Physical function assessment scales used in rehabilitation for upper limb lymphedema: a scoping review

ABSTRACT

Purpose:

The aim of this scoping review was to identify the physical function assessment scales for the rehabilitation treatment of upper limb lymphedema. This review was conducted to establish a consensus on assessment scales for use in clinical practice worldwide.

Methods:

Four electronic databases (PubMed, Cochrane Library, PEDro, and OTseeker) were searched. Search strategy included identified search terms. Articles were selected based on specific inclusion and exclusion criteria.

Results:

A total of 411 results were retrieved, and 16 articles were analysed after screening. We identified 13 types of physical function assessment scales and six functional categories. Disabilities of arm, shoulder, and hand (n = 9), range of motion (n = 6), and grip strength (n = 4) were the most commonly reported assessment scales.

Conclusions:

Current assessment scales in upper limb lymphedema are dominated by patient-reported outcome measures, motion, and strength. However, the gold standard for physical function assessment scales in upper limb lymphedema remains uncertain. In the future, there is a need to standardize or develop physical function assessment scales that reflect the effectiveness of rehabilitation treatment in patients with upper limb lymphedema.

KEYWORDS:

• Upper limb lymphedema
• physical function
• assessment scale
• scoping review

Introduction

Lymphedema is a chronic localized form of tissue swelling that results from excessive retention of lymphatic fluid in the interstitial compartment and is caused by impaired lymphatic drainage [1]. Lymphedema can occur anywhere in the body and is generally classified as either primary (genetic) or secondary (acquired) lymphedema, with many patients suffering negative effects on their physical activities of daily living and quality of life. In particular, secondary lymphedema of the upper limbs following breast cancer treatment that often causes functional disability and psychological and social problems [2].

Complex decongestive physiotherapy is commonly used in lymphedema rehabilitation. This technique includes skin care, manual lymph drainage, compression therapy, and exercise therapy under compression. Furthermore, patient education is also important to enable patients to manage edema adequately their own. Previous reports have shown that rehabilitation for upper or lower limb lymphedema reduces the circumference or volume of the lymphedema [3,4].

However, little is known regarding the effects of rehabilitation on physical function. No consensus has been reached on the assessment scales for measuring physical function in patients with lymphedema. Importantly, to establish evidence or rehabilitation of lymphedema, the assessment scales of physical function must be determined.

This article presents a scoping review aimed to identify the physical function assessment scales used in published research articles on upper limb lymphedema rehabilitation.

Materials and methods

Study design

This scoping review was conducted in accordance with the five-stage framework initially presented by Arksey and O’Malley [5] further developed by Levac [6]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR) guidelines were also followed [7,8].

Framework stage 1: identifying the research question

We defined the research question in this study as follows: “which physical function assessment scales are used when rehabilitation of upper limb lymphedema?”.

Framework stage 2: identifying relevant studies

The article search was conducted on June 1, 2023. All articles were written in English and published by the time of the search date. Four electronic databases (PubMed, Cochrane Library, PEDro, and OTseeker) were searched. In the database search, the key concepts were divided into five items, namely, pathological condition, treatment, site, physical function, and outcome measurement, and the search was conducted. In the pathological condition section, one term was used, namely, “lymphedema”. In the treatment section, one term was used, namely, “rehabilitation”. In the site section, two terms were used, namely, “upper limb” and “upper extremity”. In the physical function section, three terms were used, namely, “physical”, “function*”, and “performance”. In the outcome measure section, five terms were used, namely, “outcome”, “parameter”, “measurement”, “task”, and “assessment”. The Boolean operators “OR” and “AND” were used to link the search terms from each concept. A list of key concepts and search terms is presented in Table 1. In addition, for the database search, we obtained references through manual searching.

Table 1. List of the key concepts and search terms.

Key concepts	No.	Search terms
Pathological condition	#1	lymphedema
Treatment	#2	rehabilitation
Site	#3	“upper limb”
	#4	“upper extremity”
	#5	(#3 OR #4)
Physical function	#6	physical
	#7	function*
	#8	performance
	#9	(#6 OR #7 OR #8)
Outcome measurement	#10	outcome
	#11	parameter
	#12	measurement
	#13	task
	#14	assessment
	#15	(#10 OR #11 OR #12 OR #13 OR #14)
search formula	#16	#1 AND #2 AND #5 AND #9 AND #15

The following criteria were used for inclusion in the study: (1) inclusion of physical function assessment scales, (2) use of non-invasive and commonly used assessments in rehabilitation practice, (3) original articles with a study design demonstrating a level of evidence higher than that typically found in observational studies, and (4) the author or evaluators were not limited to rehabilitation-related professions.

The exclusion criteria were as follows: (1) use of subjective measurements alone, such as Visual Analogue Scale and Numerical Rating Scale, (2) exclusively measuring the circumference or volume of the affected limb for physical function assessment, (3) intervention or treatment utilizing invasive approaches, (4) study designs, including case reports, review articles, systematic reviews, and meta-analyses, and (5) conference abstracts.

Framework stage 3: study selection

Independent reviewers examined the inclusion and exclusion criteria for all relevant articles. Title and abstract screening were conducted independently by two authors (Y.F. and H.T.), followed by full-text screening, with discrepancies resolved by a third arbiter (Y.Y.).

Framework stage 4: charting the data

The reviewers collaboratively developed a data-extraction method. Base on the research question and review purpose, the extraction categories were as follows: first author, year of publication, article title, study location, study design, number of participants, intervention, lymphedema measurement (circumference and/or volume), outcome measure of physical function, and other measurement tools.

Framework stage 5: collating, summarizing, and reporting the results

Data were extracted from all eligible articles by an independent author and the verified by another author, and the results were analysed numerically and thematically. For the thematic analysis, we identified how the articles were related to the research question and created codes (labels) that best reflected the assessment of the physical function assessment scales. After repeating the code creation process and successfully identifying patterns among the codes, categories were created. The results of the numerical and thematic analyses are presented in Table 2.

Table 2. Synthesis of eligibility article characteristics.

No.	First Author, Year of publication	Study location	Title	Study design	Number of subjects	Intervention	lymphedema measurement
							Circumference	Volume
1	Kim Y, 2023	South Korea	The effect of myofascial release in patients with breast cancer-related lymphedema: a cross-over randomized controlled trial	RCT	30 patients with BCRL	2 groups: (crossover design) Group A: Myofascial release for 4 weeks, followed by 4 weeks of washout period, and then received placebo Myofascial release. Group B: Group B received interventions in the reverse order of Group A.		〇
2	Pajero Otero V, 2022	Spain	Intensive complex physical therapy combined with intermittent pneumatic compression versus Kinesio taping for treating breast cancer-related lymphedema of the upper limb: A randomized cross-over clinical trial	RCT	43 patients with BCRL	2 groups: (crossover design) Group A: Complex physical therapy combined with intermittent pneumatic compression during the first phase of intervention and Kinesio taping during the second phase of intervention. Group B: Group B received the same therapies in the reverse order.		〇
3	Baran E, 2021	Turkey	Upper limb sensory evaluations and ultrasonographic skin measurements in breast cancer-related lymphedema receiving complex decongestive physiotherapy	pretest-posttest design	27 patients with BCRL	All patients underwent complex decongestive physiotherapy phase 1 program for BRCL. Complex decongestive physiotherapy consists of five sessions per week, for 3 weeks (a total of 15 sessions, 60 min per session).		〇
4	Korucu TS, 2021	Turkey	Comparison of Shoulder-Arm Complex Pain, Function, and Scapular Dyskinesia in Women With and Without Unilateral Lymphedema After Breast Cancer Surgery	case-control study	117 patients (patients with BRCL: healthy = 50: 57)	No intervention (Because, observational study)		〇
5	Lampinen R, 2021	USA	Treatment of Breast Cancer-Related Lymphedema Using Negative Pressure Massage: A Pilot Randomized Controlled Trial	RCT	25 patients with BCRL	2 Groups: (single blinded) Group 1: The intervention group received treatment with the negative pressure massage treatment device. Group 2: Group 2 received manual lymph drainage.		〇
6	Sen EI, 2020	Turkey	Manual Lymphatic Drainage May Not Have an Additional Effect on the Intensive Phase of Breast Cancer-Related Lymphedema: A Randomized Controlled Trial	RCT	54 patients with BCRL	2 Groups: The patients in both groups participated in a 15-session program (every weekday for 3 weeks) that included compressive multilayer bandaging and exercise training. Complex decongestive therapy group: The patients in this group received manual lymph drainage (a 45 min to 1 h session) before bandaging in addition to the standard therapy group. Standard therapy group: No manual lymph drainage.		〇
7	Tastaban E, 2020	Turkey	Role of intermittent pneumatic compression in the treatment of breast cancer-related lymphoedema: a randomized controlled trial	RCT	76 patients with BRCL	2 Groups: Group 1: The patients received complex decongestive therapy including skin care, manual lymphatic drainage, multi-layer compression bandaging, and exercise. Group 2: The patients received Group 1 program in combination with intermittent pneumatic compression.		〇
8	Tantawy SA, 2019	Kingdom of Bahrain	Comparative Study Between the Effects of Kinesio Taping and Pressure Garment on Secondary Upper Extremity Lymphedema and Quality of Life Following Mastectomy: A Randomized Controlled Trial	RCT	66 patients with BCRL	2 Groups: Both groups received a home exercise program in the form of range of motion exercises. KT group: This group received Kinesio taping application twice per week. PG group: This group received pressure garment (20–60 mmHg) for at least 15–18 h per day for 3 weeks.	〇
9	Pajero Otero V, 2019	Spain	Kinesio taping versus compression garments for treating breast cancer-related lymphedema: a randomized, cross-over, controlled trial	RCT	30 patients with BCRL	2 Groups: Group A: This group received the intervention with Kinesio taping first which was followed by therapy with compression garments. Group B: This group received the same interventions in the reverse order.		〇
10	Sezgin Ozcan D, 2018	Turkey	Complex Decongestive Therapy Enhances Upper Limb Functions in Patients with Breast Cancer-Related Lymphedema	pretest-posttest design	37 patients with BCRL	Treatment protocol: Treatment protocol Complex decongestive therapy-phase 1 program, consisting of meticulous skin and nail care, MLD, compression bandaging, and remedial exercises, was applied to all participants. All patients received MLD for five times a week during 3 weeks (a total of 15 sessions). Each MLD session lasted 45–60 min.		〇
11	Lee D, 2015	South Korea	Analysis of factors related to arm weakness in patients with breast cancer-related lymphedema	Cross-sectional study	80 patients with BCRL	No intervention (Because, cross-sectional study)	ー	ー
12	Buragadda S, 2015	Saudi Arabia	Effect of complete decongestive therapy and a home program for patients with post mastectomy lymphedema	RCT	60 patients with BCRL	2 Groups: CDT group: This group received manual lymphatic drainage, wore a compression garment for 23 h daily, and performed remedial exercises and a home program. CDT group individuals and occasionally family members received training in self-massage. Conventional treatment group: non home program	〇
13	Dayes IS, 2013	Germany	Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer	RCT	95 patients with BCRL	2 Groups: CDT group: This group received for 1 h of manual lymphatic drainage each day. This intervention continued for 4 weeks (5 working days per week) for a total of 20 sessions. Control group: This group was fitted with immediate elastic compression garments consisting of a sleeve (30 to 40 mmHg) and glove and instructed to wear the garments for 12 waking hours per day.		〇
14	King M, 2012	Canada	Compression garments versus compression bandaging in decongestive lymphatic therapy for breast cancer-related lymphedema: a randomized controlled trial	RCT	21 patients with BCRL	2 Groups: Participants received manual lymph drainage massage, followed by skin care, compression glove/sleeve, and exercise. During the initial treatment phase, day, and night, as tolerated. Group 1: wear a compression glove and sleeve Group 2: compression bandages		〇
15	Smoot B, 2010	USA	Upper extremity impairments in women with or without lymphedema following breast cancer treatment	cross-sectional design	144 patients with BCRL	No intervention (Because, cross-sectional study)		〇
16	Didem K, 2005	Turkey	The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery	RCT	53 patients with BCRL	2 Groups: CDP group: This group served as the experimental group and was treated with CDP applications including manual lymph drainage, compression bandaging, remedial exercises, and skin care. SP group: This group was treated with standard physiotherapy applications including bandaging, elevation, head – neck and shoulder exercises.	〇	〇
No.	Physical function assessment scales							Another measurement tools
	Motion	Strength	Sensory	PROMS	Manual dexterity	Fine motor skill	Other
1	●			●				NRS(pain) Chest mobility FACT-B
2	●			●				Lymphedema-related symptom SQ-TTD-BCRL
3			●					Ultrasonographic
4				●				VAS(heaviness) Pain threshold Observational scapular dyskinesia Lateral scapular test
5				●				Bioimpedance
6				●				VAS Lymph-ICF
7		●		●				VAS(activity pain, rest pain, night pain, heaviness, tightness) Beck Depression Inventory
8		●		●				QLQ-c30
9	●							Lymphedema-related symptom Self-perception of comfort
10	●			●				VAS (pain, heaviness) SF-36
11		●		●				VAS (pain, fear, limitation) Physical activity score
12				●				VAS(pain)
13				●				SF-36
14				●
15	●	●		●	●	●
16	●

RCT: Randomized Controlled Trial, BCRL: Breast Cancer-Related Lymphoedema, VAS: Visual Analogue Scale, NRS: Numerical Rating Scale.

Results

A total of 411 results were retrieved from all the sources. Duplicate articles were removed (n = 174), yielding 237 articles for eligibility screening. The titles and abstracts were screened, and 205 articles were excluded. Thirty-two articles were examined in full text and assessed for eligibility, and an additional 16 articles were excluded. Finally, 16 eligible articles were analysed in the present study. The number and strategy of articles reviewed, selected, and checked at each stage are shown in the PRISMA flow diagram [7,8] (Figure 1).

Figure 1. PRISMA flow diagram.

Synthesis of eligibility article characteristics

Table 2 summarizes the characteristics of the eligible articles. Sixteen articles published between 2005 and 2023 were included in this review. The studies were conducted in Turkey (n = 6), USA (n = 2), Spain (n = 2), South Korea (n = 2), Germany (n = 1), Canada (n = 1), Bahrain (n = 1), and Saudi Arabia (n = 1). The study designs were randomized controlled trial (n = 11), pretest-posttest design (n = 2), cross-sectional study (n = 2), and case–control study (n = 1). A total of 900 patients with upper limb lymphedema were included in this review. All the studies included Breast Cancer-Related Lymphedema (BCRL) as a factor in the pathogenesis of upper limb lymphedema. The interventions in the articles were complex physical therapy or complex decongestive therapy (n = 9), kinesio taping (n = 2), negative pressure massage (n = 1), myofascial release (n = 1), and none for observational studies (n = 3). The morphometric measurements of lymphedema included circumference (n = 2), volume (n = 12), circumference and volume (n = 1), and none (n = 1).

Reported physical function assessment scales

The reported physical function assessment scales are presented in Table 3. We identified 13 types of physical function assessment scales and six functional categories (motion, strength, sensory, manual dexterity, fine motor skill, and patient-reported outcome measures). The three most commonly reported assessment scales were disabilities of arm, shoulder, and hand (DASH) (n = 9), range of motion (n = 6), and grip strength (n = 4).

Table 3. Reported physical function assessment scales in upper limb lymphedema.

Category	Assessment scale	Authors (year of publication)
Motion	Range of Motion	Kim Y, et al. (2023) [9]
		Pajero Otero V, et al. (2022) [10]
		Pajero Otero V, et al. (2019) [11]
		Sezgin Ozcan D, et al. (2018) [12]
		Smoot B, et al. (2010) [13]
		Didem K, et al. (2005) [14]
Strength	Grip strength (hand dynamometer)	Tastaban E, et al. (2020) [15]
		Tantawy SA, et al. (2019) [16]
		Lee D, et al. (2015) [17]
		Smoot B, et al. (2010) [13]
	Pinch	Smoot B, et al. (2010) [13]
Sensory	Semmes Weinstein Monofilament test	Baran E, et al. (2021) [18]
		Smoot B, et al. (2010) [13]
	2 point discrimination	Baran E, et al. (2021) [18]
	Pressure pain threshold	Baran E, et al. (2021) [18]
	Tactile localization test	Baran E, et al. (2021) [18]
	Vibration perception threshold	Smoot B, et al. (2010) [13]
Manual dexterity	Purdue Pegboard	Smoot B, et al. (2010) [13]
Fine motor skill	Finger tapper	Smoot B, et al. (2010) [13]
PROMS	DASH	Kim Y, et al. (2023) [9]
		Pajero Otero V, et al. (2022) [10]
		Korucu TS, et al. (2021) [19]
		Lampinen R, et al. (2021) [20]
		Sezgin Ozcan D, et al. (2018) [12]
		Lee D, et al. (2015) [17]
		Buragadda S, et al. (2015) [21]
		Dayes IS, et al. (2013) [22]
		King M, et al. (2012) [23]
		Smoot B, et al. (2010) [13]
	Quick-DASH	Sen EI, et al. (2020) [24]
		Tastaban E, et al. (2020) [15]
	SPADI	Tantawy SA, et al. (2019) [16]

PROMs: Patient Reported Outcome measures, DASH: Disability of the Arm, Shoulder, and Hand, SPADI: Shoulder Pain and Disability Index.

Discussion

We conducted a scoping review to identify physical function assessment scales in upper limb lymphedema. As a result, 16 articles met the inclusion criteria. This article provides important insight into the assessment of rehabilitation in patients with upper limbs lymphedema.

Patient-reported outcome measures (PROMs), which are subjective scales, are the physical function assessment scales used in most articles. This concept and terminology have recently emerged as a health outcome measures, particularly in the evaluation of technologies such as drugs and medical devices, as this concept is more practical and easier to share compared with quality of life [25]. Among the various PROMs, the DASH, including the Quick-DASH, was the most frequently used assessment scales in this review [9,10,12,13,15,17,19–24]. The DASH is a typical PROM designed to measure functional disability resulting from upper limb condition. It evaluates not just the specific site of disability but also subjectively measures activities of daily living involving the entire upper limb. Moreover, the DASH is frequently used not only for lymphedema but also for other diseases [26]. Its versatility in addressing many upper limb dysfunctions and its ease of assessment likely account for its use in lymphedema studies. Another noteworthy PROM for measuring upper limb function is the shoulder pain and disability index [16], which has demonstrated excellent reliability akin to the DASH [27,28]. Therapy for lymphedema improves a patient’s quality of life, as evidenced by improvements in the patient’s well-being. Consequently, PROM studies assessing patient subjectivity are poised to gain increasing importance in the future. However, this method has several problems. For example, solely relying on PROM measurements many obscure the actual physical function. Therefore, the combination of measurement of PROMs and the assessment of actual physical function is necessary to effectively demonstrate the impact of rehabilitation on lymphedema. In the present study, all selected eligible articles assessed not only PROMs but also physical functions.

The next category for measuring physical function assessment scales in upper limb lymphedema was Motion. In the Motion category, ROM was measured in all articles. All the articles included in this review focused on had patients with BCRL as the study subjects. During the perioperative period of breast cancer, patients often present with a loss of shoulder joint motion [29,30]. Furthermore, upper limb lymphedema is expected to result in the loss of ROM due to swelling, weight, and mechanical properties of the skin. Among the selected eligible articles, there were studies that measured ROM before and after lymphedema therapy to determine treatment efficacy [9–12,14]. They also compared ROM between lymphedema and non-lymphedema patients [13], all of which showed loss of ROM in patients with upper extremity lymphedema.

The third most common category was Strength. (The Sensory category had the same number, but many duplicate articles were identified.) Grip strength is a widely used and accessible test that can be performed in hospital practices and specialty clinical settings [31,32]. It is commonly used in clinical practice as a diagnostic or screening tool to detect low skeletal muscle weakness caused by sarcopenia and/or frailty [33]. In upper limb lymphedema, edema may cause difficulties with full finger grip and decreased muscle output. Among the selected eligible articles, there were reports indicating that therapy for lymphedema resulted in increased grip strength [15,16], suggesting that patients may have had decreased grip strength prior to treatment.

Other categories used were Sensory, Manual dexterity, and Fine motor skill. The sensory category consisted of two duplicate articles, each using five outcome measures, which represented the highest number of outcome measures among all categories. Among the five outcome measures, both articles used the Semmes-Weinstein Monofilament test (SWM) [13,18], a sensory test that applies tactile stimuli to the skin and to determine the threshold or static tactile sensation based on the response. The SWM, as a quantitative test, demonstrates high reliability in diagnosing and evaluating therapeutic efficacy, being the only method with established reliability and validity in assessing sensory function [34,35]. Given the often-unclear sensory functions of lymphedema, these two articles sought to clarify these functions using the SWM, a test recognized for its reliability and validity. The results indicated a trend toward mild sensory impairment in both studies [13,18]. Nonetheless, other sensory tests were explored and have not yet achieved standardization in lymphedema assessments.

Manual dexterity and fine motor skills were used in the same article [13]. Although finger lymphedema is expected to reduce hand usability, few studies have assessed this aspect of the disease. Therefore, the most suitable assessment method is unclear, and the results of this review cannot be generalized. Moreover, no study has used the Box and Block Test, a highly reliable and validated tool used in measuring hand usability for various upper limb dysfunctions [36–38].

This study had some limitations. First, we searched the electronic databases from their inception until June 1, 2023. Thus, documents published after these dates were excluded. Second, this scoping review excluded non-English articles, grey literature, and previous review articles. Finally, we did not assess the effectiveness of lymphedema therapy in patients with upper limb lymphedema using each physical function assessment scales, because it is optional in the PRISMA-ScR guidelines [7,8]. This is because scoping studies do not aim to assess the quality of evidence and, consequently, cannot determine whether particular studies provide robust or generalizable findings.

In conclusion, we demonstrated the physical function assessment scales that are used in the treatment of upper limb lymphedema. This study classified these physical function assessment scales into six categories and 13 types. Current scales in upper limb lymphedema are dominated by patient-reported outcome measures, motion, and strength. However, no consensus has been reached on the physical function assessment scale in upper limb lymphedema which remains a subject of uncertain. In the future, there is a need to standardize or develop physical function assessment scales that reflect the effectiveness of rehabilitation treatment in patients with upper limb lymphedema.

Data availability statement

Data are available upon reasonable request from corresponding author.

Disclosure statement

No potential conflict of interest was reported by the author(s).