Kinesiology Taping reduces lymphedema of the upper extremity in women after breast cancer treatment: a pilot study

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1 DOI: /m Prz Menoauzalny 2014; 13(4): Original aer Kinesiology Taing reduces lymhedema of the uer extremity in women after breast cancer treatment: a ilot study Iwona Malicka, Agnieszka Rosseger, Justyna Hanuszkiewicz, Marek Woźniewski Wydział Fizjoteraii, Akademia Wychowania Fizycznego we Wrocławiu Abstract Introduction: Secondary lymhedema affects aroximately 40% of women treated for breast cancer and is recognized as a major roblem associated with the theray of malignant tumors. Consequently, new theraeutic methods are constantly being sought to effectively eliminate the condition. One of the new forms of edema management, esecially in the initial stages of edematous develoment, is Kinesiology Taing (KT). Aim of the study: The aim of the study was to assess the effects of KT alications on the extent of lymhedema of the uer extremity in women ost cancer treatment. Material and methods: The study grou consisted of 28 women after axillary lymhadenectomy due to breast cancer. All the atients were diagnosed with grade I secondary lymhedema. Kinesiology Taing was alied to a total of 14 randomly selected women. The remaining 14 atients constituted a control grou. The extent of lymhedema was measured using a centimeter tae and Limb Volumes Professional 5.0 software. Results: A significant reduction in the extent of lymhedema ( = ) was achieved in the KT grou between baseline and ost-treatment s. No such reduction, however, was found in the control grou ( = 0.36). Conclusions: Kinesiology Taing alications are an effective method of early-stage edema management. Kinesiology Taing may be a safe new theraeutic otion in atients who are contraindicated for the use of other methods. Key words: breast cancer, lymhedema, Kinesiology Taing. Introduction Studies conducted to date show that the most effective method of secondary lymhedema treatment in women after axillary lymhadenectomy due to breast cancer is comlete decongestive theray (CDT) consisting of manual lymhatic drainage (MLD), comression techniques (bandaging, comression sleeves), hysical exercise and skin care. Comlete decongestive theray makes it ossible to achieve an average of 45% of edema reduction. A slightly less effective theraeutic otion is comlex hysical theray (CPT), a combination of different methods of lymhedema treatment, tyically MLD and intermittent neumatic comression (IPC), though other otions are also ossible deending on the healthcare facility s exerience. With CPT, edema can be relieved by an average of ca. 30%. Self-alication of MLD or IPC allows for u to 25% edema reduction. The efficacy of other methods used for the treatment of secondary lymhedema of the uer extremity, such as continuous comression theray, laser theray, self-massage, hysical exercise or aroriate extremity ositioning, ranges between 5% and 11% of edema reduction [1]. Analyses of theraeutic efficacy of different secondary lymhedema-reducing methods erformed so far fail to include Kinesiology Taing (KT) because it is a relatively new treatment modality, though it becomes increasingly common for lymhedema control. The mechanism underlying KT has not, as yet, been fully understood. Similarly to other methods that deform the skin of the extremity, KT increases lymh flow and can be used in the treatment of eriheral lymhedema. According to authors using KT in their ractice, the method relieves tissue fluid congestion, augments blood and lymh circulation, and imroves subcutaneous lymhatic drainage [2, 3]. Kinesiology Taing alications ull the skin slightly, creating more sace between the dermis and fascia [4]. Lymhatic taing is thus quite similar to lymhatic drainage, though it allows atients to receive theraeutic benefits 24 hours a day [5]. Based on analysis of hysiological effects it can also be argued that KT is more similar to comression theray in that it reduces caillary filtration rather than enhancing lymhangiomotor function. A few studies (e.g. Tsai et al.) [6] demonstrated no significant differences in edema reduction between Corresonding author: dr Iwona Malicka, Wydział Fizjoteraii, Akademia Wychowania Fizycznego we Wrocławiu, iwona.malicka@awf.wroc.l Submitted: Acceted:

2 Przegląd Menoauzalny/Menoause Review 13(4) 2014 standard CDT combined with neumatic comression (bandage) and modified CDT (combined with KT). A 17% edema reduction was seen in the grou treated with CFT combined with bandage and only 3% reduction in the grou receiving CFT with KT. It was found, however, that KT might be a more useful otion for atients with oor tolerance of bandaging, as it is more comfortable to the skin esecially in hot climates and during the summer. Moreover, KT is a simler and less demanding technique than comression bandaging, which romts atients to use it more systematically. At the same time, the study demonstrated a higher risk of wounds caused by K-tae than bandage. Kinesiology Taing, on the other hand, may have a significant influence on lymh flow during exercise, as noted in exerimental studies in rabbits. Even though the use of taes resulted in no significant differences in lymh flow, their alication during assive exercise markedly increased lymh flow rates [7]. The observation can be exlained by thermal and mechanical rocesses involved in KT. In view of the above, the aim of the study was to assess the effects of KT on the extent of lymhedema of the uer extremity in women ost cancer treatment. Material and methods Study grou The study was conducted in a grou of 28 middleaged women, with a mean age of years (± 5.95), after axillary lymhadenectomy due to breast cancer. All the study atients were diagnosed with grade I secondary lymhedema and were not given any anti-edema treatment either before or during KT alications. The atients were randomized into 2 grous. The first grou (study grou, n = 14) consisted of women who received KT alications. 78.6% of them had undergone mastectomy and 21.4% breast-conserving surgery. In addition, 71.4% had received radiotheray, 85.7% chemotheray and 64.3% hormone theray. The mean ost-treatment eriod was 6.0 ± 4.8 years. Patients in the second grou (control grou, n = 14) did not receive any anti-edema treatments. 85.7% of them had undergone mastectomy and 14.3% breastconserving surgery. In addition, 35.7% of study articiants had received adjuvant treatment in the form of radiotheray, 71.4% chemotheray and 50% hormone theray. The mean ost-treatment eriod was 5.8 ± 4.8 years. There were no significant differences between grous in variables that could otentially affect study results. Detailed characteristics of study atients are given in Table I. Methods Lymhedema measurement All the women studied had the circumference of their uer extremities measured at 6 levels, using a centimeter tae. The first level was at the roximal base of the metacaral bones and the second across the ulnar and radial styloid rocesses. The remaining four levels were defined by measuring consecutive 10 cm distances from the styloid rocesses u the extremity. The results obtained from the above measurement, based on the difference of the circumference between the swollen limb and the not-swollen limb were used to calculate the edema volume [ml] (Table II). The Limb Volumes Professional 5.0 rogram was used to erform the calculations. This is a software for limb edema and lymhedema tracking, documentation and reorting. Tab. I. Characteristics of study atients and significance of values for differences between the study grou (1) and the control grou (2) Parameter Grou 1, n = 14 Grou 2, n = 14 Age [years] 60.1 ± ± Body mass [kg] 75.4 ± ± Body height [cm] ± ± Radical surgery [n] Surgery on the right breast [n] Post-surgery eriod [years] 6.0 ± ± Adjunctive treatment [n] Radiotheray [n] Chemotheray [n] Hormone theray [n]

3 Przegląd Menoauzalny/Menoause Review 13(4) 2014 Tab. II. Examle circumference result calculation into volume values Centimetres from wrist Circumferences (cm) Segment number Volume (ml) Right (affected) Left (not affected) Right Left Edema 258 It automatically uses the alication of circumferencebased methods to determine the edema volume on the basis on the aroriate algorithm. The first measurement (1) was erformed at baseline, i.e. rior to the initiation of theray. The second after 2 weeks of KT alications and the final one (in the study and control grous) after the comletion of KT, i.e. 4 weeks. Kinesiology Taing alications All the study grou women received KT theray. A total of 4 alications were made, one in each consecutive week. The atients were randomly divided into two sub-grous of seven. Each sub-grou was given two different tyes of alications according to the KT methodology. Lymhatic alication was erformed using tae with a 1 cm wide base and tails divided into four arts. The maximum tension of the tails was 15%, after holding down the base of the tae during alication. During the tae alication rocedure the atients were in the sitting and suine osition, deending on the alication given. In the first sub-grou, the tae was alied to the edematous uer extremity in individual fan shaes on the arm and forearm, and along anastomoses (Fig. 1A). It is assumed that in big lymhatic vessels of trunk lanes in certain laces there occur links with collectors of neighboring territories. These are so called anastomoses fusions. Lymhatic encumbrances for the given region of lymh confluence can in such a case be transorted to adjoining areas with lymh nodes without morbid condition. In our research this was the lymh nodes area based oosite armit: armit armit anastomosis. In the second sub-grou, the tae was alied only to the uer extremity in a double fan shae within the arm and forearm (Fig. 1B). None of the above grous took art in any other hysiotheraeutic sessions during the research. Within the grous there were also no hysical imrovement exercises. Statistical analysis Statistical analysis was made with STATISTICA software using basic descritive statistics and, due to the fact that the atient grous were small, non-arametric analyses of the significance of differences: for indeendent variables (between grous) the Mann-Whitney U test; for deendent variables (between measurements within grous) the Wilcoxon test; and for the analysis of reduction in the extent of lymhedema the Friedman test. A B Fig. 1. A) KT alications in subgrou 1. B) KT alications in subgrou 2 223

4 Przegląd Menoauzalny/Menoause Review 13(4) 2014 Tab. III. Significance of differences between edematous and the oosite extremity Grou Edematous extremity V [ml] Baseline Final Non-edematous extremity V [ml] Baseline Final Baseline Final Study grou (1) ± ± ± ± Control grou (2) ± ± ± ± Tab. IV. Significance of differences between reliminary and final s within and between grous Grou Difference: edematous extremity vs. non-edematous extremity, V [ml] Baseline Final Study grou (1) ± ± Control grou (2) ± ± X Results Subgrou 1 Subgrou 2 Control grou Edematous extremity, baseline [ml] Edematous extremity, final [ml] Non-edematous extremity [ml] Fig. 2. Mean values [ml] obtained in 2 subgrous deending on the tye of KT alications The results were based on the total extremity values obtained from the circumference measurements with the use of LVP rogram. During baseline (1), a significant difference in total volume [ml] was found between the uer extremity on the oerated side and the oosite side for both grous. Nonetheless, the difference was not demonstrated in the study grou during final (3) (cf. Table III). This means that in the grou of atients undergoing KT alications a significant reduction in the extent of lymhedema was obtained between the baseline 1 and final 3 (0.0009). No such difference was found in the control grou (0.36), even though the study grou (subjected to KT alications) had a statistically greater ( = 0.04) extent of lymhedema (cf. Table IV). Further statistical analysis was erformed only for the study grou, describing in detail all changes observed as a result of KT alications. Figure 2 resents results referring to two sub-grous selected randomly based on the tye of KT alications. A statistically significant reduction was found in both cases (cf. Table V). Discussion Lymh flow can be romoted e.g. by walking, arterial ulsation, lymhangiomotor function, muscle activity, hysical exercise, massage or breathing, which are all recognized as causes of tissue deformation. Lymh formation and transort can be exlained as a result of extension and comression of the initial lymhatics, determined by the deformation of tissues in which they are embedded. Passive exercise or cyclic comression have been shown to roduce an increase in lymh flow rates in rabbit hind legs [7]. The observation suggests that all methods which deform the skin of the extremities may also imrove lymh flow and hence can be successfully used for the theray of eriheral lymhedema. At resent, the mechanism is used by hysical theray comrising comression theray, MLD and hysical exercise. A relatively new method of tissue deformation is KT, first develoed in 1973 [3]. Kinesiology Taing has been increasingly used for lymhedema reduction even though its mechanism of action has not been sufficiently elucidated and there is no absolutely convincing evidence that KT is clinically beneficial. Kinesiology Taing is believed to alleviate ain or abnormal sensation, enhancing muscle function, removing lymh accumulating under the skin and imroving the osition of joints. Kinesiology Taing increases the sace between the skin and muscle tissue, thus facilitating blood and lymh flow. Kinesiology Taing is better tolerated by atients and can be worn for 1-3 days or longer. 224

5 Przegląd Menoauzalny/Menoause Review 13(4) 2014 Tab. V. Significance of differences found in 2 subgrous deending on the tye of KT alications A) KT with anastomoses Subgrou 1 1 [ml] NE [ml] B) KT without anastomoses Subgrou 2 1 [ml] 2 [ml] 3 [ml] X [ml] 2 [ml] 3 [ml] 1 [ml] X NE [ml] Edematous extremity, 1 [ml], 2 Edematous extremity, 2 [ml], 3 Edematous extremity, 3 [ml], NE non-edematous extremity [ml] Being waterroof, the tae does not need to be removed before washing. Because of the rogressive nature of lymhedema, the effects of treatment deend both on whether it is initiated early enough and whether the right method is adoted. Even early stages of lymhedema should not be overlooked since lymh circulation disorders adversely affect muscle function, fascia and skin tone, thus reducing atients mobility [2]. Women ost breast cancer treatment usually reort reduced mobility and muscle weakness in the uer extremity on the oerated side as well as ain, discomfort, subjective sensation of tissue burst and increased limb circumference, leading to the develoment of secondary lymhedema [8-10]. Disturbed lymh flow in mastectomy atients can manifest itself any time. It may emerge during the first ostoerative days or have a latency eriod of u to 30 years [11]. Consequently, this grou of atients should receive secial care. The majority of women after breast cancer treatment scale down their daily hysical activity, rimarily due to fatigue, which is the most common symtom associated with cancer treatment [12, 13]. Comromised hysical activity, in turn, makes it imossible for lymh circulation to be imroved by muscle um activation, resulting in the develoment or exacerbation of secondary lymhedema. A vicious circle emerges. Reduced mobility, originally a consequence of disease treatment, decreases the activity of the muscle um. Lymhedema occurs, further reducing the hysical activity of atients and adversely affecting their daily functioning and quality of life, often leading to social isolation and mental disturbances [8, 14]. Therefore, it is vital to introduce edema rohylaxis and early hysical theray in atients. Deending on the site and tye of alication, KT can roduce different effects. Alied in lymhologic disorders, KT imroves lymh microcirculation. Regardless of the tye of KT alication (with or without anastomoses), a statistically significant reduction in circumferences was noted in the uer extremities on the oerated side in the study grou. Lack of significant differences deendent on the tye of KT alication (with or without anastomoses) may stem from the discussion on the ossible waste of lymh flow after armit lymhadenectomy. The median sagittal lymhatic watershed boundary and the transverse lymhatic watershed boundary, divide the trunk into four quadrants. However the density of the anastomoses varies from individual to individual [15]. Besides, desite existing anatomical ossibilities, collateral athways will not form if the area is blocked by extensive scars. In this context, it is said that both the generation of new lymh vessels and the formation of lymho-lymhatic anastomoses lay an imortant role [15]. The above result may thus suggest a successful use of KT in the initial symtoms of the lymhedema regardless of the lymhatic alication used. The tae acts as a um continually stimulating the lymh circulation on a 24 hr/day basis. Next, there occurs lifting and folding of eidermis with the aillary layer of dermis. That, in result, leads to the increase in the blood flow caacity within the subaillary vessel net and in dee skin vessels and multilication of lymh transort from ailla lymh caillaries to blood vessels. Thanks to this rocess, more beneficial circumstances for regeneration within the morbid condition area develo. Finally, normalization of muscle tension aears followed by activation of blood and lymh flow and decrease in ain ailments and motility imrovement [16]. Excet for a few reorts [2, 4, 17-20] in the literature, there are no well-conducted randomized, controlled studies with KT and breast cancer related lymhedema. More efficient treatment rotocol is needed for clinical ractice. 225

6 Przegląd Menoauzalny/Menoause Review 13(4) 2014 In view of the above observations, it aears that KT alications might be beneficial in standard edemareducing hysical theray. Physical exercise is esecially imortant during comlete decongestive theray, i.e. lymhatic drainage combined with bandaging. Limb bandaging, however, markedly reduces the ossibility of leading an active life and erforming a full sectrum of movements. In this light, relacing bandaging with KT alications seems a theraeutically reasonable solution. A study by Tsai et al. [6] confirms this ossibility. The researchers demonstrated a significant reduction in the extent of lymhedema both in the grou of atients receiving bandaging and in the grou undergoing KT alications. Benefits of this modification of CDT have also been demonstrated exerimentally in rabbit studies. Kinesiology Taing combined with a 15-minute exercise rogram resulted in significant differences in lymh flow rates [7]. Physical exercise is of crucial imortance for the elimination of edema, as the muscle um romotes lymh flow. Insufficient hysical activity may lead to inadequate outflow of lymh [17]. Kinesiology Taing thus oens u the way for a safe new theraeutic modality in the treatment of atients who have contraindications to other methods. It can be a good alternative for atients with bandaging roblems (oor tolerance or contraindications resulting from coexisting conditions). In a study by Tsai et al. [6], KT alications were better tolerated by atients than bandaging, mainly due to greater comfort and no roblems with everyday activities. Kinesio Tex tae, similar in its roerties to human skin, can be a simle and well-acceted method of edema management which, as a rule, is multi-hase, long and costly, and does not always bring entirely satisfactory results. Major limitations of the resent study were its relatively small study grou, which increased the risk of randomness of results, and a short follow-u eriod. Future studies would be useful to investigate the extent of lymhedema reduction after KT alications in a larger grou of atients. A bigger study grou would increase the reliability of conclusions and lower the risk of errors. Furthermore, remote effects of the method should be monitored to evaluate long-term maintenance of efficacy. Conclusions 1. Kinesiology Taing is an effective method of reduction in early-stage lymhedema of the uer extremity in women after breast cancer treatment. 2. Regardless of the tye of KT alications, the edema was found to have decreased significantly. 3. There were no differences in the extent of edema reduction induced by different tyes of Kinesiology Taing. Disclosure Authors reort no conflicts of interest. References 1. Moseley AL, Carati CJ, Piller NB. A systematic review of common conservative theraies for arm lymhoedema secondary to breast cancer treatment. Ann Oncol 2007; 18: Białoszewski D. Przydatność kliniczna metody Kinesiology Taing w redukcji obrzęków kończyn dolnych u acjentów leczonych metodą Ilizarowa doniesienie wstęne. Ortoedia, Traumatologia, Rehabilitacja 2009; 1: Kenzo K, Walles J. Clinical Theraeutic Alications of the Kinesio Taing Method. 2 nd ed. Ken Ikai Co. Ltd., Liińska A, Śliwiński Z, Kiebzak W, et al. Wływ alikacji kinesiotaingu na obrzęk limfatyczny kończyny górnej kobiet o mastektomii. Fizjoteraia Polska 2007; 3: Put M. Taing jako metoda ostęowania teraeutycznego. Fizjoteraia 2007; 15: Tsai H-J, Hung H-Ch, Yang J-L, et al. Could Kinesio tae relace the bandage in decongestive lymhatic theray for breast-cancer-related lymhedema? A ilot study. Suort Care Cancer 2009; 17: Shim JY, Lee HR, Lee DC. The use of elastic adhesive tae to romote lymhatic flow in the rabbit hind leg. 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