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Bioimpedance assessment of edema in patients with mastectomy-related lymphedema treated by mechanical lymph drainage using the ragodoy® device
Abstract
Few apparatuses have been developed for the treatment of arm lymphedema. The objective of this study was to use bioimpedance to evaluate the efficiency of the RAGodoy® mechanical drainage device in reducing swelling in the treatment of mastectomy-related arm lymphedema. Twenty-one patients with arm lymphedema after mastectomy were enrolled in a prospective study (clinical trial) to quantitatively evaluate reductions in limb size using a passive electromechanical device to perform mechanical lymph drainage. The study was conducted in the Vascular Laser Center in Sao Jose do Rio Preto. The InBody S10® body composition analyzer was used to evaluate edema. The paired t-test was used for statistical analysis with significance being set for an alpha error = 5% (p-value < 0.05). The results showed that a significant reduction in edema was observed after mechanical lymph drainage using the RAGodoy® device (p-value < 0.012). In conclusion, lymph drainage performed with the electromechanical RAGodoy® device is effective in reducing volume of arm lymphedema as assessed by bioimpedance.
... Other assessment tools were used as part of a lymphedema assessment. Bioimpedance spectroscopy (BIS) was used to quantify the volume of extracellular fluid of the whole arm in 11 (22%) studies (16,24,26,33,34,44,48,57,61,63,64), with one study also measuring the interlimb ratio for extracellular fluid within 10 cm segments along the arm (48). The Impedimed V R SFB7 was used in five studies reporting the interlimb extracellular fluid ratio (24,34,48,57,61) and the Impedimed U400 was used in three studies. ...
... Kuhnke formula) (22,31,32); iii) simplified Frustum formula; (21,30) iv) numerical integration by piecewise quadratic approximation (a.k.a. Simpson's rule of integration for volume) (13) and v) one other unlabelled formula for volume (24,40) (Appendix 2). BIS was used in 11 studies (15,16,24,26,33,34,44,48,57,61,64) of which all but one reported change in size (64). For measurements using BIS, the interlimb extracellular fluid volume was presented as a ratio in five studies (24,34,48,57,61) and converted to an L-Dex V R score in three (15,16,26) Of the remaining three studies, one reported results by 'arbitrary bioimpedance machine units' (44), one cited results in an unpublished table (64), and the third presented results, however, it was unclear what data were representing (33). ...
... Kuhnke formula) (22,31,32); iii) simplified Frustum formula; (21,30) iv) numerical integration by piecewise quadratic approximation (a.k.a. Simpson's rule of integration for volume) (13) and v) one other unlabelled formula for volume (24,40) (Appendix 2). BIS was used in 11 studies (15,16,24,26,33,34,44,48,57,61,64) of which all but one reported change in size (64). For measurements using BIS, the interlimb extracellular fluid volume was presented as a ratio in five studies (24,34,48,57,61) and converted to an L-Dex V R score in three (15,16,26) Of the remaining three studies, one reported results by 'arbitrary bioimpedance machine units' (44), one cited results in an unpublished table (64), and the third presented results, however, it was unclear what data were representing (33). ...
Purpose: To ascertain how change in upper body lymphedema is assessed and understand how clinically significant change is determined.
Method: A systematic search of the literature resulted in 55 eligible studies for analysis.
Results: A range of assessment methods, measurement protocols, and outcomes were used in the literature. Of the 21 studies in which thresholds for change were set a priori, 20 different thresholds were reported.
Conclusion: How data was measured, analysed and reported was inconsistent across studies. Consensus on a core outcome set with standardised assessment protocols and reporting; and investigation into empirically based minimum important differences (MID) is needed.
... The first study was published in 2009 and showed a reduction in volume when the device was used as monotherapy [36]. In 2011, bioimpedance was used to assess the results of the device as monotherapy, revealing a reduction in edema [37]. In 2012, two new studies reproduced these evaluations and confirmed the effectiveness of the device [38][39]. ...
Lymphatic drainage is the main form of therapy for lymphedema, as it affects the pathophysiology of this clinical condition. The two main objectives of lymphatic drainage are the formation and drainage of lymph. In recent years, Godoy & Godoy developed a novel concept of mechanical lymphatic drainage involving a device denominated RAGodoy®, which performs passive exercises of the lower and upper limbs as a form of lymphatic drainage. The aim of the present study was to address the concept of this therapy as well as perform a literature review on its forms of use and the results obtained. All studies analyzed show that this technique used as monotherapy enables the treatment of lymphedema, but superior results are achieved when combined with compression mechanisms.
... The first study was published in 2009 and showed a reduction in volume when the device was used as monotherapy [36]. In 2011, bioimpedance was used to assess the results of the device as monotherapy, revealing a reduction in edema [37]. In 2012, two new studies reproduced these evaluations and confirmed the effectiveness of the device [38][39]. ...
... 5 The changes in limb volume resulting from the use of this device have been evaluated by lymphoscintigraphy, 6-8 volumetry 9 and bioimpedance. 10 Over the years the Godoy & Godoy technique has evolved and several books and articles evaluating the therapeutic results have been described. 3,4,[11][12][13][14][15] The first descriptions used rollers for manual lymph drainage with the technique evolving to self-applied manual lymph drainage using rollers (Figures 3 and 4). ...
Introduction: Pain associated with lymphedema is common, but it is rarely a limiting factor. The aim of the present study is to report the effect of five days of intensive treatment of a patient with sequelae of poliomyelitis associated to an infection that progressed to lymphedema and six months of intense pain.
Case summary: A 65-year-old patient with sequelae of poliomyelitis from the first year of life evolved with infectious processes and lymphedema after several surgeries for fractures. The patient suffered constant limiting pain for six months. The lymphedema was confirmed by bioimpedance after she sought treatment. The patient was submitted to intensive treatment eight hours/day for five consecutive days using Mechanical Lymphatic Therapy (RA Godoy©).
Outcome Measures: After the first day of treatment the pain was reduced to moderate intensity, after the second day, ankle movement improved facilitating ambulation and after the third day, she felt no more pain. The patient is continuing with maintenance therapy using the RA Godoy© device for one hour/day at home.
Conclusion: Limiting pain is uncommon in lymphedema but in this case, it was associated with repetitive infectious events. The pain disappeared with Mechanical Lymphatic Therapy.
... The first study was published in 2009 and showed a reduction in volume when the device was used as monotherapy [36]. In 2011, bioimpedance was used to assess the results of the device as monotherapy, revealing a reduction in edema [37]. In 2012, two new studies reproduced these evaluations and confirmed the effectiveness of the device [38][39]. ...
BACKGROUND: Compression mechanisms are essential in the treatment of lymphovenous diseases as they help to reduce the swelling and to maintain the results. The objective of the current study was to evaluate the association of Mechanical Lymphatic Therapy with elastic stockings in the treatment of leg lymphedema. METHODS: The daily evolution of treatment for grade II lymphedema was evaluated in a prospective clinical study. The 14 legs of seven women with bilateral edema of whatever cause were treated using the RAGodoy® Mechanical Lymphatic Therapy device and Venosan ® 20/30 knee-length elastic compression stockings for two weeks. The volume of each leg was evaluated before and after each daily treatment session by bioimpedance. The study was approved by the Research Ethics Committee of the Medicine School in São José do Rio Preto (FAMERP). The paired t-test was used for statistical analysis, with an alpha error of 5% (P-value <0.05) being considered significant. RESULT S: Positive and negative variations in the volume of the legs were detected compared to the previous day, but overall the treatment still reduced the volume and there was a significant reduction by the end of the two-week treatment period (P-value <0.001). CONCLUSIONS: Elastic stockings associated with Mechanical and Manual Lymphatic Therapy cause positive and negative variations during treatment although overall the edema continually reduces during treatment.
... 5 The changes in limb volume resulting from the use of this device have been evaluated by lymphoscintigraphy, 6-8 volumetry 9 and bioimpedance. 10 Over the years the Godoy & Godoy technique has evolved and several books and articles evaluating the therapeutic results have been described. 3,4,[11][12][13][14][15] The first descriptions used rollers for manual lymph drainage with the technique evolving to self-applied manual lymph drainage using rollers (Figures 3 and 4). ...
Manual lymph drainage has become the mainstay in the treatment of lymphedema for decades now. Five evolving variants have been described by Godoy & Godoy over the years: i) manual lymph drainage using rollers; ii) self-applied manual lymph drainage using rollers; iii) manual lymph drainage using the hands (manual lymphatic therapy); iv) mechanical lymphatic therapy using the RAGodoy® device; and v) lymphatic therapy using cervical stimulation in general lymphatic treatment. After breast cancer treatment using adapted technique with intermittent compression therapy. Lymphoscintigraphy, volumetry and bioimpedance were employed to analyze such treatment techniques applied to the upper and lower extremities. These treatment and evaluation topics are described in this brief report.
One of the main complications in the treatment of breast cancer is lymphedema. The tests are more specific for the diagnosis of lymphedema in the extremities, though the lymphatic drainage of the chest is also compromised and in need. The aim of the current study was to evaluate the prevalence of chest edema in patients who had been submitted to breast cancer treatment. The prevalence of chest edema in 35 women being treated for arm lymphedema due to breast cancer treatment was evaluated in a retrospective randomized quantitative, blind study in the Clinica Godoy in the period from January to October 2012 using bioimpedance of the thorax. For the descriptive analysis of the results will be used prevalence of the event. The patients’ ages ranged from 42 to 82 years old with an average of 63.7 years. Eight patients had a body mass index (BMI) of less than 25, 16 had between 25 to 30 and 10 had a BMI greater than 30. Chest edema was detected by bioimpedance in four (11.42%) patients. Chest lymphedema is less prevalent than upper limb lymphedema in patients submitted to axillary dissection or it improves faster.
One of the main complications in the treatment of breast cancer is lymphedema. The tests are more specific for the diagnosis of lymphedema in the extremities, though the lymphatic drainage of the chest is also compromised and in need. The aim of the current study was to evaluate the prevalence of chest edema in patients who had been submitted to breast cancer treatment. The prevalence of chest edema in 35 women being treated for arm lymphedema due to breast cancer treatment was evaluated in a retrospective randomized quantitative, blind study in the Clinica Godoy in the period from January to October 2012 using bioimpedance of the thorax. For the descriptive analysis of the results will be used prevalence of the event. The patients’ ages ranged from 42 to 82 years old with an average of 63.7 years. Eight patients had a body mass index (BMI) of less than 25, 16 had between 25 to 30 and 10 had a BMI greater than 30. Chest edema was detected by bioimpedance in four (11.42%) patients. Chest lymphedema is less prevalent than upper limb lymphedema in patients submitted to axillary dissection or it improves faster.
The aim of this paper is to report new options in the treatment of lymphedema for under-
privileged populations. Several articles and books have been published reporting recent
advances and contributions. A new technique of manual lymph drainage, mechanisms of
compression, development of active and passive exercising apparatuses and the adaptation of
myolymphokinetic activities have been developed for the treatment of lymphedema. This
novel approach can be adapted for the treatment of lymphedema in mass.
lymphatic drainage. The aim of the current study was to evaluate a new method of mechanic lymphatic drainage. Volumetric reductions were evaluated after passive exercises in 25 patients with arm lymphedema resulting from breast câncer treatment. Their ages ranged between 42 and 86 years old. All patients were submitted to one-hour sessions using the RAGodoy® electromechanical apparatus which performs from 15 to 25 elbow bending and stretching exercises per minute. Volumetry, using the water displacement technique, was performed before and after the sessions. The paired t-test was employed for statistical analysis with an alpha error of less than 5% being considered acceptable. The reduction in volume was significant (P-value < 0.001) with a mean initial volume of 2026.4 and final volume of 1967.2 giving a mean loss of 59.2 mL. The RAGodoy® apparatus was efficient to reduce the volume of lymphedematous arms and is an option for the
treatment of lymphedema.
The aim of the present study was to evaluate a new, more simplified physiotherapy technique for management ofperipheral lymphedema. Fifteen patients (11 female, 4 male) with ages varying from 22 to 63 years (average 54 years) were included in this study. All presented with stage 1 or II lower limb lymphedema confirmed by lymphoscintigraphy. Each patient underwent a newly designed modified manual lymph drainage technique regularly performed five times a week, one hour per session after one month. The new technique consisted of utilizing sticks, rollers or other cylindrical, flexible, and malleable material which served as a lymph promoting drainage device. All patients demonstrated a highly significant uniform reduction in girth of the leg affected by lymphedema (circumference reduction 2 to 4 cm; average 2.4 cm). After treatment, repeat lymphoscintigraphy
suggested a generalized improvement in the scintiscans compared with the initial patterns. This new manual lymph drainage technique efficiently reduces peripheral lymphedema and is less cumbersome and time
consuming than standard combined ("decongestive") physiotherapy methods
The fibrous process of chronic ulcerated lesions of lower limbs can impair the mobility of the affected limb. The aim of this work was to assess the benefits of lymph drainage in patients who suffer from this disease. Twenty female and five male patients with ages ranging from 53 to 69 years (mean age 60.6 years) were evaluated. All had a history of at least 10 years of varicose veins and/or ulcerated lesions of the lower limbs with initial dermatofibrosis, with the positive Godet sign during the physical examination of the limb. Patients with intermittent claudication, diabetes and trauma were excluded from the study, as well as patients with chronic dermatofibrosis, and in whom positive Godet sign was not seen. Patients with immobility or very limited movement of the ankle and with some limitation in the toe joints were selected. The patients were randomly divided into group A comprising 15 individuals, and group B 10. All the individual treatments were established before the start of the evaluation period. Lymph drainage was performed on the patients of group A four or five times per week. Group B was subjected to a type of massage for the same period and at the same frequency. The mobility of the ankle joints was evaluated using goniometry before the start and after 30 days of treatment. In all the patients who underwent lymph drainage, an improvement of the joint mobility was seen, whereas in the control, group B, there was no obvious change. In conclusion, lymph drainage gave an improvement in the mobility of the ankle joint after impairment due to initial dermatofibrosis in patients with chronic ulcerated lesions.
Lymphedema, defined as the abnormal accumulation of protein-rich fluid in soft tissues, results from the dysfunction of lymphatic system, an imbalance between lymph formation and its absorption into the initial lymphatics. Primary lymphedema occurs rarely on idiopathic or developmental abnormalities, especially hypoplasia or aplasia of lymphatics. Secondary lymphedema commonly develops when lymph transport is impaired due to lymphatic damage or resection of lymph nodes in surgery, infection, and radiation. Lymphatic endothelial cells (LECs) actively participate in the phenotypic consequences of a deranged lymphangiogenesis relating to tissue fluid accumulation in the pathogenesis of lymphedema. Recent insights into molecular genetic bases have shown an updated genotype-phenotype correlation between lymphangiogenesis, lymphatic function, and lymphedema. FOXC2, EphrinB2, VEGFR-3, VEGF-C, angiopoietin-2, Prox-1 and podoplanin have proved to be important factors of the genetic cascade linking to hereditary lymphedema, and embryonic and postnatal lymphatic development. FOXC2 may have a key role in regulating interactions between LECs and smooth muscle cells, and in the morphogenesis of lymphatic valves. Reduced VEGFR-3 tyrosine kinase activity and subsequent failure in transducing sufficient physiological VEGF-C/-D signals may affect LEC function and structure in the intercellular junctions and peri-lymphatic components. Identification of genetic markers in humans and animal models would facilitate the management of environmental factors influencing the expression and severity of lymphedema, and provide a basis for developing novel targeted therapies for the disease.
About 100 million people around the world have lymphedema; however, a large number do not have access to any kind of treatment. The current study reports on a technique of lymphatic self-drainage. The method consists of utilizing rods, bars, or any cylindrical object that rolls smoothly over the skin area to be drained. During this gliding motion a pressure of around 30 to 40 mm Hg should be exerted by the patient. The classical concepts of lymphatic drainage should be followed. This new method was subjected to a lymphoscintigraphic, anthropometric, and clinical evaluation demonstrating its usefulness in treating lymphedema.
Currently not enough evidence to draw conclusions about the best method of treating infections related to lymphoedema Lymphoedema is the build up of fluid in mainly the arms and legs. People can be born with it, it can develop as a result of a parasitic infection (common in developing countries), or it can result from surgery (most commonly arm oedema from breast cancer surgery). The usual treatment is compression hosiery (eg bandaging, sleeves etc.), skin care and exercise. Sometimes limbs become infected and extra treatment is required. This review found that there is currently not enough good quality evidence to draw conclusions about which treatment is most useful in treating these infections.
In a previous publication, it was demonstrated that the abdominal subcutaneous fat layer thickness (SFL) is strongly correlated with the abdominal electrical impedance when measured with a transversal tetrapolar electrode arrangement. This article addresses the following questions: 1) To which extent do different abdominal compartments contribute to the impedance? 2) How does the hydration state of tissues affect the data? 3) Can hydration and fat content be assessed independently? For simulating the measured data a hierarchical electrical model was built. The abdomen was subdivided into three compartments (subcutaneous fat, muscle, mesentery). The true anatomical structure of the compartment boundaries was modeled using finite-element modeling (FEM). Each compartment is described by an electrical tissue model parameterized in physiological terms. Assuming the same percent change of the fat fraction in the mesentery and the SFL the model predicts a change of 1,24 omega/mm change of the SFL compared to 1,1 omega/mm measured. 42% of the change stem from the SFL, 56% from the mesentery and 2% from changes of fat within the muscle compartment. A 1% increase of the extracellular water in the muscle is not discernible from a 1% decrease of the SFL. The measured data reflect not only the SFL but also the visceral fat. The tetrapolar electrode arrangement allows the measurement of the abdominal fat content only if the hydration remains constant.