular patients was statistically significant (p = 0.012): duration of treatment for regular patients (n = 18) was 7.3 ± 3.4 weeks (less than 2 months); duration of treatment for irregular patients (n = 7) was 18.0 ± 17.1 weeks; mean treatment duration for patients with concomitant cancer therapy leading to cancellations (n = 12) was 17.0 ± 14.8 weeks. |
| Lattanzi et al., 2012 [35] United States |
Case report | 1 | 44 NA |
10 days. | Lumpectomy and sentinel node dissection. Thirty-five sessions of radiotherapy. | First week: soft tissue mobilization of cords, skin traction techniques, and myofascial release techniques. Second week: + two-person cord traction technique, self-elongation techniques, and skin traction and scar massage. Home stretching program. Supervised. |
Physical/occupational therapy 3 times/week for 2 weeks followed by pause during 35 radiotherapy treatments. Then, 2 times/week for 1 week, and then 1 time/week for 2 weeks (total of 5 weeks of protocol duration). Volume: NR Intensity: NR. |
NR | ROM, cords evaluation, muscle strength and function, DASH. | This case report presents 1 post-surgical BC AWS patient (44 years old). She was treated 10 days after surgery. The main finding is represented by the improvement in ROM, cords, muscle strength and function, and DASH score (32.5 vs. 7.5). |
| Fourie et al., 2009 [36] South Africa, United Kingdom |
Case report | 1 | 47 NA |
22 days. | Left modified radical mastectomy with removal of six axillary lymph nodes. | Manual soft tissue techniques. Home program of gentle stretching and self-mobilization. Supervised. |
First week: 2 sessions; Days 8–10: 1 session a day; Up to 26 days: 6 sessions. Total of 11 sessions. 30–45 min each session. Intensity: NR. |
NR | AROM, PROM, tissue movement and glide. | This case report presents 1 post-surgical BC AWS patient (47 years old). She was treated 22 days after surgery. The main finding is represented by the improvement in AROM, PROM, tissue movement and glide, until full range of movement with no visible or palpable cording. |
| Wei et al., 2013 [37] China |
Case report | 1 | 39 NA |
3 days. | Breast-conserving surgery and axillary lymph node biopsy; 17 days later secondary breast-conserving surgery. | Home program: shoulder exercises and massage to the cord-like structure. Non-supervised. |
Plant-based medicament (Aesculus hippocastanum) 300 mg twice a day. Physical program every day in the morning and at bedtime for 30 min, for 3 weeks. Intensity: NR |
NR | ROM, VAS, cords evaluation both manual and ultrasound. | This case report presents 1 post-surgical BC AWS patient (39 years old). She was treated 3 days after surgery. The main finding is represented by the improvement after 3 weeks in ROM (90° vs. 170°), VAS (7 vs. 0), cords that became invisible and non-palpable (both manually and by ultrasound). Numbness and tightness were still present but diminished. The plant-based medication Aesculus hippocastanum could have played a role. |
| Tilley et al., 2009 [38] Canada |
Case report | 1 | 37 NA |
1 week. | Lumpectomy, sentinel lymph node biopsy, and ALND for a node-positive BC. | Moist heat to the axilla and inner arm for 10 min per session. Shoulder flexion and abduction ROM exercises and gentle stretching. Cord stretching. Home exercises (gentle arm flexion and horizontal abduction). Supervised. |
6 physiotherapy sessions in 3 weeks period. Volume: NR Intensity: NR |
NR | ROM, cords evaluation. | This case report presents 1 post-surgical BC AWS patient (37 years old). She was assessed 1 week after surgery. The main finding is represented by the improvement in ROM (135° and 123° vs. 180° and 180°, flexion and abduction, respectively). The cord improved but was still palpable at the end of her treatment sessions, 7 weeks after surgery. |
| de Sire et al., 2020 [13] Italy |
Case report | 1 | 66 22 |
1 month. | Left inner upper quadrantectomy with negative sentinel node biopsy. | Manual therapy: myofascial release techniques with soft-tissue mobilization, massage and manipulation of the tight cord and scar tissues, therapeutic shoulder exercises including stretching, and MLD. Supervised. |
Fondaparinux 2.5 mg/day for 3 weeks. Rehabilitation program 3 times/week for 3 weeks, 45 min per session. Intensity: NR |
NR | ROM, NPRS, Quick DASH, EQ-5D-3L index, EQ-VAS. | This case report presents 1 post-surgical BC AWS + Mondor’s disease patient (66 years old). She was treated 1 month after surgery. The main finding is represented by the improvement after 3 weeks treatment in shoulder ROM (80° and 100° vs. 170° and 170°, flexion and abduction, respectively), NPRS (5 vs. 0), Quick DASH (40 vs. 0), EQ-5D-3L index (0.662 vs. 1.000), EQ-VAS (75 vs. 90). |
| Crane et al., 2017 [39] United States |
Case report | 1 | 48 NA |
1 year. | Bilateral mastectomy and negative lymph node dissection. Following surgery, a course of chemotherapy. Three months after completion of chemotherapy, bilateral latissimus dorsi flap reconstruction. | IASTM to the axilla at end range abduction for 5 min, thoracic/thoracolumbar junction manipulation, and flexibility exercise. Home exercise program consisting of shoulder girdle and thoracic stretching. Supervised. |
4 times/week for 4 weeks. Home exercises 3 times/day each day. Volume: NR Intensity: NR |
NR | ROM, NPRS, PSFS, thoracic rotation. | This case report presents 1 post-surgical BC AWS patient (48 years old). She was treated 1 year after surgery. The main finding is represented by the improvement in shoulder ROM (140° and 150° vs. 178° and 174°, flexion and abduction, respectively), bilateral thoracic rotation (25% vs. 100%), NPRS (5 vs. 1), and PSFS (19/30 vs. 30/30). |
| Jacob et al., 2019 [40] Israel |
Case report | 1 | 65 23.4 |
7 months | Left breast lumpectomy + ALND + intraoperative radiation therapy and whole breast radiation. | MLD, scar tissue techniques, cord stretching, self-massage, supportive bras. Home program: self-lymph-massage, compression garments, stretching exercise, Tidhar method of aqua lymphatic therapy, physical activity program. Supervised. |
1 time/week for 6 weeks, 60 min per session. Intensity: NR |
NR | ROM, VAS during shoulder ROM, cording evaluation. | This case report presents 1 post-surgical BC AWS patient (65 years old). She was treated 7 months after surgery. The main finding is represented by the improvement in VAS during shoulder ROM (8 vs. 0), which was never limited, and the disappearance of cording at the end of treatment. |
Abbreviations: 1RM: one repetition maximum; ALND: axillary lymph node dissection; AROM: active range of motion; AWS: axillary web syndrome; BC: breast cancer; BMI: body mass index; DASH: Disability of the Arm, Shoulder and Hand; EORTC QLQ-BR23: Breast Cancer-Specific Quality of Life Questionnaire; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Core; EQ-5D-3L: European Quality of Life, 5 Dimensions, 3 Levels; EQ-VAS: European Quality of Life Visual Analogue Scale; IASTM: instrument-assisted soft tissue mobilization; MLD: manual lymphatic drainage; NA: not applicable; NPRS/NRS: numerical pain rating scale; NR: not reported; PROM: passive range of motion; PSFS: patient-specific functional scale; PT: physical therapy; PTMLD: physical therapy combined with manual lymphatic drainage; QOL: quality of life; QuickDASH: Disabilities of the Arm, Shoulder and Hand Questionnaire, Short Form; RCT: randomized controlled trial; ROM: range of motion; VAS: visual analogue scale.