The physiological effects of massage on individuals with lymphoedema/chronic oedema, and its role in the development of clinical techniques used in practice: a systematic review.

Review question/objective This review examines the physiological rationale for the various indications and contraindications for massage. The overall objective of this review is to examine the physiological effects of massage (including manual/medical lymphatic drainage, MLD) on people's lymphatic and vascular systems. More specifically, the review questions are: What are the local physiological effects of massage, which include MLD, on the lymphatic and vascular systems? What are the systemic effects of massage on the body, with particular reference to individuals with lymphoedema? What is the physiological rationale for the various techniques, indications and contraindications for massage and MLD? Background This systematic review is being undertaken as part of the Lymphoedema Framework Project (LFP) in the United Kingdom. The LFP is a major initiative that seeks to improve the care and management of people with various forms of lymphoedema and represents a partnership between researchers, patients, specialist lymphoedema practitioners and industry. Central to the ethos of the Framework Project is raising awareness of lymphoedema and the dissemination of greater knowledge and understanding through education and training, publications and research, including systematic reviews. Lymphoedema is a chronic and progressive condition, resulting from an accumulation of fluid and other tissue elements in the extravascular space due to the transport capacity of the lymphatic system being ineffective(1). Lymphoedema has many causes. It may be due to congenital malformation of the lymphatic system, or develop following damage to or incompetence of the lymphatic vessels or lymph nodes due to trauma, disease (malignant or venous), surgery, infection, irradiation, filariasis, immobility, dependency syndrome(2). Lymphoedema/chronic oedema affects a wide range of groups from children to the elderly. It is the prevailing belief in the developed world that lymphoedema is almost exclusively related to cancer and its treatment. However, in the developing world it is generally believed that lymphoedema is most closely associated with filariasis. In both cases such beliefs have dominated how the condition is managed and how lymphoedema services have been developed. Typically, lymphoedema management follows a two-phased approach: firstly, an intensive phase often referred to as Decongestive Lymphoedema Therapy (DLT); and secondly, the maintenance phase, which is essentialy a period of self-care(3). A combination of physical therapies is used including Manual Lymphatic Drainage (MLD) or other types of massage, compression/support with multilayer lymphoedema bandaging (MLLB) and or compression garments, skin care and isotonic exercises. During the intensive phase, patients usually attend on a daily basis over a period of 2-4 weeks, for skin care, MLD and MLLB in order to reduce the swelling and improve limb shape. The success of the ongoing maintenance phase may rely on the active participation of the person with lymphoedema in various self-care activities that may include: self-massage and exercise, skin care and wearing of compression garments(4). A number of questions about MLD and other forms of massage have provided impetus to this systematic review. Firstly and most importantly, the physiological mechanisms through which MLD and other forms of massage exert their influence and how these relate to the underlying pathophysiological changes in lymphoedema are not entirely clear. There is also a lack of clarity regarding the link between the physiological mechanisms of MLD and the main principles of the techniques used. Secondly, the psychological and social effects of MLD and massage, including their influence on quality of life measures, an improved sense of wellbeing and its contribution to the patient's motivation to self-manage are poorly understood. Thirdly, the extent to which MLD and other forms of massage have an impact on clinical, patient centred and economic outcomes and the implications for the future use of resources requires illumination. The second and third aspects of massage will be addressed in other systematic reviews for the Lymphoedema Framework Project. MLD and other forms of massage are widely used and highly valued forms of treatment for lymphoedema/chronic oedema. Its use, however, is not without question, and much of this relates to a lack of conventional research validation of its efficacy. The focus of this systematic review is on the physiological evidence of massage that will increase practitioners' knowledge and understanding and enable patients to make informed choices. Ultimately, this review is concerned with how massage is used to manage cases of lymphoedema/chronic oedema. Inclusion criteria Types of participants This review will consider all studies focusing on the treatment of adults and children. Animal studies examining the role of MLD will be included in the review providing there is evidence that they have met the standards for ethical animal research that were available at the time of publication. The systematic review team will consider all studies where there is concern for the correct welfare of animals and a group decision will be made whether to include or exclude these studies. This decision will be made on a case-by-case basis. Types of intervention(s)/phenomena of interest The quantitative and textual components of this review will focus on any form of massage including MLD, in the treatment of lymphoedema/chronic oedema. Types of outcomes The types of outcomes considered in this review comprise the following: changes in lymphatic and vascular function and development; oedema formation and resolution; the effects of massage on inflammation and fibrosis; and influences on the lymphatic nervous system. Types of studies This review will consider quantitative studies in the form of randomised controlled trials. In the absence of RCTs other research designs, such as non-randomised controlled trials, case studies/reports, before and after studies, longitudinal studies, prospective studies will be considered for inclusion to enable the identification of current best evidence regarding the physiological effects of MLD. Studies combining MLD and massage within decongestive complex therapy and self-maintenance will also be included. In the absence of any research studies this systematic review will consider expert opinion, commentaries, discussion papers, position papers, etc. Search strategy The search strategy aims to find both published and unpublished studies, and will include papers written in English and other languages from 1930 to 2008. Given the origins of MLD and massage it is envisaged that papers will be written in German, French, Chines and Indian dialects. All papers will be translated by a medical translation service and key international experts used to check the integrity of the scientific content following translation. A three-step search strategy will be utilised for each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe each article. A second search using all identified keywords and index/thesaurus terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified studies, reports and articles will be searched for additional material. The databases to be searched include: Academic One File, Academic Search Premier, Cochrane Library (Cochrane Controlled Trials Register, DARE, Cochrane Database of Systematic Reviews, Cochrane Methodology Register), BioMed Central, JBI, PsycINFO, SCOPUS, TRIP, EBM Reviews, BMJ Clinical Evidence, Current Contents, British Library Index, Inside Conferences, Dissertation Abstracts, International Bibliography of the Social Sciences, CSA Social Abstracts. The search for unpublished studies or grey literature will include: WorldCat, Index to Theses, Digital Dissertations, Theses Canada Portal, Networked Digital Library of Theses and Dissertations (NDLTD), Institute for Health and Social Care Research (IHSCR), NLM Gateway, Grey Literature Report (via New York Academy of Medicine), CAMEOL, AHRQ (Agency for Healthcare Research and Quality), Althealth Watch, ACTR Clinical Medicine Netprints Collection, CCT (Current Controlled Trials), NHS Library, TRoPHI (Trials Register of Promoting Health Interventions), Geneva Foundation for Medication Education and Research (GFMER), Grey Source, National Cancer Institute, NurseScribe, NUH Clinical Alerts and Advisories, OPHL (Ontario Public Health Libraries Association), Primary Care Clinical Practice Guidelines, SIGLE, UptoDate, and WHOLIS (World Health Organisation Library Database). Additionally, an international board will be contacted to identify sources of literature as well as professionals who may have written studies that have not yet been published. Manuals based on the different schools of massage will be located and where necessary translated into English. Other specialist organisations such as MLD UK and the International Lymphology Societies will be contacted for information. Hand searches will be made of the Proceedings of the ISL, the Lymphology Journal and the range of books and booklets produced by the various lymphatic drainage groups. Selected relevant websites will be identified and searched including those of the British Lymphology Society, International Society of Lymphology, the Lymphoedema Association of Australia and the National Lymphoedema Network. Internet-based search engines such as Google Scholar and Scirus.com will also be used for literature searching. Initial keywords to be used searched in title and/or abstract will be: lymphedema, lymphoedema, elephantiasis, swelling or edema, oedema, lymphatic system, massage, manual drainage complex, lympho(e)dema therapy, physical therapy, modalities, combined decongestive therapy, intensive therapy, simple lymphatic drainage, self therapy, aromatherapy, bowen technique, trigger point, acupressure, soft tissue manipulation, rolfing, effleurage, craniosacral, cranio-sacral therapy, craniosacral manipulation, complementary therapies, reflexotherapy, therapeutic touch and/or musculoskeletal manipulations. The above keywords/terms will be combined with those to find the appropriate physiology-focused citations, for example: physiology, physiological, physiological adaptation, physiological process, physiological pattern recognition, physiological theory, neovascularisation, physiological/physiologic monitoring, physiological studies, physiologic neovascularisation, physiological effects. Assessment of methodological quality Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix 1). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix 1). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix 2). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Textual data will be extracted from papers included in the review using the standardised data extraction tool (JBI-NOTARI) (see Appendix 2). Data synthesis Quantitative papers will, where possible, be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Textual papers will, where possible be pooled using the Narrative, Opinion and Text Assessment and Review Instrument (JIB-NOTARI). This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, by assembling the conclusions to generate a set of statements that categorise these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that serve as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Conflicts of interest There are no conflicts of interest involved in this systematic review.

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