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Ar t i g o Ci e n t í f i C o
ISSN 1413-3555
Rev Bras Fisioter, São Carlos, v. 12, n. 1, p. 31-6, jan./fev. 2008
©Revista Brasileira de Fisioterapia
Influence of complex descongestive
physical therapy associated with intake
of medium-chain triglycerides for treating
upper-limb lymphedema
Influência da fisioterapia complexa descongestiva associada à ingestão de
triglicerídeos de cadeia média no tratamento do linfedema de membro superior
Oliveira J1, César TB2
Abstract
Objective: To investigate the influence of complex decongestive physical therapy (CDP) in association with diet therapy using medium-
chain triglycerides (MCT), as an intervention in cases of upper-limb lymphedema. Methods: The lymphedema was evaluated by measuring
circumferences, volumes, skin folds and whole-body water content. Feelings of discomfort, pain and heaviness in the arms were evaluated
using a visual analog scale. Ten women who had undergone mastectomy and presented upper-limb lymphedema homolateral to the surgery
participated in this study. Their mean age was 65.9 ± 10.4 years and their mean body mass index (BMI) was 26.8 ± 3.0kg/m². After nutritional
evaluation, they were randomly divided into two groups: the Control Group (n= 5), which underwent physical therapy treatment consisting of
CDP (classical massage, manual lymphatic drainage, compression taping and skincare) three times a week, for four weeks; and the MCT Group
(n= 5), which underwent the same physical therapy protocol with the addition of daily diet therapy consisting of intake of MCT, for four weeks.
Results: At the end of the intervention, analysis of the circumference and volume measurements showed significant differences between the
groups (p≤ 0.05), with a greater reduction in lymphedema in the MCT Group. There were no significant differences in the skin fold measurements
or whole-body water content. The feeling of heaviness in the arms after the intervention was significantly less in the MCT Group (p≤ 0.05),
compared with before the intervention. Conclusion: Physical therapy treatment together with diet therapy with intake of MCT in women with upper-
limb lymphedema following surgery and breast cancer treatment was effective in reverting this condition.
Key words: lymphedema; complex decongestive physical therapy; diet therapy; medium-chain triglycerides.
Resumo
Objetivo: Verificar a influência da utilização da fisioterapia complexa descongestiva associada à dietoterapia com triglicerídeos de cadeia
média (TCM) como forma de intervenção no linfedema de membro superior (MS). Métodos: Para a avaliação do linfedema, foram utilizadas
cirtometria, volumetria, pregas cutâneas e quantidade de água corporal total. A Escala Visual Análoga (EVA) foi utilizada para avaliar as
sensações de desconforto, peso e dor no MS. Participaram deste estudo dez mulheres mastectomizadas com linfedema de MS homolateral
à cirurgia, com idade média de 65,9 ± 10,4 anos e índice de massa corpórea (IMC) de 26,8 ± 3,0kg/m² que, após avaliação nutricional, foram
divididas aleatoriamente em dois grupos: Grupo Controle (n= 5), submetido ao tratamento fisioterapêutico constando da terapia complexa
descongestiva (massagem clássica, drenagem linfática manual, bandagem compressiva e cuidados com a pele) três vezes na semana,
durante quatro semanas; Grupo TCM (n= 5), submetido ao mesmo protocolo fisioterapêutico somado ao tratamento dietético diário com
ingestão de TCM, por quatro semanas. Resultados: Ao final da intervenção, a análise da cirtometria e da volumetria mostraram diferenças
significativas entre os grupos (p≤ 0,05), com maior redução do linfedema no Grupo TCM. Não houve diferença significativa nos valores
das pregas cutâneas e da quantidade de água corporal total. A sensação de peso no membro superior, antes e após a intervenção, foi
significativamente menor (p≤ 0,05) no Grupo TCM. Conclusões: O tratamento fisioterapêutico somado à dietoterapia com ingestão de TCM
em mulheres portadoras de linfedema de MS pós-cirurgia e tratamento de câncer de mama foi efetivo na involução desta condição.
Palavras-chave: linfedema; fisioterapia complexa descongestiva; dietoterapia; triglicerídeos de cadeia média.
Recebido: 30/01/2007– Revisado: 30/07/2007 – Aceito: 20/11/2007
This study was presented in the form of a poster at the First Physical Therapy Meeting: New Trends in Physical Therapy, promoted by the Physical Therapy course of the School of Philosophy and
Sciences, State University of São Paulo (UNESP), Marília Campus, held on March 29 and 30, 2006.
1 Physical Therapy course, Centro Universitário de Araraquara, Araraquara (SP), Brazil
2 Department of Food and Nutrition, School of Pharmaceutical Sciences, Universidade Estadual Paulista (UNESP), Araraquara (SP), Brazil
Correspondence to: Jussara de Oliveira, Avenida Cônego Jerônimo César, 1.190, Carmo, CEP 14800-470, Araraquara (SP), e-mail: jussaraft@netsite.com.br
31
Rev Bras Fisioter. 2008;12(1):31-6.
Oliveira J, César TB
32
Rev Bras Fisioter. 2008;12(1):31-6.
Introduction
Follow-up for breast cancer patients after adjuvant treat-
ment is important because complications may occur, such as
chest wall adherences, restrictions on shoulder movements,
pain, hypoesthesia and, particularly, upper-limb lymphedema1.
When the lymphatic vessels are removed or damaged, the
lymphatic transportation is damaged and the lymphatic uid
accumulates in the interstitial spaces of the tissue around the
aected site. is extends to the upper limbs on the aected
side and characterizes lymphedema2.
To evaluate lymphedema, a variety of measurements are
used, such as circumference measurements3, volumetry4 and
multiple frequency electrical bioimpedance5. ese enable pre-
dictions regarding the degree of lymphedema in the aected
limb6 and make it possible to choose the most appropriate
intervention7. Electrical bioimpedance is used to estimate
the quantities of liquid in body compartments and has been
applied in investigating uid volumes in limbs presenting
lymphedema8,9. e triceps and biceps skinfolds are nutritio-
nal indicators that can be used to investigate the malleability
of the skin and the consistency of lymphedema10.
Among the interventions for treating lymphedema, com-
plex decongestive physical therapy4 stands out. is includes
procedures such as manual lymphatic drainage (MLD)11,
compressive bandaging (CB)12 or elastic restraint, pelvic oor
exercise programs and skin care2.
Biochemical analyses of human lymphedema show the pre-
sence of high proportions of long-chain triglycerides (LCTs) with a
high content of kilomicrons13. Change s in the qua ntitie s of LCTs in
the lymph uid may alter the composition of the uid, thus leading
to decreased ow and pressure in the lymphatic system, thereby
diminishing its overload13,14. Medium-chain triglycerides (MCTs)
with six to 12 carbons are absorbed directly into the bloodstream
because, dierently from long-chain fatty acids, they are not incor-
porated into kilomicrons15. After passing through the enterocytes,
they reach the portal circulation and are transported to the liver
by albumin, without going through the lymphatic system16.
Soria et al.13 described the use of MCTs, corresponding
to 58% of the total fat consumed, as a substitute for LCTs for
patients with idiopathic lymphedema. ey showed that there
was a signicant reduction in the circumference measurement
of the aected limb after four months of an LCT-free diet in
association with physical therapy treatment.
Because lymphedema is a frequent complication following
breast cancer and results in the loss of functional abilities and
esthetic deformities17, new forms of interventions in associa-
tion with the conventional techniques are needed in order to
reduce the presence of lymphedema. erefore, the present
study had the objective of investigating the inuence of using
classical massage, manual lymphatic drainage and compres-
sive bandaging in association with consumption of MCTs as a
means of intervention for lymphedema cases.
Methodology
After obtaining approval (on June 9, 2005) from the Research
Ethics Committee of the School of Pharmaceutical Sciences of
UNESP in Araraquara, State of São Paulo (case no. 01/2005),
16 women with upper-limb lymphedema were recruited and
sent to the UNIARA Physical erapy Clinic. e participants
were selected by means of individual interviews explaining
the objectives, duration and procedures of the study. Cases of
metastasis, phlebitis, acute-phase erysipelas and dyslipidemia
were excluded. All the participants signed a consent state-
ment, in compliance with National Health Council resolution
no. 196/96. After beginning of the study, three women were
found to demonstrate erysipelas in the aected upper limb,
two were unavailable for carrying out the weekly protocol and
one terminated her participation.
is study, which was blind and randomized, was conduc-
ted on 10 women of a mean age of 65.9 ± 10.4 years and a BMI
of 26.8 ± 3.0, who had homolateral upper-limb lymphedema
subsequent to breast cancer surgery and axillary lymphade-
nectomy. Among these patients, seven underwent quadran-
tectomy and three had modied radical surgery. ere was an
equal prevalence of breast laterality and aected upper limb:
half of the breast cancer sample involved the right side and
the other half, the left side. All cases needed axillary emptying
up to level III. With regard to postsurgical treatment, eight pa-
tients needed more than 30 radiotherapy sessions and only two
had less than 28 applications, while six patients underwent six
chemotherapy sessions and four had between seven and 12
applications. e lymphedema appeared within one year in ve
patients, while two of them reported lymphedema between
one and three years after surgery and the other three patients
presented this between three and ve years after their breast
cancer treatment.
e participants were allocated alternately into two groups
according to when they were sent to the clinic: the control group
(n= 5) underwent physical therapy treatment for lymphedema,
three times a week for four weeks, the MCT group (n= 5) un-
derwent physical therapy treatment, three times a week with
daily dietary consumption of MCT oil, for the same period. e
MCT Group was instructed to use the MCT oil (Triglyceryl CM)
as their main source of dietary fat, representing around 50-60% of
total lipid consumption. e control group used corn oil as their
fat source, which mostly contains LCTs, with trace quantities of
MCTs. None of the participants knew which group they were in,
Interdisciplinary intervention for lymphedema
33
Rev Bras Fisioter. 2008;12(1):31-6.
but they were aware that they were using one or another of the
provided oil sources. To monitor their consumption, they were
asked, while following the protocol, to make periodic records so
that each participant’s nutritional intake could be followed up.
e data collection consisted of bilateral upper-limb cir-
cumference measurements, at the beginning of each session,
at predened xed points18. Volumetry was performed on the
upper limbs before and after the interventions, by immersing
the limb in a volumetric column, with water leveled up to the
middle third of the arm. e liquid that overowed out of the
column was measured in order to obtain the volume of the
limb. e electrical bioimpedance was measured using specic
total body water apparatus (Biodynamics, model 310) to gene-
rate a 50 kHz electric current that measured the total quantity
of body water. Feelings of discomfort, heaviness and pain in the
aected upper limb were obtained using a visual analog scale
(VAS), before and after the experiment.
e body weight was obtained with the volunteers in a
standing position, at the center of the base of a duly calibrated
platform balance, with as little clothing as possible. eir height
was measured using a tape measure attached to a wall, with the
patient standing against the wall, without shoes, with heels toge-
ther, vertebral column upright, arms extended next to the body
and with the head aligned. e triceps skinfold was measured
using a skinfold adipometer positioned on the posterior face of
the arm, at the midpoint between the superolateral edge of the
acromion and the olecranon. e biceps skinfold was measured
on the anterior face of the arm, one centimeter above the loca-
tion marked for the triceps skinfold measurement, with the palm
of the patient’s hand turned to the front5. e dietary prole was
obtained from the food frequency questionnaire, in which the
patients described their frequencies of intake; their daily, weekly
and monthly food consumption; and by the 24-hour dietary re-
call record, with descriptions of all food and drinks consumed
within 24 hours19 in homemade measures.
e treatments for the aected upper limb consisted of
applications, at each session, of various types of classical mas-
sage with the use of supercial and deep sliding maneuvers, for
the whole upper limb, followed by compression maneuvers20.
Manual lymphatic drainage was performed in accordance with
the maneuvers of Leduc and Vodder1,21, starting with evacuation
and ending with capture11,21. Compressive bandaging was perfor-
med after manual lymphatic drainage and was maintained for a
period of at least 10 hours. e upper limb was rst wrapped with
tubular mesh, followed by protective sponge. Elastic bandages of
width ve cm were wrapped around the ngers and the hand.
Bandages of an eight cm width were overlaid on the wrist region
and the proximal third of the forearm. Bandages of a 10 cm width
were wrapped over these, up to the level of the axillae, leaving
the elbow region free to maintain functionality of the limb2.
e parametric data was analyzed using Student’s t test
and the nonparametric data using the Mann-Whitney test and
the Wilcoxon matched pairs test, with p≤ 0.05.
Results
Figure 1 illustrates the mean values for the dierences in
circumference measurements between the aected and heal-
thy upper limbs of the MCT group, gathered at the beginning
and end of the study protocol, in comparison with the mean
values for the dierences in these measurements between the
aected and healthy limbs of the control group. Statistically
dierent values at p<.03 could be seen from analyses of the
reduction in the dierences in circumference measurement
between the involved and healthy limbs of the MCT group, in
relation to the same measurements for the control group. is
demonstrated that, in the forearm region, there was a greater
reduction (p≤ 0.05) in the MCT group, i.e., more pronounced
decreases in lymphedema in the patients of this group.
Figure 2 shows the volumetry for the upper limbs, compa-
ring the mean reductions in volume dierences between the
two limbs (aected and healthy) and between the groups, at
the end of the intervention. From this, it can be seen that there
was a greater reduction in the MCT group, at the end of the tre-
atment (p≤ 0.05). e mean values for the control group were
negative, meaning that there was an increase in the dierences
in volume between the aected and healthy limbs of the parti-
cipants in this group. Hence, in the end, there was an increase
in lymphedema for this group.
Comparisons of the reduction in skinfold thicknesses in
the aected upper limb (Figure 3) showed that there were no
signicant dierences in the nal values between the groups.
Figure 1. Comparisons between the mean differences in circumference
measurements of the affected and healthy upper limbs of the two groups,
before and after the intervention.
0
1
2
3
4
5
6
7
8
9
MCT
Control
Control
Control
Control
Control
Control
MCT
MCT
MCT
MCT
MCT
1 2 3 4 5 6
Circumferential points
cm
Initial
Final
*
Point 1: the metacarpophalangeal joints of the second to fifth fingers; Point 2: an
imaginary line going through the metacarpophalangeal joint of the first finger; Point
3: 10 cms below the olecranon; Point 4: 6 cms below the olecranon; Point 5: 6 cms
above the olecranon; Point 6: 10 cms above the olecranon.
*p≤ 0.05.
Oliveira J, César TB
34
Rev Bras Fisioter. 2008;12(1):31-6.
0
3
6
9
12
15
mm
MCT G roup
Contro l Group
TS BS
TS= triceps skinfold; BS= biceps skinfold.
Figure 3. Comparisons between the mean reductions in skinfolds in
the affected upper limbs, at the end of the treatment.
Figure 4. Comparisons between the mean reductions in the quantities
of body liquid in the two groups, at the end of the intervention.
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Groups
Liters
MCT Group
Control Gro up
Regarding the total body water quantities found by electri-
cal bioimpedance, comparisons of the mean reduction in body
water between the groups, after the intervention, did not show
any signicant dierences, as seen in Figure 4.
From the patients’ subjective feelings about their lymphe-
dema found through the VAS, Figure 5 shows that there was
a statistically signicant decrease (p≤ 0.05) in the degree of
discomfort for both groups, comparing the initial and nal va-
lues for each group. Regarding feelings of arm heaviness, only
the MCT group presented a signicant decrease (p≤ 0.05) at
the end of the intervention. ere were no dierences in the
feelings evaluated between the two groups.
Discussion
Lymphedema develops from an imbalance between
the lymphatic demands and the system’s capacity to drain
the lymph. Since high molecular weight proteins that are
extravasated to tissue interstices are solely absorbed by the
lymphatic system, if this system loses its drainage capacity
because of the destruction or obstructions of the lymph
ducts at some point, this causes stagnation of the lymph
in the vessel and subsequent extravasation back to the in-
terstices22. It also results in a combination of factors such
as obesity. Studies have reported that the patient’s age and
whether the surgery was on the dominant or nondominant
side were not statistically associated with the development
of edema23. However, Freitas et al.24 noted that there were
significant relationships between lymphedema frequency
and the weight and age of the patients. In the present study,
the patients demonstrated a mean BMI of 26.8 and classified
as being pre-obese5, which proved to be an important factor
in establishing lymphatic edema.
e skin is responsible for supercial absorption of the
lymph uid and skincare is essential to lymph therapy pro-
cedures20. Classical massage was shown to be eective in the
present study, since it assisted in reducing the lymphedema.
-150
-100
-50
0
50
100
150
200
250
300
mL
MCT
Control Group
*
Figure 2. Comparisons between the mean reductions in volume
difference (ml) in the affected and healthy upper limbs, for the two
groups, at the end of the treatment.
*p≤ 0.05.
Figure 5. Comparisons between the degrees of feelings shown by the
VAS, before and after the intervention. For discomfort: Degree 1: no
discomfort; Degree 2: slight discomfort; Degree 3: moderate discomfort;
Degree 4: a lot of discomfort; Degree 5: severe discomfort. For heaviness
in the affected limb: Degree 1: no heaviness; Degree 2: slight heaviness;
Degree 3: moderate heaviness; Degree 4: heavy; Degree 5: very heavy.
For pain in the affected limb: Degree 1: no pain; Degree 2: slight pain;
Degree 3: moderate pain; Degree 4: severe pain; Degree 5: unbearable.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Degree
Initial
Final
* * *
HeavinessDiscomfort Pain
MCT Control MCT Control MCT Control
*p≤ 0.05.
Interdisciplinary intervention for lymphedema
35
Rev Bras Fisioter. 2008;12(1):31-6.
Manual lymphatic drainage is used to drain the excess li-
quids that bathe the cells and maintain the hydric equilibrium
of the interstitial spaces21. e technique used in the present
study enabled reductions in the circumference and volume
of the aected limb in the MCT group, thus reinforcing the
importance of this procedure for decreasing lymphedema.
Manual lymphatic drainage may be indicated together with
other treatments, so that it is possible to contain the edema at
a comfortable level, reduce the pain and brosis and also bring
relaxation and provide a feeling of well-being25. In our study,
there was a general improvement in the subjective feelings in
the upper limb aected by lymphedema.
Compressive bandaging has been shown to be an eective
resource, because it increases the lymphatic absorption and
ow achieved through prior manual lymphatic drainage26. In
the present study, there were signicant decreases in the lym-
phedema in the patients who had MCT intake in addition to
the physical therapy interventions.
With regard to electrical bioimpedance, it is known that
its results vary according to the tissue that is being measu-
red. It can thus be said that the values obtained were direc-
tly proportional to the body fat percentage. In addition to
body fat and lean mass evaluations, this method establishes
the quantity of body water and is therefore an important
follow-up tool for patients with pathological conditions of
increased extracellular liquid27. The bioimpedance study by
Cornish et al.28 indicated that there was higher precision
in calculating body water volumes using segmental body
impedance, rather than taking the body as a whole. In the
present study, this examination was not done segmentally,
and therefore it was not possible to obtain definitive con-
clusions from evaluating the lymphedema. Nonetheless, it
was shown to be important for nutritional evaluation of the
patients. Thus, more studies are needed using segmental
bioimpedance to evaluate lymphedema.
e biceps and triceps skinfold measurements did not indi-
cate any direct relationships with the conventional methods for
lymphedema evaluation, since these are traditionally nutritional
indicators. According to Shills et al.29, indirect calculation of body
composition by measuring the subcutaneous fat in the skin-
folds is the method most used in such investigations. Skinfold
measurements have the purpose of estimating total body fat,
because there is a relationship between localized fat deposited
under the skin and body density30. Measurement of these folds
was used here in an attempt to investigate improvements in skin
malleability and the consistency of the lymphedema.
In agreement with the results from Soria et al.13, the use of
MCT by patients with lymphedema was shown to be eective,
considering that in the present study there were signicant
reductions in the circumference measurements and volume of
the aected limb, in comparison with the group control, thus
signifying a decrease in the lymphedema in the patients who
used MCT as additional therapy.
MCTs, which are rich in medium-chain fatty acids, are
hydrolyzed by pancreatic lipase action and are absorbed in
the duodenum more rapidly than are long-chain fatty acids.
According to Yokocama and Fagundes31, a low-fat diet that
is rich in MCTs must be used for individuals with intestinal
lymphangiectasia and consequent lymphatic insuciency,
in order to decrease accumulations in the lymph ducts and
reduce the pressure in these dilated vessels. MCTs are not
esteried or absorbed in the intestinal lymphatic system and
chest duct, but enter directly into the portal system: hence
the reason for their use. Alcauza and César32 used MCT as
a diet therapy method among women with upper-limb lym-
phedema and obtained positive results, with reductions of
the clinical symptomatology.
In the present study, it could be seen that the use of
MCTs as a means of lymphedema treatment was satisfactory,
since the patients who used MCT as a nutritional supplement
demonstrated significant improvements compared with
the control patients. This also leads us to wonder whether
the lipid diet of vegetable oil that was administered in the
control group might have constituted a contributory factor for
non-regression or even increased lymphedema because that
diet was composed of long-chain fatty acids. After absorption
of these fatty acids derived from vegetal oil, they leave the
intestine in the form of triglycerides through the lymph
ducts, incorporated in kilomicrons and transported by
the lymphatic system. By increasing the overload in a lym- overload in a lym-
phatic system that is already compromised, this may come
to negatively inf luence the involution of the lymphedema.
Therefore, the present study draws attention to the fact
that ordinary diets that are rich in long-chain fatty acids
may not be ideal for people with lymphedema, and sug-r people with lymphedema, and sug-
gests that further studies in this area are needed .
In conclusion, physical therapy treatments with the addi-
tion of dietary therapy consisting of MCT intake among wo-
men with upper-limb lymphedema following mastectomy was
eective for the involution of this condition. Further studies
are needed in order to investigate the importance of interdisci-vestigate the importance of interdisci-
plinary therapies for treating this condition.
Oliveira J, César TB
36
Rev Bras Fisioter. 2008;12(1):31-6.
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