lymphedema ( le ) is a condition in which lymphatic transport is compromised , allowing lymph 
 fluid to accumulate between tissues .
the accumulation causes progressive fibrosis between 
 the skin and subcutaneous tissue , and is characterized by non - pitting swelling .
this 
 fibrosis and swelling damage lymphocytes and weaken the immune system , which eventually 
 progresses to chronic inflammation and degeneration in the lymphatic system and peripheral 
 tissues1 .
le causes various problems 
 such as pain , tingling sensation , loss of sensation , muscle weakness , stiffness , and reduced 
 joint range of motion ( rom)2 .
according to 
 previous studies , complex decongestive therapy ( cdt ) for le includes manual lymph drainage , 
 application of a short stretch compression bandage ( sscb ) , reduction of edema , and skin 
 care .
however , an sscb does not 
 continuously maintain the pressure and must be rolled back every day6 .
if adverse 
 effects on the skin occur and a sscb can not be applied , therapeutic exercises can not be 
 safely performed .
after right breast resection on june 2 , 2006 , a 57-year - old woman underwent axillary lymph 
 node dissection and radiotherapy on october 24 , 2012 . beginning in december 2013 , edema 
 developed in the right upper extremity , for which she presented to the department of 
 rehabilitation .
she was diagnosed with le and received treatment of edema three times 
 weekly . on the day of presentation ,
a physical therapist partially measured the circumference of the upper 
 extremity by using a tape measure as follows : axillary , at 10  cm above the elbow , at the 
 elbow , and at 10  cm below the elbow , wrist , and hand7 .
the measurements for the right upper limb were 34 , 28 , 28.5 , 23 , 
 16 , and 19  cm , respectively .
those for the left upper limb were 32 , 25 , 25 , 22 , 16 , and 
 18  cm , respectively .
the moisture ratio between the body water and the intracellular fluid 
 in the upper extremity was measured by performing a biological analysis with inbodys10 
 ( biospace ltd . ,
the body water volume in the right arm was 
 1,550  ml , and the extracellular to total cellular ( e / t ) fluid ratio was 0.384% .
the body 
 water volume in the left arm was 1,390  ml , and the e / t fluid ratio was 0.378% .
furthermore , 
 the patient showed a restricted rom in the right arm as follow 120 flexion , 80 abduction , 
 15 external rotation , and 15 internal rotation . on the day of evaluation ,
the treatment was explained to the patient , and the patient 
 underwent cdt and sscb application . on the next treatment day ,
because of the skin condition , 
 cdt was administered without a sscb three times per week for 14 weeks . after the treatment 
 on march 27 , 2014 , the patient was reevaluated .
the measurements of the upper right limb 
 ( axillary , at 10  cm above the elbow , at the elbow , and at 10  cm below the elbow , wrist , and 
 hand ) were reduced to 34.5 , 29 , 24.5 , 25 , 16 , and 18.5  cm , respectively .
the body water 
 volume was 1,680  ml ( 10.8% ) , and the e / t fluid ratio was 0.387% in the inbody biological 
 analysis .
rom improved to 160 flexion , 120 abduction , 40 external rotation , and 35 
 internal rotation . however , even though the values of the parameters of the right upper 
 extremity were reduced , the le increased .
next , the patient underwent pnf d2 flexion and breathing exercises three times a week for 
 14 weeks ( 36 sessions in total ) .
the starting position for the exercise is the supine 
 position , with the shoulder joint in extension , adduction , and internal rotation ; the elbow 
 in extension ; and the forearm , wrist , and fingers in pronation .
the shoulder was slowly 
 stretched by flexion , abduction , external rotation , elbow extension , and forearm supination , 
 and the wrist and finger were slowly stretched by extension .
the arm and ear were 810 
 inches apart , and the thumb was pointed toward the floor .
the patient stretched her upper 
 extremities as much as possible and maintained the position . at the same time , breathing was 
 stopped and held for 5 seconds .
after that , while exhaling , the arm should be slowly 
 returned to the starting position .
this treatment is performed for 10 repetitions ( three 
 sets ) , followed by 1 minute of rest .
this study conformed to the ethical standards of the declaration of helsinki ( 1975 , revised 
 1983 ) .
the protocol for this study was approved by the institutional review board of hanyang 
 university ( hyi-15 - 046 - 1 ) .
after the pnf d2 flexion and breathing exercises , parameters of the right upper extremity 
 and the body water volume were reduced . moreover ,
the restricted rom of the right side was 
 improved . in the reevaluation on july 1 , 2014 , the parameters of the right upper extremity 
 ( axillary , at 10  cm above the elbow , at the elbow , and at 10  cm below the elbow , wrist , and 
 hand ) were reduced to 34 , 28 , 24 , 24 , 16 , and 18  cm , respectively .
in addition , the e / t fluid ratio was improved to 0.382% , and rom was 
 improved to 180 flexion , 180 abduction , 80 external rotation , and 45 internal 
 rotation .
in this study , the effects of pnf d2 flexion and breathing exercises were studied in a 
 patient with upper extremity le for whom the sscb treatment method could not used . as a 
 result of the intervention ,
the circumference of the armpit was reduced by 0.5  cm ; that of 
 10  cm above the elbow , by 1  cm ; that of the elbow , by 0.5  cm ; that of 10  cm below the elbow , 
 by 1  cm ; and that of the back of the hand , by 0.5  cm .
a total of 100  ml ( 9.4% ) of body water 
 volume in the right upper extremity was eliminated , and the e / t fluid ratio was decreased by 
 0.005% . in addition , the rom of the extremity was improved to 20 flexion , 60 abduction , 
 40 external rotation , and 10 internal rotation .
this study showed that pnf d2 flexion and 
 breathing exercises were effective in reducing le and improving rom .
this study suggests the 
 cdt method and pnf d2 flexion and breathing exercises for patients for who a sscb could not 
 be applied .
in addition , it is already 
 known that sscb compression force helps the natural pumping action of the muscle to increase 
 circulation of venous and lymphatic fluid in edematous areas3 . however , in a research by irdesel et al.8 , comparison between a group that maintained pressure during 
 the exercise and an opposition group did not show a beneficial difference in circulation . 

previous studies have shown that pnf exercise improves joint mobility and muscle 
 function9,10,11,12 . moreover , in a study by sharman et al.9 , active pnf stretching was found to be the most effective 
 method to improve rom .
in addition , in a study by hindle et al.10 , pnf stretching was found to improve rom , although 
 plyometric , high - intensity , or maximum - intensity exercise reduced muscle consumption .
after 
 gonzlez - rav et al.11 implemented 
 different exercises for 13 weeks and compared overall rom and shoulder rom in pnf groups , 
 rom improved by 5.91 ( 70.9676.01 ) and 5.08 ( 71.8476.88 ) , respectively , in the manual 
 exercise groups but was reduced by 2.57 ( 68.1166.06 ) in the non - exercise group .
however , in a comparison 
 between the results of their study and those of previous studies , the same results could not 
 be concluded owing to differences in study subjects .
therefore , studies on increasing 
 muscular strength through performance of pnf are needed in order to determine their effect 
 on edema .
moseley et al.13 analyzed breathing and 
 gentle arm exercises , and observing le reduction in the upper extremity by 46  ml ( 5.8% ) 
 immediately after exercise , 50  ml ( 5.3% ) after 30 minutes , 46  ml ( 4.3% ) after 24 hours , and 
 33  ml ( 3.5% ) after 1 week .
this parameter was remeasured 1 month after exercise and was 
 reported to have decreased by 101  ml ( 9.0% ) .
although their research method differed , they 
 reported a positive effect on le reduction because of the combined effects of breathing and 
 upper extremity exercises .
this study is a case report of individual treatment results in one patient , without a 
 control group . because of this limitation
, correlation could not be conclusively determined 
 between the effects pnf d2 flexion and those of breathing exercises on le and rom .
therefore , the present authors 
 referred to studies such as that by moseley et al.11 and concluded that pnf d2 flexion and breathing exercises improved 
 le and rom .
although this study is a case report of a single patient , its results indicate 
 that these exercises should be studied on a larger scale .
 [ purpose ] the aim of this study was to evaluate the effects of proprioceptive 
 neuromuscular facilitation ( pnf ) d2 flexion and breathing exercises in a patient with 
 lymphedema ( le ) . [ subject ] this report describes a 57-year - old woman with le in whom a 
 short - stretch compression bandage ( sscb ) could not be used for treatment because of skin 
 itching and redness . 
 [ methods ] the patient received complex decongestive therapy without a 
 sscb . 
 next , pnf d2 flexion and breathing exercises were conducted three times per week for 
 14 weeks ( 36 times ) . 
 [ results ] as a result , the circumference of the armpit was reduced by 
 0.5  cm ; that of 10  cm above the elbow , by 1  cm ; that of the elbow , by 0.5  cm ; that of 
 10  cm below the elbow , by 1  cm ; and that of the back of the hand , by 0.5  cm . 
 a total of 
 100  ml ( 9.4% ) of body water was eliminated from the right upper extremity , and moisture 
 ratio was reduced by 0.005% . 
 finally , range of motion was improved to 20 flexion , 60 
 abduction , 40 external rotation , and 10 internal rotation . 
 [ conclusion ] this study 
 showed that pnf d2 flexion and breathing exercises were effective in reducing le and 
 improving range of motion . 
INTRODUCTION
CASE REPORT
RESULTS
DISCUSSION