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EFFECT OF HIGH FREQUENCY TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION ON LYMPHEDEMA
M.S. Ezz1*, N.A. AbdEl-Rashed2, T.A. Amer3, N.M. Yousef2
1 Department of Physical Therapy, Ahmed Maher Teaching Hospital, Cairo, Egypt;
2 Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt;
3 Department of Plastic and Microscopic Surgery, Faculty of Medicine, Cairo University, Giza, Egypt.
* Corresponding author: [email protected]
Abstract. This study aimed to evaluate the efficacy of High-Frequency Transcutaneous Electrical Nerve Stimulation (TENS) in combination with Complex Decongestive Physical Therapy (CDPT) on lower limb lymphedema. Every participant provided informed consent for the randomized controlled trial. The trial was conducted at Ahmed Maher Teaching Hospital and High-Top Clinic in Egypt. 60 patients with secondary lower limb lymphedema, ages 35 to 65, were involved in the trial and were split into two groups at random. Group A received CDPT and High-Frequency TENS, while Group B received CDPT only. Both interventions were administered thrice weekly for eight weeks. A non-flexible tape was used to assess the limb girth as the major result; the Lymphedema Quality of Life Questionnaire (LYMQOL) was used as a secondary outcome. ANOVA tests were used in the statistical analysis to compare the pre and post-treatment outcomes within and across groups. The findings revealed that both groups had significantly lower limb girth and improved LYMQOL scores, with Group A showing more improvements than Group B (p < 0.05). The results indicate that for patients with lower limb lymphedema, the combination of High-Frequency TENS and CDPT is superior to CDPT alone in terms of limb girth reduction and improved quality of life. This combination of therapies may be a useful strategy for treating lymphedema and enhancing patient outcomes.
Keywords: complex decongestive physical therapy, high-frequency TENS, lymphedema.
List of Abbreviations
TENS - Transcutaneous Electrical Nerve Stimulation
CDPT - Complex Decongestive Physical Therapy
LYMQOL - Lymphedema Quality of Life Questionnaire
MLD - Manual Lymphatic Drainage RTP - The Reductive Treatment Phase ROM - Joint Range of Motion QOL - Quality of Life PLL - Primary Lower Lymphedema SLL - Secondary Lower Lymphedema
Introduction
A developing area or damage to the lymphatic system can result in a build-up of protein-rich tissue fluid in the intercellular space, which can lead to a persistent disease called lymphedema. While improvements in radiation therapy, a vital component of modern cancer treatment, lower death rates and lengthen life expectancy in most cases of breast cancer, they also raise the chance of developing a serious side effect like lymphedema, which occurs at a
rate of 5% to 42% after breast cancer treatment (Tatar & Turhan, 2022).
The Complex Decongestive Physical (CDP) is a multimodality technique that includes exercise, skin care, compression bandages, and Manual Lymphatic Drainage (MLD). In recent times, it has shown promise as a therapy method. In order to transfer protein-rich fluid from edematous to non-edematous regions, CDP is employed to open lymphatic channels. Despite being established several decades ago, CDP has been shown in several studies to significantly reduce the volume and percentage of lymph edema due to breast cancer (Atalay et al, 2015).
High-frequency Transcutaneous Electrical Nerve Stimulation (TENS), also known as high-tone power therapy, is one of the most advanced supplementary treatment modalities for a number of illnesses. TENS units with high frequencies are made to stimulate any part of the body (Gozani, 2016).
The main purpose of high-frequency TENS therapy is analgesia, but it can also alter how the cardiovascular system responds, the specifics of the application determine how effective
the treatment is. Changes in the cardiovascular system imply that the venous vascular response could be altered. It's been a common method for treating both acute and persistent pain. Nevertheless, this therapeutic approach alters the reactions of the cardiovascular system, resulting in vasodilatation, blood flow enhancement, and reductions in peripheral vascular resistance, heart rate, and systemic arterial blood pressure. These changes are linked to regulating the autonomic balance (Franco et al, 2014).
By examining the synergistic effect of High-Frequency TENS with CDPT on limb girth reduction and quality of life improvement, this study fills a significant gap in the literature. This work advances the treatment procedures for lymphedema by proving that the combination of these therapies produces more notable benefits than CDPT alone. By offering a more successful, non-invasive method of managing lymphedema, the findings may have an impact on therapeutic procedures and eventually enhance patient outcomes and quality of life. This work is noteworthy because it provides evidence for a more effective treatment plan by using High-Frequency TENS as an addition to CDPT. Its conclusions may influence rehabilitation tactics in the future and lay the groundwork for more studies aimed at improving lymphedema treatment.
Materials and Methods
Study design
It was a randomized controlled trial, this study. The researcher acquired informed consent from each individual. A permission form detailing the study's methods and objectives was given to the patients who were to take part. To confirm the patients met the research criteria and to screen them for demographic information, the investigator conducted a brief interview with the patients. This study adhered to ethical standards as outlined in the latest revision of the Declaration of Helsinki, and the procedures were approved by the Research Ethical Committee of Cairo University.
Participants
Sixty patients of both sexes with lower limb secondary lymphedema patients were partici-
pated in this study (Fig. 1). They were assigned randomly into two groups of equal number; group (A) and group (B), they were selected randomly to participate in this study from the patient's clinics, Department of Physical Therapy, Ahmed Maher Teaching Hospital (Cairo) and high-top clinic (Giza), Egypt. They were referred by a Lymphatic physician. To avoid a type II error, a preliminary power analysis was conducted considering girth measurement as a primary outcome with the following parameters: [power (1 - P) = 0.80, a = 0.05, effect size = 0.8]. The calculation determined a sample size of 26 for each group which will be increased by 15% up to 30 for each to overcome the expected dropout. G*power software (3.1.9.2) was used for sample size calculation.
The following were used as criteria for inclusion: their ages ranged from 35-65 years old, and all measurements would be done by the same investigator and lower limb secondary lymphedema patient. Patients with medical conditions associated with lymphedema are excluded, these conditions include parkinsonism, brain damage, anxiety and alcoholism, current metastases, Patients who had a local wound and severe fungal infection, and patients who had sensory disorders and venous thrombosis were excluded.
Patients have the right to withdraw from the study at any time. After patients signed the consent form, patients were assigned randomly into two groups of equal numbers: groups (A and B). Group (A) received complex decongestive physical therapy (CDPT) for 30 minutes and High-frequency TENS for 30 minutes, 3 sessions per week for 8 weeks while group (B) received CDPT only as the same applied to group (A) for 30 minutes, 3 sessions per week for 8 weeks.
Outcome measures
A. Tape measurement
Limb girth measured in centimeters with a non-flexible tape to determine the circumference of the limb at selected anatomic locations. Patients removed all limb coverings and, while in a standardized position, extended limbs while measurement increments were marked on
their skin. Both limbs were measured for comparison of circumferences at similar anatomic locations to compare differences in girth. Periodically, total limb circumference is calculated for comparison over time (Megens et al., 2001).
B. Lymphoedema Quality of Life Questionnaire (LYMQOL)
It is a quality of life (QOL) assessment measure designed specifically for limb lym-phoedema (National Lymphedema Networkm 2012). It is an approved disease-specific tool to gauge how lymphoedema affects a patient's quality of life (Pas et al., 2016).
Treatment Program
- All measurements were done by the same investigator.
- Patients who did not complete the procedure of the study were excluded.
- Verbal explanations about the study aims, importance, and approach were given to every patient in both groups.
- Every patient gave his / her written informed consent before the beginning of the study.
1. Complex decongestive physical therapy (CDPT) (Pneumatic compression device)
The Reductive Treatment Phase (RTP)
It is kept in a specialized lymphedema clinic until the fluid volume reduction reaches a ceiling. Manual lymph drainage (MLD), multilayer, short-stretch compression bandaging, therapeutic exercise, skin care, self-management education, and elastic compression garments are some of the components that make up the CDPT RTP. The CDPT, a method that incorporates MLD, functional compression wrapping, therapeutic exercises, skin care, lymphatic self-massage, and the use of elastic wrap, is the primary physical treatment for lymphedema (Lymphology, 2003).
Reintroducing it should be done if swelling gets worse or symptoms get worse. The CDPT consists of an initial RTP followed by an ongoing maintenance phase. After the RTP is finished, the patient begins the maintenance phase, during which they continue with self-management activities such as exercising, using a comp-ression sleeve during the day, and skin care. The RTP is kept in a specialized clinic for
lymphedema until the fluid volume reduction reaches a plateau (Uzkeser et al., 2013).
Phase I (multiple intense therapy sessions) of CDPT involve manual lymph drainage, gradient compression with short-stretch bandages and decongestive gradient compression with short-stretch bandages, exercise, skin care, and wearing properly fitting compression garments. CDPT is administered by a therapist in the clinic (Keskin et al, 2020).
Whenever edema increases or symptoms worsen, the RTP should be resumed. The maintenance phase begins after the RTP is over, during which the patient continues self-management practices such as using a compression sleeve during the day, exercising, and taking care of their skin. Phase I treatment varies in duration but often lasts two to four weeks. It ends when the patient's affected leg or limbs achieve stable values for volume and girth (Lawenda et al, 2009).
The goals of skin care in the management of lymphedema are to prevent infection, damage, and harm to the skin as well as to preserve or improve its integrity (Thomas-MacLean et al, 2005). It is advised to practice strict cleanliness in order to reduce the quantity of bacteria and fungi on the skin. Applying moisturizers with a low pH will prevent skin from drying out and breaking. Bacteria and fungi can enter the body through skin cracks and dry patches, leading to wounds and infections. Cellulitis, a skin infection, can be treated every day for 30 to 60 minutes as part of CDPT's maintenance phase. Pneumatic compression devices that are deemed acceptable ought to possess numerous chambers that sequentially apply pressure (Ridner et al., 2010).
Compression pump therapy, sometimes referred to as intermittent pneumatic compression, is a valuable addition to Phase I CDPT or an essential part of a fruitful at-home regimen (Phase II CDPT) for certain patients (Hammond, 2009).
The discrepancy in upper limb size and volume between the affected and unaffected limbs were decreased by the CDPT and compression pumping. Patients who get instruction in CDPT skills may be able to sustain the decreases in limb measures brought about by ambulatory care. Compression pumping is used in conjunction with CDPT.
2. High-frequency TENS
To ensure dependability, a physical therapist performed a high-frequency TENS intervention (frequency 100 Hz, pulse width 100 [j,s, motor threshold) to sore trigger sites in the quadriceps muscles. The intervention consisted of a single 30-minute session using a dual-channel TENS machine (Suh etal., 2015).
Statistical analysis
The Chi-square test was used to ascertain the gender distribution. All the study's data were displayed using means and standard deviations. The normal distribution of the data was con-
firmed using the Shapiro-Wilk test. Levene's test was performed to determine whether or not there was homogeneity in the variances between groups. ANOVA test would be used to compare the mean values of each parameter between the pre and post tests within each group, and ANOVA test would be used to compare the mean values of each parameter between the two groups before and following treatment. All statistical tests were conducted with a significance level of p < 0.05. The statistical package for social studies (SPSS) version 25 for Windows (IBM SPSS, Chicago, IL, USA) was used for all statistical analysis.
Analyzed (n=30) 0 Excluded from analysis (n=0) Analyzed (n=30) 0 Excluded from analysis (n=0)
Fig. 1. The flow chart of the study
Results
Subjects' demographic data A p-value larger than 0.05 in the data presented in Table 1 suggests that there was no statistically significant difference in the age values between groups A and B. This implies that the age distributions of the two groups were similar, proving that age had no bearing on the study's conclusions. Furthermore, a p-value larger than 0.05 in the gender distribution anal-
ysis suggested that there was no significant difference between the two groups. This suggests that the gender distribution of the two groups was well matched and that gender differences cannot be the cause of any effects found in the study. These results verify that the age and gender demographics of both groups were comparable, enabling the study to concentrate on the therapy interventions' effects without being influenced by these characteristics.
Table 1
Characteristics of respondents (age)
Mean values of a ge of groups (A and B)
Variable Groups X ± SD t-value p-value
Age (years) Group (A) n = 30 46.53 ± 7.16 0.51 0.613 NS
Group (B) n = 30 47.47 ± 7.04
Note: X: Mean. SD: Standard Deviation. t-value: Paired and Un-paired t- test value. p-value: Probability value. S: Significant.
Table 2
Characteristics of respondents (gender)
Comparison of gender distribution in groups (A and B)
Gender distribution N (%) X2 p-value Level of significant
Group (A) n = 30 Group (B) n = 30
Women 14 (45%) 12 (40%) 0.23 0.175 NS
Men 16 (55%) 18 (60%)
Note: X: Mean. SD: Standard Deviation. X2: Chi squared value. P-value: Probability value. NS: NonSignificant.
Measured variables
1. Before treatment comparison among two groups (A as well as B)
The findings show that there were no appreciable variations in limb girth and LYMQOL values before treatment between the two groups (A and B) (p > 0.05). According to this, there may not have been any pre-existing differences between the two groups at baseline that could have influenced the post-treatment outcomes. An important conclusion is that there were no significant differences (p > 0.05) in limb girth
and LYMQOL scores between Groups A and B prior to therapy. It implies that there were no fundamental differences between the two groups at baseline, therefore any changes that were seen following treatment may be ascribed to the interventions rather than the groups themselves. The study's internal validity is reinforced by this baseline homogeneity, which lowers the possibility of confounding variables resulting from beginning variations in lymphedema severity or quality of life (Table 3).
Table 3
Comparison of limb girth measurement (cm) and LYMQOL for two groups (A and B)
Note: X: Mean. SD: Standard Deviation. P-value: Probability value. NS: Non-significant. S: Significant.
Group (A) n = 30 X ± SD Group (B) n = 30 X ± SD p-value
1) Knee level (cm) Before treatment 53.5 ± 3.44 54.23 ± 4.12 0.457NS
After treatment 47.83 ± 3.38 51.57 ± 3.76 0.0001s
p-value 0.0001s 0.0001s
2) Above knee level (1st point) (cm) Before treatment 57.57 ± 3.68 59.13 ± 4.27 0.133NS
After treatment 50.77 ± 3.28 54.03 ± 3.91 0.001s
p-value 0.0001s 0.0001s
3) Above knee level (2nd point) (cm) Before treatment 63.33 ± 3.25 64.37 ± 4.04 0.28NS
After treatment 54.93 ± 3.29 58.5 ± 4.18 0.001s
p-value 0.0001s 0.0001s
4) Above knee level (3rd point) (cm) Before treatment 69.5 ± 3.21 70.2 ± 3.8 0.444NS
After treatment 59.8 ± 2.98 62.83 ± 3.87 0.001s
p-value 0.0001s 0.0001s
5) Above knee level (4th point) (cm) Before treatment 76.2 ± 2.94 77.17 ± 3.72 0.269NS
After treatment 64.13 ± 3.01 68.47 ± 4.02 0.001s
p-value 0.0001s 0.0001s
6) Below knee level (1st point) (cm) Before treatment 50.73 ± 3.65 51.17 ± 4.1 0.667NS
After treatment 44.77 ± 2.43 48.47 ± 4.02 0.001s
p-value 0.0001s 0.0001s
7) Below knee level (2nd point) (cm) Before treatment 54.57 ± 3.4 55.13 ± 3.95 0.554NS
After treatment 48.87 ± 3.37 52.4 ± 3.52 0.0001s
p-value 0.0001s 0.0001s
8) Below knee level (3rd point) (cm) Before treatment 46.5 ± 3.42 47.9 ± 3.1 0.102NS
After treatment 40.77 ± 3.37 43.73 ± 3.42 0.001s
p-value 0.0001s 0.0001s
9) Below knee level (4th point) (cm) Before treatment 42.2 ± 2.99 43.4 ± 3.01 0.127NS
After treatment 37.07 ± 2.6 39.83 ± 3.2 0.001s
p-value 0.0001s 0.0001s
10) LYMQOL Before treatment 3.4 ± 0.5 3.5 ± 0.51 0.445NS
After treatment 1.03 ± 0.7 1.57 ± 0.5 0.001s
p-value 0.0001s 0.0001s
2. Before as well as after treatment comparison regarding group (A)
Following treatment, there were significant improvements in LYMQOL scores and reductions in limb girth in Group A (p < 0.05), which received CDPT in addition to High-Frequency TENS. This suggests that the use of CDPT and TENS together was successful in lowering limb edema and enhancing patients' quality of life.
While the improvement in LYMQOL scores indicates a beneficial influence on the patient's well-being and everyday functioning, the considerable reduction in limb girth implies that TENS may augment the effects of CDPT by encouraging fluid drainage and improving tissue function. The synergistic effect of the combination of therapy seems to enhance the advantages of each modality (Table 3).
3. Before as well as after-treatment comparison regarding group (B)
Following therapy, limb girth and LYMQOL values significantly improved in Group B, which got CDPT without TENS (p < 0.05). Because CDPT is known to minimize lymphatic fluid buildup by procedures like manual lymph drainage, compression, and exercise, this finding validates the recognized efficacy of CDPT in controlling lymphedema. Although CDPT is useful on its own, the results do not imply that it is better than the combined therapy employed in Group A (Table 3).
4. After treatment comparison among two groups (A as well as B)
Following the intervention, Group A demonstrated notably superior results in terms of limb girth reduction and improvements in LYMQOL when compared to Group B (p < 0.05). This suggests that the combined use of High-Frequency TENS and CDPT produced more therapeutic advantages than either treatment alone. Given that Group A's limb girth decrease was more noticeable, it is possible that High-Frequency TENS increased the physiological effects of CDPT by lowering tissue resistance or enhancing lymphatic circulation. Furthermore, it appears that patients in Group A saw a more significant improvement in their mental and physical health based on the higher improvement in quality of life (LYMQOL scores) (Table 3).
In conclusion, these findings imply that although CDPT is still a useful treatment for lymphedema, High-Frequency TENS provides a substantial benefit over CDPT. Combining these two treatments seems to have better effects on patients' general quality of life in addition to lessening physical symptoms like limb swelling. The results suggest that medical professionals should think about using High-Frequency TENS in addition to CDPT in lymphedema treatment regimens, particularly for patients who want better results.
Discussion
A chronic, crippling condition that needs lifelong care is lower limb lymphedema. The
gold standard of treatment for lymphedema is CDPT. It was revealed that CDPT had positive effects on volume reduction in patients at all stages of lower limb lymphedema (Kostanoglu et al, 2019).
While various therapies are available for treating lymphoedema, one well-known conservative multicomponent method that tries to reduce limb girth is CDPT. Because of its cost-effective administration, safety, and lack of recorded side effects, it is regarded as the best-known method (Agarwal et al., 2024). By combining MLD, skin care, compression, and exercise, a CDPT program can lessen oedema and enhance functional activities (Holtgrefe, 2006). It might have an ongoing influence for years at a time (Boris et al., 1994).
Pre- and post-treatment results for all variables measured in group (A) showed a significant difference that is consistent with Feger et al. (2015) findings that TENS is one of the first edema treatment methods that allows for quantitative management of treatment intensity, duration, and frequency for reliable and accurate edema region treatment.
In a study by Bilgili et al. (2016) that looked at how TENS affected pain, edema, and joint range of motion (ROM) in patients with pain syndrome, it was found that while joint ROM rose in the experimental group receiving TENS therapy, pain, and edema decreased. In a second trial, 11 patients with lower extremity lymphedema were enrolled by Choi and Lee (2016), who then randomly assigned them to an experimental group (TENS group, n = 6) or a control group (n = 5) that received doctor-prescribed medication treatment. For three weeks, the experimental group underwent three weekly TENS treatments at the edema site. They concluded that by increasing venous blood flow in the lower extremities, TENS is particularly helpful in lowering edema.
In a different investigation, Broderick et al. (2009) examined the impact of electrical stimulation on calf muscles to prevent edema by contrasting the alterations in lower limb blood flow during bed rest with those that occurred after electrical stimulation of the calf muscles. They concluded that electrical stimulation could im-
prove lower limb blood flow and lessen the incapacitating consequences of venous stasis.
Additionally, the results of Munir et al. (2021), who discovered that TENS application has shown to be a useful treatment technique for varicose veins, are accepted with the findings of group (A). In addition to lowering patients' pain scores, TENS use has increased venous blood flow, which lowers the risk of venous stasis, edema development, and other issues.
All of group B's measured variables showed a significant difference between pre- and post-treatment results. This finding is consistent with the findings of Abakay et al. (2021), who discovered that CDPT improved patients' quality of life while reducing edema in those with both primary lower lymphedema (PLL) and secondary lower lymphedema (SLL). Compared to those with PLL, those with SLL had a higher improvement in their QOL.
Furthermore, the outcomes of our research in group (B) are concurred with the findings of Costello et al. (2021). Both edema and QOL are enhanced by CDPT. Nonetheless, people require more assistance to continue actively engaging in successful self-care techniques given the variations in edema following therapy.
In addition, CDPT given in addition to the exercises has been demonstrated to offer notable improvements in limb volumes, pain, and physical function, according to the Atan and Bahar-Ozdemir (2021) study. Additionally, CDPT is beneficial for a group of palliative cancer patients with a poor chance of life, according to Cobbe et al. (2018). There were improvements in skin quality, limb volume, and QOL associated to lymphedema. Measures of QOL and skin validity must be created. More extensive, blinded trials are required to identify the patients who benefit from CDPT.
The study by Casley-Smith et al. (1996), the only one describing long-term follow-up of patients after the conclusion of the course of treatment with the technique, corroborates the findings of the current study. These researchers were able to verify that the advantage of CDPT in terms of limb volume reduction persisted by following some of the lymphedematous subjects for a full year.
The results of group (B) match those of Damstra et al. (2008), who showed that CDPT causes an instantaneous decrease in limb volume, lowering bandage pressure and supporting frequent bandage changes at the start of CDPT. Furthermore, according to Pekyavas et al. (2024), CDPT was more effective at reducing lymphedema, which can promote edema reduction for long-term consequences.
The previous results of the current study are supported by the results of Liao et al. (2012), who applied 12 sessions of CDPT since most of the decrease in lymphedema volume occurs in the first 10 days of CDPT treatment with a smaller decrease after 10 days. Tugral et al. (2017) obtained a reduction in the amount of edema by applying CDPT 5 days a week for 4 weeks.
The results of group (B) corroborated the findings of Atalay et al. (2015), who reported a negative association between ROM and depression levels and a positive correlation between circumference reduction with depression levels. Depression, a common condition among breast cancer survivors, is made worse by limb swelling and range of motion limitations brought on by lymph edema following mastectomy. In addition to being a useful treatment for arm swelling and a decline in physical function, CDPT can support the management of psychological discomfort, including depression.
The findings of Zasadzka et al. (2018), who discovered that CDPT cannot achieve the maximal reduction in lymphedema and that the therapeutic effect cannot be sustained, are not consistent with the results of our investigation of group (B). Additionally, it proves its efficacy as a stand-alone technique that can lower therapy costs and make lymphedema therapy more accessible to elderly patients.
This study's findings conflict with those of Sluka et al. (1998), who found that while edema was not significantly affected by TENS, both low- and high-frequency TENS efficiently reduced discomfort. Furthermore, our work was used by Damstra and Partsch (2013), who report that the CDPT program for severe limb deformity and handicap causes a delay in intervention and is ineffective for lower limb lymphedema. This contrasts with our findings.
Limitations
This study has a few limitations. Changes in patient's lifestyle habits and educational level, motivations differences between all patients, some of the patients did not complete the protocol of treatment due to different causes and they already got excluded from the study, possible conflict of knowledge gained from course work and not known if skills will transfer to the clinical environment.
Conclusion
High-frequency TENS with CDPT was more effective than CDPT alone in treating lymphedema.
Acknowledgments
A special thank note goes to the study's participants and to the Department of Physical Therapy, Ahmed Maher Teaching Hospital (Cairo) and high top clinic (Giza), Egypt, for providing the chance to conduct the study procedures easily.
Disclosure statement
No financial funding has been provided for the current research work.
Conflicts of interest
No conflict of interest has been declared by the authors of this academic work, and there are no conflicts of interest relevant to this article.
References
ABAKAY H., DOGAN H., £ALI§ H.T. & AKBAYRAK T. (2021): Is the effect of complex decongestive therapy the same for primary and secondary lower lymphedema? Lymphatic research and biology 19(2), 165-174.
AGARWAL A., AZAIS P., CIFARELLI L., DE BOER J., EROGLU D., GEBEL G. ... & WAGNER H.J. (2024): Physics for the environment and sustainable development. In: EPS Grand Challenges: Physics for Society in the Horizon 2050. IOP Publishing.
ATALAY O.T., OZKIR A., CALIK B.B., BASKAN E. & TA§KIN H. (2015): Effects of phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer related lymph edema. Journal of Physical Therapy Science 27(3), 865-870.
ATAN T. & BAHAR-OZDEMIR Y. (2021): The effects of complete decongestive therapy or intermittent pneumatic compression therapy or exercise only in the treatment of severe lipedema: a randomized controlled trial. Lymphatic research and biology 19(1), 86-95.
BILGILI A., CAKIR T., DOGAN §.K., ERCALIK T., FILIZ MB. & TORAMAN F. (2016): The effectiveness of transcutaneous electrical nerve stimulation in the management of patients with complex regional pain syndrome: a randomized, double-blinded, placebo-controlled prospective study. Journal of back and musculoskeletal rehabilitation 29(4), 661-671.
BORIS M., WEINDORF S., LASINSKI B. & BORIS G. (1994): Lymphedema reduction by noninvasive complex lymphedema therapy. Oncology (Williston Park, NY) 8(9), 95-106.
BRODERICK B.J., O'BRIAIN D.E., BREEN P.P., KEARNS SR. & OLAIGHIN G. (2009): A hemodynamic study of popliteal vein blood flow: the effect of bed rest and electrically elicited calf muscle contractions. In: 2009 Annual International Conference of the IEEE Engineering in Medicine and Biology Society, pp. 2149-2152. IEEE.
CASLEY-SMITH JR. (1996): TREATMENT OF LYMPHEDEMA BY COMPLEX PHYSICAL THER APY, WITH AND WITHOU T ORAL AND TOPICAL BENZOPYRONES: What Should Therapists and Patients Expect. Lymphology 29(2), 76-82.
CHOI Y.D. & LEE J.H. (2016): Edema and pain reduction using transcutaneous electrical nerve stimulation treatment. Journal of physical therapy science 28(11), 3084-3087.
COBBE S., NUGENT K. & REAL S. (2018): Pilot study: the effectiveness of complex decongestive therapy for lymphedema in palliative care patients with advanced cancer. Journal of palliative medicine 21(4), 473-478.
COSTELLO M., MOORE Z., AVSAR P., NUGENT L., O'CONNOR T. & PATTON D. (2021): Non-cancer-related lower limb lymphoedema in complex decongestive therapy: the patient experience. Journal of Wound Care 30(3), 225-233.
DAMSTRA R.J. & PARTSCH H. (2013): Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multicomponent compression bandages in
the initial treatment of leg lymphedema. Journal of Vascular Surgery: Venous and Lymphatic Disorders 1(1), 13-19.
DAMSTRA R.J., BROUWER E.R. & PARTSCH H. (2008): Controlled, comparative study of relation between volume changes and interface pressure under short-stretch bandages in leg lymphedema patients. Dermatologic surgery 34(6), 773-779.
FEGER M.A., GOETSCHIUS J., LOVE H., SALIBA S.A. & HERTEL J. (2015): Electrical stimulation as a treatment intervention to improve function, edema or pain following acute lateral ankle sprains: A systematic review. Physical Therapy in Sport 16(4), 361-369.
FRANCO O S., PAULITSCH F.S., PEREIRA A.P.C., TEIXEIRA A O., MARTINS C.N., SILVA A.M.V. ... & SIGNORI L.U. (2014): Effects of different frequencies of transcutaneous electrical nerve stimulation on venous vascular reactivity. Brazilian Journal of Medical and Biological Research 47(5), 411-418.
GOZANI S.N. (2016): Fixed-site high-frequency transcutaneous electrical nerve stimulation for treatment of chronic low back and lower extremity pain. Journal of Pain Research, 469-479.
HAMMOND T. (2009): Reduction of complications and associated costs with flexitouch® therapy for lymphedema. The Open Rehabilitation Journal 2(1).
HOLTGREFE K.M. (2006): Twice-weekly complete decongestive physical therapy in the management of secondary lymphedema of the lower extremities. Physical therapy 86(8), 1128-1136.
KESKIN D., DALYAN M., UNSAL-DELIALIOGLU S. & DUZLU-OZTURK U. (2020): The results of the intensive phase of complete decongestive therapy and the determination of predictive factors for response to treatment in patients with breast cancer related-lymphedema. Cancer Reports 3(2), e1225.
KOSTANOGLU A.L.i.S., RAMOGLU M. & GUNEREN E. (2019): Results of home-based modified combined decongestive therapy in patients with lower extremity lymphedema. Turkish journal of medical sciences 49(2), 610-616.
LAWENDA B.D., MONDRY T.E. & JOHNSTONE P A. (2009): Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA: a cancer journal for clinicians 59(1), 8-24.
LIAO S.F., LI S.H. & HUANG H.Y. (2012): The efficacy of complex decongestive physiotherapy (CDP) and predictive factors of response to CDP in lower limb lymphedema (LLL) after pelvic cancer treatment. Gynecologic oncology 125(3), 712-715.
MEGENS A.M., HARRIS SR., KIM-SING C. & MCKENZIE DC. (2001): Measurement of upper extremity volume in women after axillary dissection for breast cancer. Archives of physical medicine and rehabilitation 82(12), 1639-1644.
MUNIR H., ALI S., SIDDIQUE A., SAFDAR S., WAQAS S. & KIANI J.A. (2021): Effect of Transcutane-ous Electrical Nerve Stimulation in Pain Reduction and Venous Blood Flow Augmentation in Varicose Vein Patients. Pakistan Journal of Physiology 17(2), 31-34.
NLN MEDICAL ADVISORY COMMITTEE (2012): Position statement of the national lymphedema network. Topic: Lymphedema risk reduction practices.
OF LYMPHOLOGY I.S. (2003): The diagnosis and treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology. Lymphology 36(2), 84-91.
PEKYAVA§ NO., TUNAY V.B., AKBAYRAK T., KAYA S. & KARATA§ M. (2014): Complex decongestive therapy and taping for patients with postmastectomy lymphedema: a randomized controlled study. European Journal of Oncology Nursing 18(6), 585-590.
RIDNER S.H., MURPHY B., DENG J., KIDD N., GALFORD E. & DIETRICH M.S. (2010): Advanced pneumatic therapy in self-care of chronic lymphedema of the trunk. Lymphatic research and biology 8(4), 209-215.
SLUKA K.A., BAILEY K., BOGUSH J., OLSON R. & RICKETTS A. (1998): Treatment with either high or low frequency TENS reduces the secondary hyperalgesia observed after injection of kaolin and car-rageenan into the knee joint. Pain 77(1), 97-102.
SUH H.R., KIM T.H., & HAN G.S. (2015): The Effects of High-Frequency Transcutaneous Electrical Nerve Stimulation for Dental Professionals with Work-Related Musculoskeletal Disorders: A Single-Blind Randomized Placebo-Controlled Trial. Evidence-Based Complementary and Alternative Medicine 2015(1), 327486.
TATAR K.K. & TURHAN B. (2022): The effects of complex decongestive therapy on pain and functionality in individuals with breast cancer who developed adhesive capsulitis due to lymphedema: an evaluation by an isokinetic computerized system. The Korean Journal of Pain 35(3), 280-290.
THOMAS-MACLEAN R., MIEDEMA B. & TATEMICHI SR. (2005): Breast cancer-related lymphedema: women's experiences with an underestimated condition. Canadian Family Physician 51(2), 246-247.
TUGRAL A., VIREN T. & BAKAR Y. (2017): Tissue dielectric constant and circumference measurement in the follow-up of treatment-related changes in lower-limb lymphedema. International angiology: a journal of the International Union of Angiology 37(1), 26-31.
UZKESER H., KARATAY S., ERDEMCI B., KOC M. & SENEL K. (2015): Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: a randomized controlled trial. Breast Cancer 22, 300-307.
VAN DE PAS C.B., BIEMANS A.A.M., BOONEN R.S.M., VIEHOFF P.B. & NEUMANN, HAM. (2016): Validation of the lymphoedema quality-of-life questionnaire (LYMQOL) in Dutch patients diagnosed with lymphoedema of the lower limbs. Phlebology 31(4), 257-263.
ZASADZKA E., TRZMIEL T., KLECZEWSKA M. & PAWLACZYK M. (2018): Comparison of the effectiveness of complex decongestive therapy and compression bandaging as a method of treatment of lymphedema in the elderly. Clinical interventions in aging, 929-934.
