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Purpose: To investigate reliability, concurrent validity and clinical feasibility of local tissue water measurements in patients with lower limb lymphedema and healthy controls., Methods: In this cross-sectional study the Moisture Meter D Compact device ® (MMDC) measurement and "pitting test" were performed three times by two assessors to test intra- and inter-rater reliability in 47 patients and 30 healthy controls. To investigate the between-session reliability, 29 patients and 21 healthy controls were reassessed two weeks later. Time efficiency and practical limitations were evaluated. The concurrent validity was investigated between the two tests. Clinical trial registration number: NCT:05269264., Results: Of the MMDC values, 58% showed strong to very strong intra-rater reliability, 32% showed strong to very strong inter-rater reliability and 36% had strong to very strong between-session reliability. Absolute values had generally a higher reliability than inter-limb or leg-to-arm ratio values. The pitting test had nil to perfect agreement between assessments (Cohen's kappa = -0.03-1.00) with fewer practical limitations and shorter performance time than the MMDC. Between both tests nil to a moderate relationship was found (Kendall's tau c  = 0.00-0.60)., Conclusion: The MMDC and pitting test are reliable and feasible measurements to assess local tissue water depending on the location, but should not be used interchangeably.

Background: Patients undergoing treatment for prostate cancer may develop lymphoedema of the midline region. This has a substantial impact on a patient's quality of life and its diagnosis is often delayed or missed. Therefore, the purpose of this study is to compare the characteristics of patients with leg and midline lymphoedema to patients with only leg lymphoedema., Methods: We retrospectively collected patient-, cancer-, lymphoedema- and lymphoedema treatment-related data of 109 men with lymphoedema after treatment for prostate cancer. First, 42 characteristics were compared between both groups. Second, factors predicting presence of midline lymphoedema were explored by multivariable analyses., Results: The mean age of the patients with lymphoedema was 68 ( ±7) years and mean BMI is 28 (±4) kg/m 2 . Median duration of lymphoedema before the first consultation was 27 (9;55) months. Based on univariable analyses, patients with leg and midline lymphoedema had more frequently upper leg lymphoedema (89% (31/35) vs. 69% (51/74), p = 0.026), skin fibrosis (34% (12/35) vs. 16% (12/74), p = 0.034) and lymphatic reconstructive surgery (9% (3/35) vs. 0% (0/71), p = 0.020) than patients with only leg lymphoedema. Additionally, patients with leg and midline lymphoedema reported less frequently lower leg lymphoedema (77% (27/35) vs. 95% (70/74), p = 0.007). Based on the multivariable analysis, not having lower leg lymphoedema, skin fibrosis, performing self-bandaging and self-manual lymphatic drainage appear to be predictors for having midline lymphoedema., Conclusions: If patients with lymphoedema after prostate cancer do not have lower leg lymphoedema, have skin fibrosis, perform self-bandaging or self-manual lymphatic drainage, they possibly have midline lymphoedema., (© 2024. The Author(s).)

Purpose: This study investigated the accuracy of activity trackers in chronic lower limb lymphoedema (LLL) patients and in comparison to matched controls., Materials and Methods: Seventeen LLL patients and 35 healthy subjects wore an activity tracker at the hip (Fitbit Zip/Inspire; hip-AT) and one at the wrist (Fitbit Alta/Inspire; wrist-AT) combined with a reference activity monitor (Dynaport Movemonitor; DAM), for 14 consecutive days. To analyze accuracy and agreement, mean daily step count from both AT's were compared to DAM. To evaluate the accuracy as coaching tool, day-by-day differences were calculated. The Kendall correlation coefficient was used to test consistency of ranking daily steps between the AT's and the DAM., Results: The wrist-AT significantly overestimated daily step count compared to DAM in the LLL group (+1221 ± 1754 steps per day, p = 0.011) while the hip-AT underestimated the step count, although not significantly. Similar results were found in the healthy control group. As a coaching tool, both wrist-AT and hip-AT showed a moderate correlation with the DAM (r = 0.507 and 0.622, respectively) in the LLL group regarding consistency of ranking from most to least active days., Conclusion: Wrist-AT's significantly overestimate daily step count in a LLL population. As a coaching tool, both trackers show moderate validity, indicating applicability to improve physical activity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Blondeel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: To investigate reliability, concurrent validity, and clinical feasibility of measurements assessing volume in patients with lower limb lymphedema (LLL) and healthy controls., Materials and Methods: To investigate intra- and interrater reliability, 47 patients with LLL and 30 healthy controls were assessed three times by two assessors. To investigate between session reliability, 50 participants were reassessed two weeks later. Each assessment included measurements of the midline region (hip circumference; suprapubic volume), leg volume (perimeter every 4 cm; Perometer ® ), and foot volume (water displacement; figure-of-eight method). Concurrent validity was assessed with correlation coefficients. Measurements were timed and practical limitations were reviewed. Clinical trial registration number: NCT: 05269264., Results: Measurements of the total volume of different regions showed weak to very high intraclass correlation coefficients (ICCs) (0.131-998). Absolute and relative volume differences had lower ICC values (0.360-0.976). A strong correlation was found between the total volumes of the same region. The Perometer ® and figure-of-eight method were the fastest method for leg and foot volume, respectively., Conclusions: The assessed total volumes might be more valuable in assessing the evolution of volume in bilateral LLL than the calculated absolute and relative differences between both limbs. The Perometer ® and figure-of-eight method were the most time efficient for leg and foot volume, respectively.Implications for rehabilitationLymphedema is a chronic condition for which a reliable and clinically feasible assessment of volume is essential for the diagnosis, treatment decisions, and the evaluation of the treatment.This study shows that the total leg/foot volumes were more reliable than the calculated absolute and relative differences between both limbs and could therefore more valuable to evaluate bilateral lower limb lymphedema.For the assessment of leg volume, the Perometer ® was the most reliable and fastest method.For the evaluation of the foot volume, the figure-of-eight method was overall the best method.

We appreciate the commentary by Pierre Bourgeois [...].

Introduction: Lymphoedema is a chronic condition caused by lymphatic insufficiency. It leads to swelling of the limb/midline region and an increased risk of infection. Lymphoedema is often associated with mental and physical problems limiting quality of life. The first choice of treatment is a conservative treatment, consisting of exercises, skin care, lymph drainage and compression. Reconstructive lymphatic surgery is also often performed, that is, lymphovenous anastomoses, lymph node transfer or a combination. However, robust evidence on the effectiveness of reconstructive lymphatic surgery is missing. Therefore, the objective of this trial is to investigate the added value of reconstructive lymphatic surgery to the conservative treatment in patients with lymphoedema., Methods and Analysis: A multicentre randomised controlled and pragmatic trial was started in March 2022 in three Belgian university hospitals. 90 patients with arm lymphoedema and 90 patients with leg lymphoedema will be included. All patients are randomised between conservative treatment alone (control group) or conservative treatment with reconstructive lymphatic surgery (intervention group). Assessments are performed at baseline and at 1, 3, 6, 12, 18, 24 and 36 months. The primary outcome is lymphoedema-specific quality of life at 18 months. Key secondary outcomes are limb volume and duration of wearing the compression garment at 18 months. The approach of reconstructive lymphatic surgery is based on presurgical investigations including clinical examination, lymphofluoroscopy, lymphoscintigraphy, lymph MRI or CT angiography (if needed). All patients receive conservative treatment during 36 months, which is applied by the patient's own physical therapist and by the patient self. From months 7 to 12, the hours a day of wearing the compression garment are gradually decreased., Ethics and Dissemination: The study has been approved by the ethical committees of University Hospitals Leuven, Ghent University Hospital and CHU UCL Namur. Results will be disseminated via peer-reviewed journals and presentations., Trial Registration Number: NCT05064176., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of this study was to investigate the effect of pain neuroscience education compared to biomedical pain education after breast cancer surgery on (1) work status, (2) time until work resumption, and (3) change in return-to-work expectations up to 18 months post-surgery., Methods: Participants were randomly assigned to either pain neuroscience education (intervention group) or biomedical pain education (control group) in addition to a standard physical therapy program after surgery for breast cancer. The first four months following surgery, one to two physiotherapy sessions and three educational sessions were scheduled. After, two educational sessions and two physiotherapy sessions were held at six and eight months postoperatively. All outcomes were assessed at four, six, eight, 12 and 18 months postoperatively., Results: At 12 months, in the intervention group, 71% of the women returned to work compared to 53% in the control group (18% points difference, 95%CI:-0.1 to 35;p = 0.07). At 18 months, the differences decreased to 9% points, 95%CI:-26 to 7;p = 0.35). Neither time until work resumption (p = 0.46) nor change in estimation of own ability to return to work up to 18 months postoperatively (p = 0.21) significantly differed between both groups., Conclusion: No significant differences were found regarding return to work outcomes between women receiving pain neuroscience education versus biomedical pain education after breast cancer surgery. Further research is warranted to explore the potential role of pain neuroscience education in return-to-work interventions following breast cancer surgery., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Secondary upper limb dysfunctions are common after breast cancer treatment. Myofascial treatment may be a valuable physical therapy modality for this problem., Objective: To investigate the effect of myofascial therapy in addition to physical therapy on shoulder, trunk, and elbow movement patterns in women with pain and myofascial dysfunctions at the upper limb after breast cancer surgery., Design: A double-blinded randomized controlled trial., Setting: Rehabilitation unit of a university hospital., Participants: Forty-eight women with persistent pain after finishing breast cancer treatment., Interventions: Over 3 months, all participants received a standard physical therapy program. The experimental (n = 24) and control group (n = 24) received 12 additional sessions of myofascial therapy or placebo therapy, respectively., Main Outcome Measures: Outcomes of interest were movement patterns of the humerothoracic joint, scapulothoracic joint, trunk, and elbow, measured with an optoelectronic measurement system during the performance of a forward flexion and scaption task. Statistical parametric mapping (SPM) analyses were used for assessing the effect of treatment on movement patterns between both groups (group × time interaction effect)., Results: A significantly decreased protraction and anterior tilting was found after experimental treatment. No beneficial effects on movement patterns of the humerothoracic joint, trunk, or elbow were found., Conclusion: Myofascial therapy in addition to a 12-week standard physical therapy program can decrease scapular protraction and anterior tilting (scapulothoracic joint) during arm movements. Given the exploratory nature of these secondary analyses, the clinical relevance of these results needs to be investigated further., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Purpose: Consumer-based activity trackers are used to measure and promote PA. We studied the accuracy of a wrist- and waist-worn activity tracker in cancer survivors and compared these results to a healthy age-matched control group., Methods: Twenty-two cancer survivors and 35 healthy subjects wore an activity tracker at the waist and at the wrist combined with a reference activity monitor at the waist (Dynaport Movemonitor). The devices were worn for 14 consecutive days. The mean daily step count from both activity trackers was compared with the reference activity monitor to investigate accuracy and agreement (paired t-test, intraclass correlation, Bland-Altman plots). To evaluate the accuracy as a coaching tool, day-by-day differences within patients were calculated. The Kendall correlation coefficient was used to test the consistency of ranking daily steps between the activity trackers and the reference activity monitor., Results: The wrist-worn wearable significantly overestimated the daily step count in the cancer group (mean ± SDΔ: + 1305 (2685) steps per day; p = 0.033) and in the healthy control group (mean ± SDΔ: + 1598 (2927) steps per day; p = 0.003). The waist-worn wearable underestimated the step count in both groups, although this was not statistically significant. As a coaching device, moderate (r = 0.642-0.670) and strong (r = 0.733-0.738) accuracy was found for the wrist- and waist-worn tracker, respectively, for detecting day-by-day variability in both populations., Conclusion: Our results show that wrist-worn activity trackers significantly overestimate daily step count in both cancer survivors and healthy control subjects. Based on the accuracy, in particular, the waist-worn activity tracker could possibly be used as a coaching tool., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pain after breast cancer surgery is a common and disabling problem. A reliable and valid questionnaire to assess pain-related disability is the Pain Disability Index (0-70). However, properties of the Dutch version (PDI-DLV) have never been investigated in this population., Objective: To assess psychometric properties of the PDI-DLV after breast cancer surgery., Methods: For reliability, relative and absolute reliability were calculated with a one-week test-retest interval, as well as internal consistency. Moreover, content and construct validity were examined to evaluate validity., Results: One hundred twenty-three women were included. Relative reliability was good (intraclass correlation coefficient = 0.80). Standard error of measurement and minimal detectable change (absolute reliability) were 5.57 and 15.45 points, respectively. The mean difference between two measurements was -1.98 points, with 95% limits of agreement equal to 13.19 and -17.15. The within-subjects coefficient of variation was 59%. Internal consistency was confirmed (α = 0.87). The PDI-DLV was scored as understandable and complete (content validity). Construct validity was supported by confirmation of more than 75% of the tested hypotheses and of the one-factor model., Conclusion: The PDI-DLV is a valid questionnaire to assess pain-related disability 1 year after breast cancer surgery. Although absolute reliability is disputable, its good relative reliability allows evaluating changes between subjects.

Abstract: Pain is one of the most common and long-lasting side effects reported by women surgically treated for breast cancer. Educational interventions may optimize the current physical therapy modalities for pain prevention or relief in this population. Pain neuroscience education (PNE) is an educational intervention that explains the pain experience not only from a biomedical perspective but also the psychological and social factors that contribute to it. Through a double-blinded randomized controlled trial (EduCan trial) it was investigated if PNE, in addition to the standard physiotherapy program immediately after breast cancer surgery, was more effective over the course of 18 months postoperatively than providing a biomedical explanation for pain. Primary outcome was the change in pain-related disability (Pain Disability Index, 0-70) over 12 months. Secondary outcomes included change in pain intensity, upper limb function, physical activity level, and emotional functioning over 4, 6, 8, 12, and 18 months postoperatively. Multivariate linear models for repeated (longitudinal) measures were used to compare changes. Preoperative and postoperative moderators of the change in pain-related disability were also explored. Of 184 participants randomized, the mean (SD) age in the PNE and biomedical education group was 55.4 (11.5) and 55.2 (11.4) years, respectively. The change in pain-related disability from baseline to 12 months postoperatively did not differ between the 2 groups (PNE 4.22 [95% confidence interval [CI]: 1.40-7.03], biomedical 5.53 [95% CI: 2.74-8.32], difference in change -1.31 [95% CI: -5.28 to 2.65], P = 0.516). Similar results were observed for all secondary outcomes. Future research should explore whether a more patient-tailored intervention would yield better results., (Copyright © 2023 International Association for the Study of Pain.)

Purpose: Pain and sensory disturbances are common side effects of breast cancer treatment. Differential somatosensory functioning may reflect distinct pathophysiological backgrounds and therapeutic needs. Aim was to examine whether questionnaires evaluating signs and symptoms related to somatosensory functioning correlate sufficiently with quantitative sensory testing (QST) in breast cancer survivors to warrant consideration for somatosensory profiling in clinical practice., Methods: One year after breast cancer surgery, 147 women underwent QST and completed following questionnaires: Douleur Neuropathique en 4 questions (DN4), Central Sensitization Inventory, Margolis Pain Diagram and Visual Analog Scales (VAS). Associations between the questionnaires and QST were evaluated using Spearman correlation coefficients (rs)., Results: Significant but weak ( r s < 0.30) correlations were found between total DN4 score and QST results at the inner upper arm for detection of sharp stimuli ( r s = 0.227), cold stimuli ( r s = -0.186), and painful heat stimuli ( r s = 0.179), as well as between QST evaluating conditioned pain modulation and the Margolis Pain Diagram on one hand ( r s = 0.176) and minimum-maximum pain intensity differences (VAS) on the other ( r s = -0.170)., Conclusion: Questionnaires evaluating signs and symptoms related to somatosensory functioning are insufficient for somatosensory profiling. Although somatosensory profiling may be valuable in a mechanism-based management, more research on the most appropriate clinical tools is needed.IMPLICATIONS FOR REHABILITATIONClinicians should be able to recognize that patients with persistent pain or sensory disturbances following breast cancer surgery may have a component of altered somatosensory processing as a significant contributor to their complaint in order to address it appropriately.Somatosensory profiling has yet to be implemented into clinical practice.No evidence-based recommendations can be made on the use of self-reported questionnaires to assess somatosensory processing in a breast cancer population based on the findings of this study.It is suggested to combine information on how individuals process and experience somatosensory stimulation with information from the patient interview or questionnaires to consider which biological, psychological and/or social factors may drive or sustain these neurophysiological processes.

Background: With over 500,000 annually reported cases worldwide, head and neck cancer (HNC) is the seventh most common type of cancer worldwide. Treatment of HNC with chemoradiotherapy frequently results in serious impairments in physical and psychosocial functioning. Besides, HNC patients typically start their cancer treatment already with poor physical and psychosocial health. It has been shown that a sufficient level of physical activity (PA) before, during, and after cancer treatment is associated with fewer negative treatment-related side effects and a better quality of life (QOL). In order to prevent worsening of functioning and limit the physical impact of the HNC treatment, a comprehensive supervised exercise program (CSEP) may be beneficial during early cancer treatment. However, up to now, the feasibility and effectiveness of such a program are not yet investigated thoroughly in HNC. Therefore, the primary objective of this study is to examine the effectiveness of a CSEP during HNC treatment, in addition to usual supportive care, compared to usual supportive care alone, on health-related QOL up to 1 year post-diagnosis. Secondary objectives entail gathering information on (1) the effectiveness of a CSEP on secondary outcomes such as physical and mental function, activities of daily life, and participation in society and (2) the feasibility, possible barriers, and facilitators for participation in a CSEP during HNC treatment., Methods: To investigate the effectiveness of the CSEP, a parallel, open-label randomized controlled trial will be performed. To study the feasibility of the CSEP, a mixed-method study will be performed in a subgroup of participants. HNC patients are eligible if they receive radiotherapy at the Radiation-Oncology department of the University Hospital of Leuven. A 4-size permuted block randomization will be used. The control group receives the current standard of supportive care. The intervention group receives a CSEP, additional to the same usual supportive care. The CSEP consists of a 12-week intensive phase with 3 exercise sessions of 1 h per week, where supervision is gradually reduced after 6 weeks. During the maintenance phase (from week 13), patients exercise at home with monthly tele-consultations with a physiotherapist. The CSEP contains supervised aerobic and resistance training. In both groups, outcomes of interest are evaluated through self-reported questionnaires and clinical assessments, at baseline, 6 weeks, 12 weeks, 6 months, and 12 months post-diagnosis. The primary endpoint is health-related QOL, measured with the EORTC QLQ-C30 at 6 months post-diagnosis., Discussion: The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the ethical committee of the University Hospitals Leuven (s65549). Recruitment started in January 2022. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses., Trial Registration: Trial Registration: ClinicalTrials.gov Identifier: NCT05256238 Date of registration: February 25, 2022., (© 2023. The Author(s).)

The objective of this trial was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD), as part of decongestive lymphatic therapy (DLT), on the superficial lymphatic architecture in patients with chronic mild to moderate breast cancer-related lymphoedema (BCRL). This trial was a multicentre, double-blind, randomised controlled trial involving 194 participants with BCRL. Participants were randomised into (1) DLT with fluoroscopy-guided MLD (intervention group), (2) DLT with traditional MLD (control group), or (3) DLT with placebo MLD (placebo group). Superficial lymphatic architecture was evaluated as a secondary outcome, visualised by ICG lymphofluoroscopy at the baseline (B0), post-intensive (P), and post-maintenance phases (P6). Variables were (1) number of efferent superficial lymphatic vessels leaving the dermal backflow region, (2) total dermal backflow score, and (3) number of superficial lymph nodes. The traditional MLD group showed a significant decrease in the number of efferent superficial lymphatic vessels at P ( p = 0.026), and of the total dermal backflow score at P6 ( p = 0.042). The fluoroscopy-guided MLD and placebo group showed significant decreases in the total dermal backflow score at P ( p < 0.001 and p = 0.044, respectively) and at P6 ( p < 0.001 and p = 0.007, respectively); the placebo MLD group showed a significant decrease in the total number of lymph nodes at P ( p = 0.008). However, there were no significant between-group differences for the changes in these variables. In conclusion, based on lymphatic architecture outcomes, the added value of MLD, in addition to the other parts of DLT, could not be demonstrated in patients with chronic mild to moderate BCRL.

Purpose: The latest systematic review on the prevalence of pain in cancer survivors was published 5 years ago. The current review aims to provide an extended overview on the prevalence of pain, pain mechanisms, pain characteristics, and assessment methods in cancer survivors., Methods: A systematic research was conducted on 17th of April 2020 using MEDLINE, Embase, Scopus, Web of Science, and Cochrane looking at studies from 2014 to 2020. Studies had to report pain prevalence rates in cancer survivors with a solid tumor who finished curative treatment at least 3 months ago. Methodological quality was assessed by two independent reviewers using the Joanna Briggs Institute quality appraisal tool. Characteristics of the included studies, participants and reported pain prevalence rates were extracted. The reported prevalence rates of the individual studies were pooled within a meta-analysis. Meta-regressions were performed to identify possible determinants of the pooled pain prevalence., Results: After deduplication, 7300 articles were screened, after which 38 were included in the meta-analysis. Risk of bias was rated low in 26 articles and moderate in 12 articles. The pooled pain prevalence was 47% (95%CI 39-55), with a heterogeneity of 98.99%., Conclusion: This meta-analysis suggests that nearly half of cancer survivors report pain after completing curative treatment at least 3 months ago. However, substantial unexplained heterogeneity warrants cautious interpretation of these results. Meta-regression using cancer type, treatment location, pain measurement, and follow-up time as a covariate could not explain influencing factors explaining the high heterogeneity., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The purpose of this study was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD) versus that of traditional and placebo MLD, when added to decongestive lymphatic therapy (DLT) for the treatment of breast cancer-related lymphedema (BCRL) (EFforT-BCRL trial), on the suprafascial accumulation of lymphatic fluid and skin elasticity., Methods: In this multicenter, 3-arm, double-blind, randomized controlled trial (EFforT-BCRL trial), 194 participants (mean age = 61 [SD = 10] years) with unilateral BCRL were recruited. All participants received standardized DLT (education, skin care, compression therapy, exercises) and were randomized to fluoroscopy-guided, traditional, or placebo MLD. Participants received 60 min/d of treatment during the 3-week intensive phase and 18 sessions of 30 minutes during the 6-month maintenance phase. During this phase, participants were instructed to wear a compression garment, to perform exercises, and to perform a self-MLD procedure once daily. This study comprises secondary analyses of the EFforT-BCRL trial. Outcomes were the amount of fluid accumulation in the suprafascial tissues (local tissue water, extracellular fluid, and thickness of the skin and subcutaneous tissue) and skin elasticity at the level of the arm and trunk. Measurements were performed at baseline; after intensive treatment; after 1, 3, and 6 months of maintenance treatment; and after 6 months of follow-up., Results: At the level of the arm, there was a significant improvement over time in the 3 groups for most of the outcomes. At the level of the trunk, no remarkable improvement was noted within the individual groups. No significant interaction effects (between-group differences) were present. Only skin elasticity at the level of the arm, evaluated through palpation, showed a significant interaction effect., Conclusion: All 3 groups showed similar improvements in response to DLT regardless of the type of MLD that was added. The effect of the addition of MLD to other components of DLT for reducing local tissue water and extracellular fluid or skin thickness and for improving skin elasticity and fibrosis in participants with chronic BCRL was limited., Impact: Although MLD has been applied all over the world for many years, evidence regarding its added value in reducing arm volume in patients with BCRL is lacking. These results show that adding MLD to other components of DLT has limited value in reducing local tissue water and extracellular fluid or skin thickness and in improving skin elasticity and fibrosis in patients with chronic BCRL. To date, there is no clinical indication to continue including time-consuming MLD in physical therapist sessions for patients with chronic BCRL., (© 2022 American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: It is not clear to what extent signs and symptoms other than arm swelling, including pain, altered sensory function, and body perception disturbances, differ between women with measurable and non-measurable breast cancer-related lymphedema (BCRL). A case-control study was performed to compare these signs and symptoms between (1) women with self-reported BCRL with objectively measurable swelling; (2) women with self-reported BCRL without objective confirmation; and (3) a control group with no self-reported BCRL., Methods: The three groups were compared for (1) the severity of self-reported signs and symptoms of BCRL, (2) problems in functioning related to BCRL, (3) pain-related outcomes, (4) sensory functions, and (5) body perception., Results: All self-reported outcomes related to signs and symptoms of BCRL and problems in functioning were significantly different between the control group and the other two groups with and without measurable self-reported BCRL (p < 0.001-0.003). Except for "skin texture" (p = 0.01), "hand swelling" (p=0.301) and 'difficulty writing' (p=0.676), no differences were found between groups. For pain-related outcomes, sensory function, and body perception, significant differences were only found for the mechanical detection threshold (p < 0.01) and self-reported disturbances in body perception (p < 0.001) between the self-reported BCRL groups and control group., Conclusions: Diverse signs and symptoms related to BCRL, sensory function, and perception were different among women with self-reported BCRL compared to controls. No differences between women with and without measurable self-reported BCRL were found., Implications for Cancer Survivors: The presence of self-reported BCRL, with or without measurable swelling, is a first indication for the need of further diagnostic evaluation., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Upper limb (UL) function is one of the health outcomes that matters the most for women with breast cancer. However, a better understanding of the factors contributing to UL dysfunctions in the late stage after breast cancer surgery is needed. This study explores associations between impairment-related and cognition-related factors and UL function in women with pain and myofascial dysfunctions at the affected UL region in this late stage after breast cancer surgery., Methods: In forty-one women, UL function (dependent variable) was evaluated by the Disabilities of Arm, Shoulder and Hand questionnaire. As independent impairment-related factors, relative excessive arm volume (perimetry), pain intensity (maximum score on the visual analogue scale past week) and humerothoracic elevation and scapular lateral rotation (kinematic analysis) were assessed. As independent cognition-related factors, pain catastrophizing (Pain Catastrophizing Scale) and pain hypervigilance (Pain Vigilance and Awareness Questionnaire) were evaluated. Bi-variable analyses and a stepwise regression analysis were used to explore associations., Results: A higher pain intensity ( r  = 0.52; p  < 0.001), more pain catastrophizing ( r  = 0.49; p  < 0.001) and more pain hypervigilance ( r  = 0.40; p  = 0.01) were related to more UL dysfunction. Pain intensity ( p  = 0.029) and pain catastrophizing ( p  = 0.027) explained furthermore 29.9% of variance in UL function., Conclusions: Pain intensity and cognition-related factors are significantly associated with UL function in women with pain and myofascial dysfunctions, indicating the need of assessing pain beliefs in women in the late stage after breast cancer surgery.IMPLICATIONS FOR REHABILITATIONPain intensity and pain-related beliefs, including pain attention and catastrophizing, are related to the severity of upper limb dysfunctions in the late stage after breast cancer surgery.Impairments such as lymphedema and movement restrictions seem not related to upper limb function in the assessed sample.To understand upper limb dysfunctions in the late stage after breast cancer, assessing pain beliefs is needed.

Purpose: We hypothesize that prediagnosis physical activity (PA) levels of breast cancer patients are below those of a reference population without breast cancer. Therefore, the aim of the present study was to compare prediagnosis PA levels (including total-, occupational-, sport- and household activity levels) of breast cancer patients with activity levels of a reference population., Methods: Female patients with primary breast cancer (n = 265) filled in the Flemish Physical Activity Computerized Questionnaire (FPACQ) the day before surgery recalling the year before diagnosis. PA levels were expressed as Metabolic Equivalent Task (MET) values. Smooth reference curves of PA levels were estimated in a representative sample of 3466 women without breast cancer with the LMS method, which allowed comparison of prediagnosis PA data of the breast cancer sample with this reference., Results: Compared to women without breast cancer, total PA levels were significantly lower in the year prior to breast cancer diagnosis over all age groups (Mean ± SD z-scores (95% CI) = -1.51 ± 1.86 (-1.74 to -1.29)). More specifically, household PA levels of breast cancer patients were significantly lower between ages 40-60, while occupational PA levels were significantly higher in this age group. No differences were found between sports PA levels., Conclusions: Patients with breast cancer show significantly lower total PA levels during the year prior to surgery compared to a reference population. Especially household activity levels are lower in patients between ages 40 and 60. Given this, a return to prediagnosis PA levels may not be sufficient for protection from disease in the future., Competing Interests: Disclosure All authors declare that they have no conflict of interest., (Copyright © 2021. Published by Elsevier Inc.)

Background: Compression is a cornerstone modality in edema treatment. Different types of bandages are available in clinical practice. Short-stretch bandages are commonly used; however, newer technologies such as the two-component compression system are available as well. This study assesses the pressure curves and static and dynamic stiffness (Static Stiffness Index [SSI] and Dynamic Stiffness Index [DSI]) of two different two-component compression systems, Coban and CoFlex, for edema treatment. Methods and Results: For this prospective cohort study, 12 healthy volunteers were recruited. The healthy volunteers wore both two-component compression systems for 48 hours. Pressure sensors (PicoPress ® ; Microlab, Italy) were placed at 10 and 25 cm above the internal malleolus and 10 pressure readings were used to obtain pressure curves. The SSI and DSI were assessed. Additionally, comfort (ICC compression questionnaire) and adverse events were assessed as well. Both two-component compression systems exert a sufficient amount of sub-bandage pressure, although CoFlex exerts systematically significantly lower pressure in comparison with Coban. This difference in sub-bandage pressure remains constant over 48 hours. Both two-component compression systems are sufficiently stiff (stiffness >15 mmHg) and remain stiff over time. Conclusions: Both two-component compression systems have pressure curves that are high enough to motivate their use in the treatment of chronic edema. Additionally, both systems were found to be comfortable and have clinically effective SSI and DSI values.

Objective: Quantitative sensory testing (QST) consists of noninvasive psychophysical assessment techniques to evaluate the functioning of the somatosensory nervous system. Despite the importance of reliability for the correct use of QST results in research and clinical practice, the relative and absolute intra- and inter-rater reliability of a comprehensive QST protocol to evaluate the functioning of both the peripheral and central somatosensory nervous system in a breast cancer population has not yet been investigated., Setting: University Hospitals, Leuven, Belgium., Subjects: Thirty women at least 6 months after unilateral breast cancer surgery., Methods: The protocol included nine static and dynamic QST methods (mechanical pain-detection thresholds, pressure pain thresholds, thermal pain-detection thresholds for heat and cold, temporal summation, and conditioned pain modulation [CPM]) performed in the surgical area and in more distant regions. Absolute and relative intra-rater reliability (60-minute interval) and inter-rater reliabilty (1-week interval) were evaluated with intraclass correlation coefficients, standard error of measurement, and Bland-Altman plots., Results: Moderate to excellent relative intra-rater reliability and inter-rater reliability were found for the evaluation of mechanical thresholds, pressure pain thresholds, and temporal summation. The reliability of the CPM paradigm was considered weak. Systematic bias between raters was noticed for the detection of mechanical and cold stimuli at the non-affected trunk and for CPM., Conclusions: Except for the evaluation of CPM, the QST protocol was found suitable for identifying differences between subjects (relative reliability) and for individual follow-up after breast cancer surgery (limited systematic bias) during a 1-week time frame. Additional research is required to determine the measurement properties that influence CPM test stability to establish a more reliable CPM test paradigm., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: The aim of the study was to investigate whether bowel symptoms related to low anterior resection for rectal cancer can be sufficiently well evaluated by the Low Anterior Resection Syndrome (LARS) questionnaire score or the ColoRectal Functional Outcome (COREFO) questionnaire compared with a stool diary., Method: All patients underwent low anterior resection for rectal cancer. They were asked to fill out a stool diary, the LARS questionnaire and the COREFO questionnaire, at 1, 4, 6 and 12 months after low anterior resection or stoma closure. The main outcome measure was the amount of association (calculated by means of canonical correlation analysis) between items on anal incontinence for faeces, frequency of bowel movements, clustering of bowel movements, urgency and soiling., Results: Ninety-five patients were included. Items on anal incontinence for faeces and frequency of bowel movements were significantly correlated between the LARS questionnaire or the COREFO questionnaire, versus the stool diary, respectively. Items on soiling were significantly correlated between the COREFO questionnaire and the stool diary., Conclusion: Although the LARS questionnaire and the COREFO questionnaire are reliable and valid for measuring low anterior resection syndrome after rectal cancer, our results show that there are no strong associations with the stool diary. Therefore, we can conclude that there is additional clinical information to be obtained from the stool diary. In order to evaluate all aspects of low anterior resection syndrome, we suggest the addition of a stool diary or a combination of different measurement methods during patient follow-up., (© 2022 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Purpose: Knowledge regarding risk factors for pain in the long term after surgery for breast cancer may be of great value in preventing this prevalent and debilitating side effect. Despite the biopsychosocial nature of pain, the predictive value of both pre- and postoperative biopsychosocial functioning for long-term pain intensity and pain-related disability has not yet been studied., Methods: One hundred sixty-six women planned for unilateral breast cancer surgery were included in this prospective cohort study. Pre- and postoperative outcomes related to pain, psychosocial, and somatosensory functioning (questionnaires and quantitative sensory testing) were evaluated as risk factors for pain intensity (visual analog scale) and pain-related disability (pain disability index) 1 year after surgery for breast cancer. Both bivariable and stepwise linear regression analyses were performed., Results: The most consistent biopsychosocial risk factors were symptoms related to altered central somatosensory functioning (central sensitization inventory), psychological symptoms, and social support (psychological symptoms and support subscale of McGill Quality of Life Questionnaire). Results also showed that a pre- and postoperative disturbed functioning of the somatosensory nervous system in the surgical area could provide additional information regarding pain intensity or pain-related disability in the long term after surgery for breast cancer., Conclusion: This study revealed several biopsychosocial characteristics that might be used to identify women more vulnerable to have pain and pain-related disability in the long term after surgery for breast cancer, allowing for more effective pain management and prevention., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Compression therapy is an important part of the treatment of patients with lymphedema or chronic venous disease. However, there is no validated questionnaire evaluating the effect of compression and its acceptance by the patient. Therefore, the aims of this study were to construct a questionnaire evaluating the effect of compression and its acceptance by the patient, that is, the Dutch ICC Compression Questionnaire (ICC-CQ), to investigate its reliability and validity, and to translate it into English. Methods and Results: Eleven experts in applying compression and 51 Dutch patients with experience of using compression were involved in the construction process. One part of the ICC-CQ has to be completed by the patient and evaluates seven domains. The other part has to be completed by the health care provider and comprises three domains. Reliability and validity of the final version was investigated in a new group of 79 Dutch-speaking patients with lymphedema or chronic venous disease, wearing compression garments ( N  = 52) or bandages ( N  = 27). Except for one domain, the Intraclass Correlation Coefficients for test-rest/interrater reliability ranged from 0.55 to 0.93. Cronbach's alpha for internal consistency ranged from 0.71 to 0.97. Eighty-nine percent of the patients fully understood the questionnaire indicating good face validity, and 87% found it complete indicating good content validity. Construct validity was considered good since 10 out of 11 hypotheses were accepted. Conclusion: The ICC-CQ is the first reliable and valid questionnaire evaluating different kinds of compression and the experience by patients with lymphedema or chronic venous disease.

Questions: When added to decongestive lymphatic therapy (DLT), what is the effect of fluoroscopy-guided manual lymphatic drainage (MLD) versus traditional MLD or placebo MLD for the treatment of breast cancer-related lymphoedema (BCRL)?, Design: Multicentre, three-arm, randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of assessors and participants., Participants: At five hospitals in Belgium, 194 participants with unilateral chronic BCRL were recruited., Intervention: All participants received standard DLT (education, skin care, compression therapy and exercises). Participants were randomised to also receive fluoroscopy-guided MLD (n = 65), traditional MLD (n = 64) or placebo MLD (n = 65). Participants received 14 sessions of physiotherapy during the 3-week intensive phase and 17 sessions during the 6-month maintenance phase. Participants performed self-management on the other days., Outcome Measures: All outcomes were measured: at baseline; after the intensive phase; after 1, 3 and 6 months of maintenance phase; and after 6 months of follow-up. The primary outcomes were reduction in excess volume of the arm/hand and accumulation of excess volume at the shoulder/trunk, with the end of the intensive phase as the primary endpoint. Secondary outcomes included daily functioning, quality of life, erysipelas and satisfaction., Results: Excess lymphoedema volume decreased after 3 weeks of intensive treatment in each group: 5.3 percentage points of percent excessive volume (representing a relative reduction of 23.3%) in the fluoroscopy-guided MLD group, 5.2% (relative reduction 20.9%) in the traditional MLD group and 5.4% (relative reduction 24.8%) in the placebo MLD group. The effect of fluoroscopy-guided MLD was very similar to traditional MLD (between-group difference 0.0 percentage points, 95% CI -2.0 to 2.1) and placebo MLD (-0.2 percentage points, 95% CI -2.1 to 1.8). Fluid accumulated at the shoulder/trunk in all groups. The average accumulation with fluoroscopy-guided MLD was negligibly less than with traditional MLD (-3.6 percentage points, 95% CI -6.4 to -0.8) and placebo MLD (-2.4 percentage points, 95% CI -5.2 to 0.4). The secondary outcomes also showed no clinically important between-group differences., Conclusion: In patients with chronic BCRL, MLD did not provide clinically important additional benefit when added to other components of DLT., Registration: NCT02609724., (Copyright © 2022 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: Scars have different biomechanical characteristics, including anisotropy and viscoelasticity compared to healthy skin. To assess these characteristics, the CutiScan CS 100 ® can be used. The aim of the present study is to investigate reliability and validity of this device in breast cancer patients., Materials and Methods: Thirty female patients, with scar adhesions following mastectomy were assessed with the CutiScan CS 100 ® . Maximal distensibility (pixels) (V1), after-suction return rate (pixels) (V2), and their ratio (%) (V3) at three points on and around the scar were assessed as measures of viscoelasticity. For intra- and interrater reliabilities, the intra-class correlation coefficient (ICC) and its 95% confidence intervals were calculated. The standard error of measurement (SEM) was calculated to interpret reproducibility of these measurements. To investigate criterion validity of the measurement of anisotropy, measurements in the direction of healthy skin were compared with measurements in the direction of the scar, using a paired t-test., Results: V1, V2, and V3 show poor to moderate intrarater reliability (ICC 0.00-0.72) and interrater reliability (ICC 0.00-0.53). The maximum displacement (V1) on the measurement point above the scar shows the best reliability (ICC 0.33-0.72). The SEM is about the same for all parameters at all three points. The paired sample t-test showed a significant difference (p < 0.05) between V1 in the direction towards the scar versus the measurement towards healthy tissue, on the point below the scar., Conclusion: These first reliability and validity results of the CutiScan CS 100 ® for measuring anisotropy and viscoelasticity in scar tissue adhesions after mastectomy seem promising. Further research is needed addressing the limitations of the present study design., (© 2021 The Authors. Skin Research and Technology published by John Wiley & Sons Ltd.)

Introduction: Lymphedema of the upper extremity is one of the most feared complications following breast cancer treatment. Lymphofluoroscopy is a sensitive instrument for detection of lymphedema and visualization of superficial lymphatic transport, thus suitable for early detection. Early detection of lymphedema is important as it can prevent lymphedema to progress into more severe stages and minimalize impact on quality of life and medical costs., Objective: To determine agreement between the presence of early disturbance of the lymphatic transport and outcome of clinical measurement tools evaluating the development of lymphedema., Methods: A prospective study was conducted in 128 breast cancer patients scheduled for breast cancer surgery. Patients were evaluated before surgery and 1, 3-, 6-, 9-, and 12-months' post-surgery. Cohen's Kappa was used to determine agreement between presence of early disturbance in lymphatic transport and presence of pitting/increased skinfold thickness/increased Percentage Water Content ratio (PWC)/increased arm-hand volume (circumference measures and water displacement)., Results: For pitting status (Kappa 0.23), for skinfold thickness (Kappa 0.29) and the PWC ratio (Kappa 0.21) a minimal agreement was found. The circumference measurement had a minimal agreement for 5% volume difference (Kappa 0.22) and no agreement for 3% volume difference (Kappa 0.19). Sensitivity was weak for all clinical assessments. The specificity was excellent for pitting status, skinfold thickness, PWC ratio, and for 5% volume difference. For 3% a high specificity was found., Conclusion: The clinical tools assessed in this study were not able to predict an early disturbance of the lymphatic transport seen on lymphofluoroscopy., (Copyright © 2021. Published by Elsevier Inc.)

Background: Breast cancer-related lymphedema (BCRL) has a notable impact on patients' quality of life. However, no instrument is available to assess the problems in functioning due to BCRL in China., Objective: The aims of this study were to translate and validate a Chinese version of the Lymphedema Functioning, Disability, and Health Questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL)., Methods: A process of translation and cultural adaptation was conducted based on international standards. The study included 155 patients with BCRL and 90 patients without lymphedema. Psychometric properties that were tested consisted of internal consistency, test-rest reliability, content, construct and discriminant validity., Results: The Cronbach's α was .92, and intraclass correlation coefficient was 0.83. Content validity was confirmed by a sufficient content validity index in item level and scale level. Exploratory factor analysis identified 5 factors accounting for 62.44% of the total variance, and confirmatory factor analysis fit indices were acceptable. Convergent validity was supported by a moderate correlation with the 36-item Short-Form Health Survey Questionnaire and relatively weak correlations with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30. There was good divergent validity with all hypotheses evaluating divergent validity were confirmed. Significant differences were found between the lymphedema and nonlymphedema groups., Conclusion: The Chinese version of the Lymph-ICF-UL is a valid and reliable instrument that can be used in both clinical and scientific settings in China., Implications: The Chinese version of the Lymph-ICF-UL could be applicable in assessing the impairments in function, activity limitations, and participation restrictions of Chinese patients with BCRL., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Overall survival rates after rectal cancer have increased. Therefore, functional outcomes rightly deserve more interest. The aims of this study were to assess progression in total, sports, occupational and household physical activity levels of rectal cancer survivors, from preoperatively to 12 months after surgery/stoma closure and to explore predictive factors., Methods: Multi-center prospective study with 125 patients who underwent low anterior resection for rectal cancer. The Flemish Physical Activity Computerized Questionnaire was completed concerning all physical activity levels at baseline (past preoperative year) and at 1, 4, 6 and 12 months after surgery/stoma closure. At these timepoints, questionnaires (LARS-/ COREFO-questionnaire) regarding bowel symptoms were also filled out. Results were analyzed using linear mixed models for repeated measures., Results: Total physical activity levels up to 12 months remained significantly lower than preoperative. Occupational and sports physical activity levels remained significantly lower until 6 and 4 months postoperative, respectively. Predictive factors for decreased physical activity levels at a specific timepoint were: younger age and no stoma (total physical activity, 1 month), low/mid rectal tumor, no stoma, non-employed status (total, 4 months), higher COREFO-scores (occupational, 4 months) and non-employed status (total, 12 months). At all timepoints, lower COREFO-scores were associated with higher total physical activity levels; male gender and lower educational levels with higher occupational levels; younger age, normal BMI, employed status and adjuvant therapy with higher sports levels; and female gender, lower educational level and unemployed status with higher household levels., Conclusions: One year after rectal cancer treatment, total physical activity levels were still not recovered. Rectal cancer patients, especially those at risk for decreased physical activity levels and with major bowel complaints, should be identified and guided to increase their activities., Trial Registration: This trial has been registered at Netherlands Trial Register ( NTR6383 , 23/01/2017)., (© 2021. The Author(s).)

Background: Assessing the circumference of the hand and fingers can be challenging. Therefore, we studied the reliability of jeweler rings and a revised figure-of-eight (figure-8) protocol for the clinical assessment of finger and hand circumference. Methods and Results: Thirteen patients residing in a rehabilitation center were recruited. Inter- and intrarater reliability of the jeweler rings as well as the revised figure-8 protocol were assessed. Jewelers rings were used to assess the circumferences of the middle and ring finger of both hands. The figure-8 method was used to assess the circumference of both hands. Reliability analyses were performed in Statistical Package for the Social Sciences 26 and demonstrated an excellent reliability for the jeweler rings as well as the revised figure-8 protocol, represented by single random measure intraclass correlation coefficient (2,1) values of at least 0.973 and Cronbach alpha of at least 0.99. Conclusions: Circumference measurements are valid to use; however, reliability issues do exist in clinical practice. Assessing the circumference of fingers with our new jeweler rings protocol and the circumference of the hand by means of a revised figure-8 protocol is highly reliable in a clinical setting.

Objective: To synthesize the evidence on the effectiveness of pain science education on pain, psychological factors and physical functioning in adults who underwent surgery., Data Sources: A systematic literature search of English articles using PubMed/Medline, Embase, Web of Science Core Collection, and Cochrane Library., Review Methods: The search strategy was constructed as follows: (((pain) AND (education)) OR (pain education)) AND (surgery). Only controlled quantitative studies in adults reporting outcome(s) on pain, psychological factors and/or physical functioning were included. Risk of bias was assessed using the Cochrane risk of bias tools. P -values and corresponding effect sizes for interaction-effect (time × group) portrayed the difference in change over time between groups were of interest. The last search was conducted on February 28, 2021., Results: Nine papers ( n  = 1078) were deemed eligible for this review. Two randomized controlled trials showed significant interaction effects. Breast cancer patients who had received one preoperative pain science education session showed a significant increase in postoperative pain compared to controls ( P -value = 0.0394). Furthermore, p sychological factors (pain catastrophizing and kinesiophobia) decreased in participants who had received pain science education before total knee arthroplasty, while this was not the case in the control group ( P -value < 0.001, ƞ2p:0.11)., Conclusions: Overall, pain science education did not result in any significant postoperative effects on pain, psychological factors and/or physical functioning compared to controls. There is currently no strong evidence for the implementation of pain science education in the perioperative period. Registration number: PROSPERO: ID 161267, registration number CRD42020161267.

Introduction: Breast cancer survivors with secondary upper limb lymphoedema (ULL) may report a wide range of self-reported symptoms. At the moment, no overview of ULL-specific symptoms is available. The first aim, therefore, was to compare the prevalence rates of self-reported signs and symptoms in people with and without secondary ULL due to breast cancer treatment. The second aim was to determine whether symptoms of lymphoedema could be predictive for the development of ULL. The third aim was to describe the association between the presence/severity of symptoms and the presence/severity of ULL., Methods: A systematic search was conducted in Medline, Scopus, CINAHL and EMBASE databases, with key words related to breast cancer, symptoms and ULL., Results: Twenty-nine articles were eligible. The most frequently reported signs and symptoms were swelling (80.9%) and heaviness (66.7%) in the ULL group and tenderness (37%) and numbness (27%) in the non-ULL group. Perceived larger arm size, as well as feelings of arm tightness, stiffness, puffiness, pain, sensory disturbances and functional changes were predictive for the development of ULL. Moderate correlations were found between the presence of swelling, firmness in the past year and tightness now and severity of ULL. There was also moderate correlation between the presence of swelling and heaviness now and the presence of ULL., Conclusions: Swelling and heaviness are the most commonly reported symptoms in patients with ULL. The presences of these two symptoms are moderately correlated with the presence and/or severity of ULL. Although limited information regarding the predictive self-reported symptoms for the development of ULL was found. Further research with standardised definitions of ULL and validated questionnaires for self-reported signs and symptoms are needed to confirm which signs and symptoms are related to ULL and which to other upper limb morbidities., (© 2021 John Wiley & Sons Ltd.)

Purpose: Upper limb lymphedema is a vexing morbidity that can occur after the treatment for breast cancer. The Lymphedema Functioning, Disability and Health Questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a valid and reliable tool assessing problems in functioning in patients with breast cancer-related lymphedema. Until now, a French-language version was lacking. The aim of this study was to perform a cross-cultural validation of the French version of the Lymph-ICF-UL questionnaire., Methods: A forward-backward translation process between the original language (Dutch) and the target language (French) was performed. Psychometric properties of this final French version were examined in 50 participants., Results: Intraclass correlation coefficients for test-retest reliability ranged from 0.66 to 0.95. Cronbach's alpha coefficients for internal consistency were higher than 0.77. Face and content validity were very good because the scoring system was clear for all participants (100%), questions were understandable (100%), and all complaints due to BCRL were mentioned by 78% of the participants. Construct validity was moderate. Convergent validity was established since 3 out of 5 expected domains of the Lymph-ICF-UL showed a moderate correlation with expected domains of the 36-item Short-Form Health Survey. There was satisfactory divergent validity as 6 out of 9 hypotheses assessing divergent validity were accepted., Conclusion: The French version of the Lymph-ICF-UL is a reliable and valid questionnaire and ready for use in clinical as well as in scientific practice.Implications for rehabilitationSince the introduction of more effective treatment modalities increasing the number of breast cancer survivors, the amount of patients dealing with lymphedema is rising likewise up to a pooled incidence rate of more than 16% of the women treated for breast cancer.The French version of the Lymph-ICF-UL is a reliable and valid questionnaire for assessing problems in functioning of patients with breast cancer-related lymphedema of the arm and/or hand.As the questionnaire provides patient information in the different domains of the International Classification of Functioning, Disability and Health, it facilitates evaluating the impact of breast cancer-related lymphedema on daily functioning.Based on the outcomes of the Lymph-ICF-UL treatment goals can be set, where after the questionnaire can be used to monitor long-term results of this treatment and self-care.

Purpose: Decongestive lymphatic treatment (DLT) is still the gold standard for treatment of breast cancer-related lymphedema (BCRL). With up to 17% of the patients treated for breast cancer developing BCRL, this morbidity imposes a tremendous financial burden for patients and society. Knowledge about this economic burden related to BCRL and its conservative treatment in a European setting is lacking. The aim of this prospective, longitudinal cohort study was to estimate the direct healthcare costs related to BCRL and its treatment in a European setting., Methods: Patients with BCRL were treated with DLT consisting of an intensive treatment phase of 3 weeks, followed by a maintenance treatment phase of 6 months. Additionally, the follow-up period comprised 6 months. During these 3 weeks and 12 months, all direct costs associated with the treatment of BCRL and its sequelae were documented through billing prices and a self-developed questionnaire which was administered after the intensive treatment phase, and subsequently 3-monthly during the entire period., Results: A total of 194 patients were enrolled in this study. Of these, 17% (n = 32) showed lymphedema stage I, 56% (n = 109) had lymphedema stage IIa, and 27% (n = 53) had lymphedema stage IIb. Total direct healthcare costs per patient were €2248.93 on average during the entire period of 3 weeks of intensive treatments and 12 months of maintenance decongestive therapy. Within these mean direct costs, €1803.35 (80%) was accounted for statutory health insurances, and €445.58 (20%) was out-of-pocket expenses for patients., Conclusion: This study is one of the first standardized high-quality health economic analyses of BRCL treatment in Europe. The present study indicates that the price tag of BCRL treatment in Belgium is high not only for the health insurance but also for the patients Clinical trial registration number The study makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Objectives: Quantitative sensory testing (QST) is a noninvasive technique to evaluate functioning of the somatosensory system. In many women surgically treated for breast cancer (BC), somatosensory functioning is disturbed with high prevalence of sensory loss and/or pain. The aims of this systematic review were (1) to summarize literature about QST methods; (2) to summarize the results within women surgically treated for BC (patients and survivors); (3) to compare QST results between women surgically treated for BC with and without pain; and (4) to compare the results between women surgically treated for BC and women without history of BC., Methods: A systematic literature search was conducted up to February 2020. Included studies had to report on QST methods (mechanical or thermal detection-pain thresholds, pressure pain thresholds [PPT], temporal summation [TS], or conditioned pain modulation [CPM]) in women over 18 years with-without pain, who had undergone unilateral surgery for BC., Results: Twenty-eight studies were included. Discrepancies in QST methods were greatest for TS and CPM. A local disturbance in thermal detection and an increased pain facilitation were found in BC survivors with pain in the surgical area. BC survivors with upper limb pain had significantly lower PPT at the surgical area and PPT were also significantly lower compared with women without history of BC, at affected and nonaffected sides for both local and remote body regions., Discussion: Standardized QST incorporating assessments of CPM is warranted in order to draw conclusions about neurobiological mechanisms of pain and somatosensory disturbances after surgical treatment for BC and to enhance mechanism-based management of these sequelae., Competing Interests: A.D.G. is a postdoctoral research fellow of the FWO-Flanders. The remaining authors declare no conflict of interest. The study is funded by Research Foundations—Flanders (FWO), Brussels, Belgium (T005117N)., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: A disturbance of the superficial lymphatic system (dermal backflow) in patients with breast cancer-related lymphedema (BCRL) can be visualized by near-infrared fluorescence imaging or lymphofluoroscopy. In clinical practice, exact measurement of the dermal backflow is difficult. The purpose of the study is to investigate the concurrent validity between the clinical assessments and the lymphofluoroscopy in patients with BCRL. Methods and Results: Forty-five patients with BCRL stage I to IIb received lymphofluoroscopy and clinical assessments of their edematous limb (pitting status, skinfold thickness, skin elasticity, water content, lymphedema volume, and extracellular fluid). The correlation between the clinical assessments and the result of the lymphofluoroscopy was determined. The best overall agreement with dermal backflow was found for the clinical assessment pitting status, skinfold thickness, and water content. Overall sensitivity was excellent for lymphedema volume (92.5%), high for skinfold thickness (86.6%) and water content (75.0%), and moderate for pitting status (67.7%). Overall specificity was excellent for skin elasticity (94.7%), high for pitting status (83.4%), and moderate for skinfold thickness (61.6%) and water content (74.8%). In the evaluation of the whole arm, measurements of the excess volume were significantly greater for patients in an advanced stage of dermal backflow in comparison with patients in an earlier stage of dermal backflow ( p  = 0.002). Conclusions: The clinical assessments of skinfold thickness, water content, and lymphedema volume are the most appropriate tools to detect dermal backflow according to the lymphofluoroscopic images. To confirm the absence of dermal backflow, pitting status can be recommended.

Purpose: Breast cancer survivors face a high risk of developing breast cancer-related lymphedema (BCRL). Besides physical symptoms such as swelling, BCRL can have a psychosocial impact and lead to problems in daily functioning. Understanding contributing variables to problems in functioning yields possibilities to improve treatment modalities and consequently patients' quality of life. Therefore, the aim of this study was to explore the association between patient-, lymphedema-, and cancer treatment-related variables with problems in functioning in patients with BCRL., Methods: A cross-sectional study was performed in 185 patients with BCRL. Problems in daily functioning (dependent variable) were evaluated with the Lymph-ICF-UL questionnaire. Following independent variables were analysed by bi-variate and multivariable analyses, including a stepwise regression analysis: patient-related variables (age, BMI, physical activity level, education), lymphedema-related variables (excessive arm volume, duration of lymphedema, total pitting score, presence of hand edema, hardness of the tissue, lymphedema stage), and cancer treatment-related variables (type of surgery, surgery at the dominant side, radiotherapy, chemotherapy, hormone therapy, immunotherapy, TNM-classification)., Results: The Lymph-ICF-UL mean total score was 38% (± 21), representing a moderate amount of problems in general functioning. Multivariable regression analyses revealed that lower physical activity level and lower age are contributing factors to more problems in daily functioning. Stepwise regression analysis indicated that up to 8% of the variance in problems in functioning could be explained by physical activity level and age of patients with BCRL., Conclusion: Especially patients with low physical activity level and younger patients experience more problems in functioning. For the determination of certain causal interactions, future longitudinal studies including other independent variables that might explain a higher amount of problems in functioning in this population, are warranted., Trial Registration: The study makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Purpose: Pain is one of the most prevalent problems reported by breast cancer survivors. As this long-lasting complication can result in disabilities on all different domains of functioning, we aimed to clarify the contribution of different factors (pain-related factors, psychosocial factors, and fatigue) to pain-related disability in female breast cancer survivors., Methods: Seventy women who had completed their primary breast cancer treatment were included in this cross-sectional study. The following outcome measures were evaluated as independent variables for their contribution to pain-related disability (measured by the Pain Disability Index, with a maximum score of 70): pain intensity, self-reported symptoms of central sensitization, fatigue, illness beliefs, pain catastrophizing, and kinesiophobia. At first, bi- and multivariable regression methods were conducted. Secondly, a stepwise regression analysis was performed to determine the explained variance of the PDI., Results: Mean score on the PDI was 16 at 4.5 years post-surgery. Multivariable regression analysis revealed higher levels of kinesiophobia as the main contributor to pain-related disability. Ultimately, stepwise regression showed that up to 40% of variance in pain-related disability could be explained by kinesiophobia, negative perceptions related to illness consequences, and pain catastrophizing., Conclusion: This study shows that breast cancer survivors portray moderate self-reported pain-related disability. Kinesiophobia emerged as the main contributor to pain-related disability at this time point, which could shine a light on the improvement of treatment modalities for pain management in this population.

Background: The Lymphedema Functioning, Disability, and Health questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a health-related quality-of-life questionnaire for patients with breast cancer-related lymphedema. Previous testing of this questionnaire showed very good psychometric properties; however, responsiveness has not yet been established. The aim of this study was to determine its internal and external responsiveness. Methods and Results: Ninety-five patients treated with decongestive lymphatic therapy in a longitudinal trial were recruited. Patients completed the Lymph-ICF-UL twice within a time interval of 7 weeks ("intensive group" receiving intensive treatment; n  = 73) or 3 months ("stable group" receiving maintenance treatment; n  = 22), and once the Global Perceived Effect (GPE) questionnaire at the second time point. The significance of change in scores and standardized response mean (SRM) were determined for the total and domain scores. Correlations between Lymph-ICF-UL and GPE were ascertained. In addition, the minimal clinical important difference (MCID) was determined. The Lymph-ICF-UL total score changed significantly in the intensive group ( p  < 0.001) and nonsignificantly for those in the stable group ( p  = 0.25). The SRM represented moderate responsiveness (0.65). Patients who reported a clinical improvement ( = responders) after intensive treatment showed a significant decrease in total score ( p  < 0.001), this was also the case for nonresponders ( p  < 0.001). Lymph-ICF-UL total and domain scores showed nonsignificant weak correlations with the GPE ( p  > 0.05). There was a significant difference in mean total score changes between responders and nonresponders ( p  < 0.001). MCID for the total score was 9%. Conclusion: The Lymph-ICF-UL is responsive to change after decongestive lymphatic therapy. No correlations were found between Lymph-ICF-UL change scores and GPE. Future studies should be conducted in a clinical setting, with more variability between participants and their treatment responses.

Objective: To perform the cross-cultural validation process of the Dutch Norman Questionnaire (NQ), a questionnaire for the detection and characterisation of breast-cancer related lymphoedema (BCRL) using self-reported signs and symptoms., Methods: Test-retest reliability and construct (including convergent, divergent and known-groups validity), face and content validity were examined in breast cancer patients with (n = 30) and without (n = 30) lymphoedema. For concurrent validity, first, agreement between the diagnostic item of the NQ and a clinical diagnosis were analysed. Second, correlations between NQ scores and clinical arm volume assessment were tested., Results: Test-retest reliability was found to be strong to very strong (ICC 0.79-0.96) in the lymphoedema group and moderate to very strong ( ICC 0.64-0.99) in the non-lymphoedema group. Seventeen out of 20 hypotheses on convergent and divergent validity were accepted. There was good face, content and known-groups validity as well. For concurrent validity, agreement between evaluation methods was only 0.462. Moderate correlations were found between 6 out of 9 symptom scores (r = 0.422-0.630) of the NQ and clinical assessment., Conclusion: The Dutch NQ is a reliable and valid questionnaire for the characterisation of BCRL using self-reported signs and symptoms. Only moderate agreement for the detection of BCRL was found., (© 2020 John Wiley & Sons Ltd.)

Background: Local tissue water in patients with breast cancer-related lymphedema (BCRL) can be assessed by measurement of the tissue dielectric constant using the MoistureMeterD Compact ® (MMDC) device, or by performing the pitting test. Although these assessment methods are commonly used in clinical practice, literature shows a lack of research on their clinimetric properties. Therefore, the aim of this study was to investigate reliability of both methods, in assessing the upper limb in BCRL. Methods and Results: Thirty women with BCRL were enrolled. Local tissue water was evaluated at nine reference points on the upper limb and trunk, using both methods. To determine intra- and inter-rater reliability of the MMDC device (using the absolute percentages of water content [PWC%] and interarm PWC% ratios based on single and multiple measures), intraclass correlation coefficients (ICCs), and standard errors of the measurement were calculated. To determine intra- and inter-rater agreement of the pitting test, Cohen's kappa coefficients were calculated as well as percentages of agreement. MMDC measurements yielded moderate to very strong intra- (ICC 0.648-0.947) and inter-rater (ICC 0.606-0.941) reliability, depending on the measurement location on the edematous limb. The pitting test showed a very strong intrarater agreement at nearly all defined points, but a weak inter-rater agreement, especially at the medial elbow and the breast. Conclusion: This study supports the MMDC device and pitting test as being useful tools in the clinical evaluation of BCRL. However, further research into the concurrent validity of both tools is warranted.

Purpose: To develop a diagnostic tool, the Breast Edema Questionnaire (BrEQ) and to determine its clinimetric properties., Methods: The BrEQ was developed based on information from literature, experts and breast edema patients. Content validity, construct validity, test-retest reliability, internal consistency and cut-off point were investigated in a group of breast cancer patients. Construct validity made up two parts; convergent and known-groups validity. Convergent validity was tested by correlating the BrEQ with skin thickness measured with ultrasound (US)., Results: In part 1 of the BrEQ, symptoms of breast edema were scored from 0 to 10: pain, heaviness, swelling, tensed skin, redness, pitting sign, enlarged skin pores and hardness. Taking into account the International Classification of Functioning, Disability and Health, several activity limitations and participation restrictions were scored from 0 to 10 in part 2. Clinimetric properties of part 1 were examined in 55 patients. US showed that 35 women had breast edema. Content validity was good. Regarding convergent validity, all breast symptoms correlated moderately with skin thickness. The total symptom score had a strong correlation with skin thickness. Concerning known-groups validity, patients with breast edema had a higher total symptom score. Test-retest reliability ranged between moderate and strong. The internal consistency was good for all items and the total symptom score. We identified that a score cut-off point of ≥ 8.5 discriminates between patients with breast edema and those without., Conclusion: Part 1 of the BrEQ-Dutch version is a valid and reliable tool for assessing clinical indicators of breast edema.

Objectives: To provide an overview of costs associated with the treatment of breast cancer-related lymphoedema (BCRL) and its possible sequelae, borne by patients or by society., Data Sources: According to the PRISMA guideline, a systematic literature search was carried out in four electronic databases: PubMed, Web of Science, Cochrane Clinical Trials and EMBASE. Searches were performed on October 1, 2018., Study Selection: Eligibility criteria: (1) expenses of adults (age > 18 years), (2) concerning patients with BCRL, (3) overview of (in)direct costs associated with BCRL, (4) expenses in which at least one type of conservative treatment modality for lymphoedema is included and/or costs for hospital admissions due to infections. Reviews and meta-analyses were excluded., Data Extraction: After assessing the risk of bias and level of evidence, quantitative data on (in)direct costs for BCRL treatment during a well-mentioned timeframe were extracted., Data Synthesis: Eight studies were included. Three studies reported on patient-borne costs related to BCRL. Mean direct costs per year borne by patients ranged between USD$2306 and USD$2574. Indirect costs borne by patients ranged between USD$3325 and USD$5545 per year. Five studies estimated society-borne costs related to BCRL from claims data, billing prices and providers' services during 12 to 24 months of follow-up. Mean direct treatment costs after 1 year of decongestive lymphatic therapy (DLT) ranged between €799 (= USD$1126.60) and USD$3165., Conclusion: This systematic review revealed that BCRL imposes a substantial economic burden on patients and society. However, more standardized high-quality health economic analyses among this field are required. Recent economic analyses related to BCRL treatment in Europe, Asia, Africa and South America are lacking. Worldwide, further scrutiny of the economic impact of DLT for BCRL in clinical settings is needed., Clinical Trial Registration Number: The review makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Objective: To investigate the reliability, time efficiency and clinical feasibility of five commonly used methods for assessing excessive arm volume in patients with breast cancer-related lymphoedema (BCRL)., Design: Cross-sectional study., Setting: University Hospitals Leuven, Belgium., Subjects: 30 participants with unilateral BCRL., Methods: Excessive arm volume was determined by five different methods: traditional volumetry with overflow, volumetry without overflow, inverse volumetry, optoelectronic volumetry and calculated volume based on circumference measurements. To investigate intra- and inter-rater reliability, measurements were performed twice by the same assessor and once by a different assessor. Intraclass correlation coefficients (ICCs), standard errors of the measurement (SEMs) and systematic changes between the means were calculated. To determine time efficiency, the mean setup time, execution time and total time were examined for each method. Furthermore, 12 limitations regarding clinical feasibility were listed and scored for each method. Finally, an overall ranking score was determined between the methods., Results: Mean age was 65 (±8) years and mean body mass index was 28 (±4) kg/m 2 . Intra- and inter-rater reliability ranged between strong and very strong. Calculated arm volume based on circumferences (mean excessive arm volume: assessor A: 477 (±367) mL; assessor B: 470 (±367) mL; assessor A (second time): 493 (±362) mL) showed the highest intra- and inter-rater ICCs of .987 and .984, respectively. Optoelectronic volumetry was the fastest method, representing a mean total time of 1 minute and 43 (±26) seconds for performing a bilateral measurement. The least limitations were reported on the calculated volume based on the circumference method (3 out of 12 limitations)., Conclusion: Calculated volume based on arm circumferences is the best measurement method for evaluating excessive arm volume over time in terms of reliability, low error rate, low cost, few limitations and the time spent.

Background: Lymphedema is associated with significant physical and psychosocial problems. The Lymphedema Functioning, Disability and Health questionnaire for upper limb lymphedema is a valid and reliable tool quantifying the amount of problems in functioning in patients with breast cancer-related lymphedema. Patients suggested a revision of the scoring system to facilitate completion of the questionnaire. Therefore, adjustment of the questionnaire was carried out by implementing a numeric rating scale instead of the existing visual analog scale. Purpose of this study was to investigate reliability and validity of the revised Lymph-ICF, called the Lymph-ICF-UL. Methods and Results: Reliability and validity of the Lymph-ICF-UL were examined in 56 participants with upper limb lymphedema. Intraclass correlation coefficients for test-retest reliability ranged from 0.79 to 0.95. Cronbach's alpha coefficients for internal consistency were higher than 0.80. Face and content validity were very good because the scoring system was clear for all participants (100%), questions were understandable for all participants (100%), and all complaints due to arm lymphedema were mentioned by 98% of the participants. Construct validity was good. Convergent validity was established since four out of five expected domains of the Lymph-ICF-UL showed a moderate correlation with expected domains of the 36-Item Short-Form Health Survey questionnaire. There was good divergent validity because seven out of nine hypotheses assessing divergent validity were accepted. Conclusion: The Lymph-ICF-UL is a reliable and valid questionnaire using a simplified and clearer scoring procedure to assess impairments in function, activity limitations, and participation restrictions of patients with breast cancer-related arm lymphedema.