What is the evidence for rehabilitation interventions for head and neck cancer–associated lymphedema (HNCaL)?
In this systematic review of 2147 patients with HNCaL, 6 randomized clinical trials and 17 observational trials were included. There is emerging evidence for complete decongestive therapy, advanced pneumatic compression devices, and kinesio taping.
This systematic review suggests that evidence for rehabilitation interventions in HNCaL remains limited but has been growing in recent years, and that more high-quality evidence is needed about the ideal type, timing, duration, and intensity of standard lymphedema therapy and adjunct modalities to inform future treatment guidelines.
Head and neck cancer–associated lymphedema (HNCaL) affects up to 90% of survivors of head and neck cancer and is a substantial contributor to disability following head and neck cancer treatment. Despite the prevalence and morbidity associated with HNCaL, rehabilitation interventions are not well studied.
To identify and appraise the current evidence for rehabilitation interventions in HNCaL.
Five electronic databases were searched systematically from inception to January 3, 2023, for studies on HNCaL rehabilitation interventions. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers.
Of 1642 citations identified, 23 studies (1.4%; n = 2147 patients) were eligible for inclusion. Six studies (26.1%) were randomized clinical trials (RCTs) and 17 (73.9%) were observational studies. Five of the 6 RCTs were published during 2020 to 2022. Most studies had fewer than 50 participants (5 of 6 RCTs; 13 of 17 observational studies). Studies were categorized by intervention type, including standard lymphedema therapy (11 studies [47.8%]) and adjunct therapy (12 studies [52.2%]). Lymphedema therapy interventions included standard complete decongestive therapy (CDT) (2 RCTs, 5 observational studies), modified CDT (3 observational studies), therapy setting (1 RCT, 2 observational studies), adherence (2 observational studies), early manual lymphatic drainage (1 RCT), and inclusion of focused exercise (1 RCT). Adjunct therapy interventions included advanced pneumatic compression devices (APCDs) (1 RCT, 5 observational studies), kinesio taping (1 RCT), photobiomodulation (1 observational study), acupuncture/moxibustion (1 observational study), and sodium selenite (1 RCT, 2 observational studies). Serious adverse events were either not found (9 [39.1%]) or not reported (14 [60.9%]). Low-quality evidence suggested the benefit of standard lymphedema therapy, particularly in the outpatient setting and with at least partial adherence. High-quality evidence was found for adjunct therapy with kinesio taping. Low-quality evidence also suggested that APCDs may be beneficial.
Conclusions and Relevance
The results of this systematic review suggest that rehabilitation interventions for HNCaL, including standard lymphedema therapy with kinesio taping and APCDs, appear to be safe and beneficial. However, more prospective, controlled, and adequately powered studies are needed to clarify the ideal type, timing, duration, and intensity of lymphedema therapy components before treatment guidelines can be established.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: May 5, 2023.
Published Online: June 29, 2023. doi:10.1001/jamaoto.2023.1473
Corresponding Author: Jessica T. Cheng, MD, City of Hope Orange County Lennar Foundation Cancer Center, 1000 Fivepoint, Irvine, CA 92618 (email@example.com).
Author Contributions: Drs Cheng and Parke had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Cheng, Langelier, Leite, Gutierrez, Kline-Quiroz, Capozzi, Krause, Parke.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Cheng, Langelier, Leite, Tennison, Kline-Quiroz, Capozzi, Krause, Parke.
Critical revision of the manuscript for important intellectual content: Cheng, Langelier, Leite, Tennison, Gutierrez, Kline-Quiroz, Yu, Krause, Parke.
Statistical analysis: Krause.
Administrative, technical, or material support: Cheng, Tennison, Kline-Quiroz, Krause, Parke.
Supervision: Langelier, Tennison, Parke.
Conflict of Interest Disclosures: Dr Gutierrez reported being the first author of 2 industry-funded studies included in this systematic review and financial support for a clinical study from Tactile Medical during the conduct of the study. Dr Kline-Quiroz reported grants from Tactile outside the submitted work. No other disclosures were reported.
Additional Contributions: We thank the American Academy of Physical Medicine and Rehabilitation for their support of the Cancer Rehabilitation Physician Consortium member community. The manuscript was edited by Sarah Bronson, ELS, of the Research Medical Library at The University of Texas MD Anderson Cancer Center, who was not compensated for her contributions.
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