lymph edema is the accumulation of a high - protein edema fluid in the interstitial tissue as 
 a result of the functional overload of the lymphatic system in which lymph volume exceeds 
 transport capabilities and the lymphatic system becomes overwhelmed , causing lymphatic 
 insufficiency or failure1 .
secondary 
 lymph edema may occur as a result of obstruction or interruption of the lymph system due to 
 surgery .
the most common cause of secondary lymph edema in the upper extremity is breast cancer 
 treatment , especially with the combination of axillary surgery and radiation and lower 
 extremity lymph edema mostly occurs as a consequence of gynecological cancer ( cervical , 
 endometrial , vulvar , head and neck cancers)2 .
the prevalence of post breast cancer surgery upper limb lymph edema is between 8% and 65% 
 as described in the literature3 , 8 .
the main reasons for this wide reported range of prevalence 
 of the upper extremity lymph edema are : the follow - up time , the number of patients included 
 in the studies , the classification and criteria used for its definition , the use of 
 different measuring methods , and the time elapsed after surgery .
the factors that contribute to the development of upper extremity lymph edema after breast 
 cancer surgery are classified in terms of extent of axillary surgery and mastectomy , 
 axillary lymph node dissection ( alnd ) , the number of nodes removed , the presence of a 
 metastatic lymph node , use of axillary radiation therapy , chemotherapy , younger age at 
 diagnosis , older age ( > 55 ) , weight , body mass index ( bmi ) , injury or infection in the 
 ipsilateral arm , and trauma3,4,5,6,7,8,9,10,11,12 . except for lymph edema
the other complications after breast cancer surgery are as follows : 
 pain in the affected shoulder and arm , restrictions of shoulder motions , decrease in the 
 muscle strength and functional capacity of the upper extremity , and difficulty with 
 activities of daily living12,13,14,15,16 .
development of 
 lymph edema after breast cancer surgery increases the upper extremity symptoms of pain , 
 numbness , stiffness , loss of strength and function5 , 
 17 .
together with physical and functional inabilities , lymph edema is also associated with 
 psychological morbidity13 .
psychological 
 impacts of lymph edema include anxiety , depression , loss of body self confidence , social 
 isolation and sexual dysfunction18 . 

moreover lymph edema and impaired upper extremity functions lead to deterioration in the 
 activities of daily living16 .
it is 
 reported that the functions of the arm decrease as the severity of lymph edema increases and 
 the levels of depression and anxiety increase as the symptoms of the upper extremity 
 increase19 , 20 .
the severity and localization of lymph edema and pain are the 
 factors that aggravate psychological distress and anxiety13 .
there are several methods of treatment for breast cancer - related 
 lymph edema including physiotherapy , exercises , medical treatment with benzopyrones and a 
 variety of microsurgical techniques .
complex decongestive physiotherapy ( cdp ) is a 
 multimodality approach that consists of manual lymphatic drainage ( mld ) , skin care , 
 compression bandages , and exercise , and it is a promising form of treatment recently .
cdp is 
 used to activate lymphatic vessels and move protein rich fluid from edematous to non 
 edematous areas .
although cdp was developed several decades ago , there are many studies that 
 show cdp can greatly reduce the volume and percentage volume of breast cancer - related lymph 
 edema . however , there are few studies about the effects of cdp on other physical aspects 
 such as pain , restriction of movements , and functions of the upper extremity or its effects 
 on psychological factors
. therefore the aim of this study was to investigate the effects of 
 phase i cdp on physical functions and depression levels of subjects with breast 
 cancer - related upper extremity lymph edema .
this interventional clinical study was carried out at pamukkale university school of 
 physical therapy and rehabilitation .
approval for this study was granted by the non - invasive 
 clinical research ethics committee of pamukkale university and the study was conducted in 
 accordance with the principles of the declaration of helsinki .
all the subjects provided 
 their informed consent . among the 96 subjects having lymph edema and referred for physical therapy , 77 subjects 
 with secondary lymph edema after modified radical mastectomy were chosen .
the subjects who 
 had metastasis , severe orthopedical or neurological deformity , acute infection , uncontrolled 
 hypertension , severe venous or arterial insufficiency , severe psychiatric symptoms or any 
 other contraindications to manual lymphatic drainage and compression were excluded . 

sixty - three subjects met the inclusion criteria of this study , but five of the subjects did 
 not attend to the decongestive physical therapy programme regularly and they were excluded 
 from the assessments .
circumference , range of motion ( rom ) measurements of both upper extremities , muscle 
 strength of the ipsilateral extremity and depression level were assessed before and after 
 the phase i cdp treatment .
the circumferences of both extremities were measured at the metacarpophalengeal joints of 
 the hand , and styloid process of radius and 5 , 10 , and 15  cm above the styloid process of 
 radius of the forearm , the lateral epycondile and 5 , 10 , and 15  cm above the lateral 
 epycondile of the upper arm by using a standard one inch , retractable , fiber glass tape 
 measure .
the shoulder range of motion was measured using standard techniques of goniometry as active 
 and passive measurements of shoulder flexion , extension , abduction and adduction , internal 
 and external rotation21 , 22 .
muscle strength of the ipsilateral extremity was measured 
 by lovett s manual muscle testing23 .
depression levels of the subjects were evaluated using the beck depression inventory ( bdi ) 
 which was first developed by beck et al . in 196124 .
participants were asked to choose the suitable option that expressed their emotional status 
 in the last 1-week period .
the maximum score is 63 , and the cutoff value for the turkish 
 version is 17 which indicates a need for help25 .
phase i complex decongestive physiotherapy consisting of mld , multi layer compression 
 bandaging , remedial exercises in combination with respiratory exercises were performed by 
 all subjects five times in a week for four weeks ( 20 sessions in total ) by a certified lymph 
 edema physiotherapist21 , 26,27,28 . at the end of the phase i cdp treatment the subjects wore 
 compression garments .
self massage , home exercises for lymph edema and skin care were 
 prescribed for the subjects by the therapist for the phase ii cdp .
differences in 
 measurements circumference , shoulder range of motion and the beck depression inventory were 
 assessed using the paired samples t test .
pearson s correlation coefficient method was used 
 to assess the influence of changes in measurement of circumference and shoulder range of 
 motion on beck depression inventory scores .
the physical characteristics and demographic data of subjects are presented in table 1table 1.physical properties and demographic data of the subjectsphysical propertiesx  sdage ( years)43.5  5.3height ( cm)161.3  6.7weight ( kg)78.4  7.8bmi ( kg / m)26.3  1.2demographic datan ( % ) education levelilliterate15 ( 25.8)<8 years27 ( 46.5)>8 years16 ( 27.5)occupationhousewife35 ( 60,34)teacher13 ( 22.4)retired10 ( 17.2 ) .
fifty - one of 
 the subjects had been given chemical therapy ( ct ) , 43 of subjects had been given 
 radiotherapy ( rt ) and 38 of subjects had received endochirine therapy ( table 2table 2.other therapies that subjects received after mrmother therapiesn ( % ) chemical therapyyes51 ( 87.9)no7 ( 12.0)radio therapyyes43 ( 74.1)no15 ( 25.8)endocrine therapyyes38 ( 65.5)no20 ( 34.4 ) ) .
the average duration of lymph edema was 32.05.5 months and the average time 
 since the operation was 38.52.1 months .
after modified radical mastectomy , the subjects were given on averagely 5.3 1.1 
 treatments of ct and 10.2 4.0 sessions of rt .
a significant difference in the circumference 
 measurement was found when compared before and after complex decongestive physiotherapy 
 ( cdp ) at all levels of measurement ( table 
 3table 3.comparison of upper extremity circumference measurementscircumference measurementb.cdp ( cm)a.cdp ( cm)mcp joint21.30.820.01.2styloideus radius22.54.320.90.95 cm 26.44.723.62.510 cm 27.05.124.77.315 cm 29.24.726.75.3lateral epicondyles30.93.929.23.65 cm 36.76.332.36.810 cm 37.07.733.95.415 cm 38.83.334.02.9 * p < 0.05 , mcp : metacarpophalengeal .
we found that the muscle strength of the subjects was good ( average 4.60.2 
 according to manual muscle testing ) and decrease in muscle strength was not found before 
 cdp .
the shoulder range of motions before and after cdp are shown in table 4table 4.comparison of upper extremity range of motionsromb.cdp ( )a.cdp ( )shoulder jointflexion136.69.6171.38.2extension54.65.758.66.2abduction128.316.4164.92.3adduction0.00.00.00.1internal rotation78.84.685.51.0external rotation76.42.484.23.6elbow jointflexion142.6 8.9146.09.6extension0.0 0.00.00.0wrist jointflexion85.5 2.585.9 3.4extension84.80.885.3 3.8ulnar deviation19.60.321.0 2.6radial deviation14.41.915.6 2.3*p<0.05 , rom : range of motion .
according to this table , a significant difference was found in all shoulder 
 range of movements except from adduction .
although active shoulder range of movement did not 
 reach to normal levels , there was a significant increase after cdp .
when we assessed the 
 average depression scores of the subjects before cdp a moderate level of depression was 
 found .
the depression score improved to mild depression levels after cdp and there was a 
 significant difference in the scores of before and after treatment as shown in table 5table 5.comparison of depression scoresdepression scoreb.cdpa.cdpbdi24.55.419.48.3 * p<0.05 , b.cdp : before complex decongestive physiotherapy .
there was a significant positive correlation between the changes in 
 circumference measurement of the affected arm and the depression level ( table 6table 6.relation between average change in depression measurement and average change in 
 circumference measurements of the affected armthe average change in depression scores ( x sd)the average change in circum ference measurements of 
 the affected arm ( x sd ) ( cm)r bdi score ( 5.6  1.4) mcp joint ( 1.0  0.8)0.4 styloideus radius ( 2.2  0.7)0.7 5 cm  ( 3.4 0.9)0.6 10 cm  ( 3.1 1.1)0.7 15 cm  ( 3.4  1.2)0.4 lateral epicondyles ( 1.00.5)0.3 5 cm  ( 4.2 1.2)0.6 10 cm  ( 2.9  0.2)0.6 15 cm  ( 4.0  1.2)0.7*p<0.05 , mcp : metacarpophalengeal ) .
the depression levels decreased as the circumference measurement 
 decreased . * p < 0.05 , mcp : metacarpophalengeal .
a.cdp : after complex decongestive physiotherapy * p<0.05 , b.cdp : before complex decongestive physiotherapy .
psychological and psychosocial factors such as anxiety , depression , distress , altered 
 emotional reactions , sleep disturbances and social isolation are common in breast 
 cancer29 . increased prevalence of 
 depression among breast cancer patients has been shown in several studies30,31,32,33 . 

fann et al . reported that the risk of major depression is 25% in women with breast cancer , 
 and within one year of diagnosis up to 30% of women with breast cancer may develop either 
 anxiety or depression , which may persist for more than 5  years after diagnosis and initial 
 treatment34 .
in one interesting study 
 it was found that those cases of mastectomy and hysterectomy had depressive symptoms and 
 problems regarding body image , spouse relationships and sexual satisfaction .
when the 
 depressive state was compared between the cases with mastectomy and hysterectomy , it was 
 found that patients with mastectomy were more depressive than patients with 
 hysterectomy35 .
the factors which are related to psychological distress include being diagnosed as having a 
 life - threatening illness , treatments and their side - effects , uncertainty of outcomes , role 
 changes as a result of activity limitation and restrictive participation , and issues related 
 to body image , especially unsatisfactory cosmetic results and lymph edema36 , 37 .
there are studies which report that psychological distress such as 
 depression , anxiety ; hopelessness and helplessness are more common in breast cancer 
 survivors with lymph edema31,32,33 , 38 .
they found that lymph edema was 
 associated with a higher impact score on the perceived impact problem profile39 . in another study ,
pyszel et al . reported 
 that breast cancer survivors with lymph edema had statistically significantly worse 
 psychological distress scores than survivors without lymph edema40 .
in our study we assessed the depression levels of women with lymph edema after modified 
 radical mastectomy with bdi . in common with the previous studies
, we found that women with 
 post mastectomy lymph edema had moderate levels of depression ( average bdi score=24.55.4 ) . 

the most common symptoms associated with lymph edema are swelling , heaviness , tightness , 
 firmness , pain , numbness , stiffness , decreased mobility , and the physical disfigurement of 
 the condition .
women with post mastectomy lymph edema are unable to complete household 
 responsibilities , in severe cases they even need assistance with daily care activities , and 
 have difficulty in performing their jobs which leads to significant role changes in social 
 life . as a result untreated or occurance of lymph edema is a cause of serious psychological 
 disturbances , e.g. depression .
another reason for the occurance of depression is difficulty 
 with coping and adjusting to a chronic disease , which is for some of the subjects a surprise 
 because of inadequate information .
many of the subjects in our study had the idea that lymph 
 edema was an untreatable condition before complex decongestive therapy , which also might 
 have been a reason for their high levels of depression .
aesthetic concerns , which might 
 prevent women from wearing their usual clothing , might also be an important cause of 
 depression .
the shoulder rom of women with post mastectomy lymph edema was significantly reduced in our 
 study .
there are many studies which indicate that following breast cancer treatment , women 
 with lymph edema present with upper extremity impairments3 , 4 , 13 , 17 , 27 , 28 . women with lymph edema 

more frequently demonstrate bilateral impairments in shoulder rom and upper extremity 
 strength than women without lymph edema .
besides swelling of the arm , rom limitation can 
 lead to reduced physical activity which may also be related to depression41 , 42 .
complex 
 physical therapy has been recommended as a primary treatment by consensus panels and is an 
 effective therapy for lymph edema43,44,45,46,47 . 

complex physical therapy resulted in some volume reduction of the affected extremity in 95% 
 of 399 patients ( 50% reduction in 56% of patients , 2549% reduction in 31% , and 124% 
 reduction in 8% ) , 54% of whom maintained the therapeutic result after 3 years48 . in agreement with the literature
, the 
 results of our study showed that after cdp , the shoulder rom of the subjects increased and 
 the circumference measurement of the affected arm significantly decreased .
several studies have shown the effects of cdp on physical functions and the quality of life 
 of lymph edema patients14 , 15 , 26,27,28 , 47,48,49 . in one of the literature reviews , researchers concluded 
 that among the therapeutic modalities used for lymph edema treatment , cdp undoubtedly had 
 the strongest scientific support50 .
cdp 
 applied lymph edema patients effectively improved the quality of lymph edema patients 
 through the reduction in the volume and circumference of the affected limb , a decrease in 
 fear of movement , and increase in physical function49 . as we discussed above , psychological distress such as depression 
 and anxiety , is also associated with lymph edema .
many studies have demonstrated the 
 effectiveness of cdp , however , not many studies have investigated the effects of cdp on 
 depression and other psychological issues . in present study we assessed the depression 
 levels of subjects before and after cdp .
we found a significant decrease in the depression 
 score to mild - minimum levels .
there was a positive correlation between circumference 
 reduction and depression levels and also a negative correlation between rom and depression 
 levels .
we think arm swelling and rom limitation as a result of lymph edema after mastectomy 
 aggravate depression which is usually found in breast cancer survivors .
cdp which is one 
 effective way of treating arm swelling and decrease in physical function can also contribute 
 treatments for psychological distress such as depression .
reduction in limb volume and increase in range of motion reduces the fear of movement and 
 increase the physical function .
the volume decrease in the affected extremity and increase 
 in rom may lead to improvements in the social roles of subjects through increase of physical 
 function .
the improvement in social participation may also be a factor that helps to 
 alleviate depression .
also , a decrease in aesthetic anxiety and becoming aware of that lymph 
 edema is treatable , are the other factors that may contribute to the alleviation of 
 depression .
our study is important as there are not many studies of the psychological distress in 
 breast cancer and/or lymph edema related to breast cancer , especially secondary lymph edema 
 after mastectomy , and there are very few studies about the effects of cdp and other 
 treatment choices on the psychological distress such as depression51 , 52 .
the lack of a 
 control group was the most important limitation of this study .
 [ purpose ] breast cancer - related upper extremity lymph edema is known to cause physical , 
 functional and psychological impairments in women after modified radical mastectomy . 
 the 
 aim of this study was to investigate the effects of phase i complex decongestive 
 physiotherapy ( cdp ) on physical functions and depression levels in women with breast 
 cancer - related upper extremity lymph edema . 
 [ subjects and methods ] fifty - eight subjects 
 with breast cancer - related upper extremity lymph edema were the subjects of this study . 
 
 the arm circumference , shoulder range of motion ( rom ) , muscle strength and depression 
 levels of the subjects were assessed before and after phase i cdp treatment . [ results ] 
 after phase i cdp , there was a statistically significant reduction in circumference 
 measurements at all levels of the affected arm . 
 there was not any statistically 
 significant difference in muscle strength after cdp . 
 the shoulder rom improved after 
 treatment . 
 there was a significant reduction in the beck depression inventory score . 
 a 
 significant positive correlation was found between depression levels and circumference 
 measurement . 
 [ conclusion ] based on the results we suggest that by reducing limb volume , 
 beside improving physical functions , phase i cdp can affect psychological status , 
 especially depression which is very common in women with breast cancer - related upper 
 extremity lymph edema . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION