Thirty-four studies (number of participants not reported) were included in the review. The authors did not report in detail the study designs used.
CPT (9 studies): study quality ranged from 3 to 5, with the majority of studies scoring 4. All studies reported a reduction in oedema (limb volume and/or percentage oedema) with either CPT alone (5 studies), CPT with pump therapy (3 studies), or as part of a combination therapy (1 study). Three studies also reported reductions in subjective symptoms such as pain, tightness, heaviness, pins and needles, cramps and tension. In the 5 studies investigating standard CPT alone, durations of treatment ranged from 8 days to 3 months and reductions in oedema from 18.7 to 66%. The optimal treatment period appeared to be 1 month, but 2 studies reported reductions after 7 to 8 days.
MLD (9 studies): study quality ranged from 2 to 8, with the majority of studies scoring 5 or 6. Two studies of MLD alone reported volume reductions of between 104 and 156 mL (up to 48%). Four studies combining MLD with compression (bandage or garments) reported even larger reductions of between 47 and 260 mL (7 to 84%). One study reported MLD alone and in combination with pneumatic pump therapy, resulting in similar reductions in percentage oedema (40% and 45%, respectively). MLD produced a significant reduction in oedema compared with self-massage (1 study), but not when compared with education combined with wearing a compression sleeve and limb exercises (1 study).
Pneumatic pump therapy (5 studies): study quality ranged from 2 to 6, with the majority of studies scoring 5 or 6. Two studies reported that pneumatic pump therapy alone reduced arm volumes; however one (a randomised controlled trial) used higher than normal pressures. Three studies reported that greater reductions were achieved through combining pump therapy with other therapies including manual lymphatic drainage (1 study), compression garments (1 study) and self-massage (1 study). Initial volume reductions were shown to be maintained by continuing pump therapy (1 study) or wearing compression garments (2 studies).
Oral pharmaceuticals (5 studies): study quality ranged from 4 to 8, with the majority of studies scoring 7. Varying reductions in limb volume were reported with Daflon (1,000 mg; 7% reduction in 1 study), Cyclo-fort (3 capsules three times daily; 12.9% reduction in 1 study) and 5,6-benzo-alpha-pyrone (200 mg; 35.6% reduction in 1 study). Two studies of coumarin showed conflicting results in comparison with placebo. One study of 90 mg and 135 mg showed a decrease in arm volume (14.9% and 13.2%, respectively) with coumarin; the other study of 400 mg showed an increase of 6% in arm volume during the treatment phase of a crossover trial. However, both studies reported that coumarin was associated with a reduction in subjective symptoms including discomfort, arm swelling, pressure, tightness, heaviness and mobility. Gastrointestinal problems were reported with the use of both coumarin and 5,6-benzo-alpha-pyrone (13.7% and 22.6%, respectively).
Low-level laser therapy (3 studies): study quality ranged from 5 to 8, with 2 studies scoring 5 and the other scoring 8. All studies (including one double-blinded, randomised placebo-controlled trial) reported benefits from low-level laser therapy including volume reduction and improved subjective symptoms and quality of life.
Compression (6 studies): study quality ranged from 1 to 6, with the majority of studies scoring 5 or 6. Four studies showed that compression resulted in modest arm volume reductions of between 20 and 49 mL and significant improvements in heaviness and tension. However, the studies lacked a follow-up period. One study showed that compression in combination with limb exercises resulted in a reduction of absolute oedema of 60%, and another that compression with self-massage resulted in a reduction of 24%; the significance of these results was not reported.
Exercise (5 studies): study quality ranged from 4 to 5, with 4 studies scoring 4 and 2 studies scoring 5. All of the studies used different exercise regimens and reported varying effects of the intervention upon limb volume (0.4% to 9%). Three studies also demonstrated improvements in subjective symptoms. Three studies reported sustained volume reductions 24 hours to 6 weeks after cessation of the intervention. One randomised controlled trial of hydrotherapy reported that exercise at a pool temperature of 28 degrees C was more effective than a control group (2.9, 4.8 and 8.6% reductions in limb volume after 3, 4 and 6 weeks, respectively).
Elevation (1 study): study quality was 6. Elevation of the arm to an 80 degree angle over a 5-hour period resulted in a significant 3.1% reduction in arm volume, but subjective symptoms and adverse events were not recorded.