Case Report

Case Report: Manual Lymphatic Drainage

and Kinesio Taping in the Secondary
Malignant Breast Cancer-Related
Lymphedema in an Arm With
Arteriovenous (A-V) Fistula for
Hemodialysis

American Journal of Hospice

& Palliative Medicine
30(5) 503-506
The Author(s) 2012
Reprints and permission:
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DOI: 10.1177/1049909112457010
ajhpm.sagepub.com

Ya-Hui Chou, PT1, Shu-Hua Li, PT1, Su-Fen Liao, MD2,3, and
Hao-Wei Tang, MD2

Abstract
Lymphedema is a dreaded complication of breast cancer treatment. The standard care for lymphedema is complex decongestive
physiotherapy, which includes manual lymphatic drainage (MLD), short stretch bandaging, exercise, and skin care. The Kinesio
Taping could help to improve lymphatic uptake. We reported a patient with unilateral secondary malignant breast
cancer-related lymphedema and arteriovenous (A-V) fistula for hemodialysis happened in the same arm, and used kinesio taping,
MLD, and exercise to treat this patient because no pressure could be applied to the A-V fistula. The 12-session therapy created an
excellent effect. We do not think the kinesio taping could replace short stretch bandaging, but it could be another choice for
contraindicating pressure therapy patients, and we should pay attention to wounds induced by kinesio tape.
Keywords
breast cancer-related lymphedema, arterio-venous fistula, kinesio tape, compression therapy, complex decongestive therapy,
manual lymphatic drainage

Lymphedema can be defined as the abnormal accumulation

of protein-rich interstitial fluid that occurs primarily as a consequence of malformation, dysplasia, or acquired disruption
of lymphatic circulation.1 Breast cancer-related lymphedema
(BCRL) is a dreaded complication of breast cancer treatment
because it may engender physical and psychological morbidity and degrade quality of life.2-4 The current standard care
for lymphedema is complex decongestive physiotherapy
(CDP), which includes manual lymphatic drainage (MLD),
compression therapy, exercise, and skin care.5 The intensive
phase of CDP comprises a course of daily exercise and MLD
to decongest the lymphedematous area of the body, followed
by multiple-layer short stretch bandaging to prevent the reaccumulation of fluid and to create a counterforce to muscle
contraction in order to promote lymph flow1,4,6 and skin care.
Several studies have reported the benefits of CDP in
BCRL.1,5,7,8 The compression therapy on its own should be
considered as a primary treatment option in reducing arm
lymphedema volume.9 Professor Foldi said that CDP would
not be successful if the patients were not able to cooperate
with the compression therapy.10 And what can we do if compression therapy is contraindicated? Dr Kenzo Kase invented

and developed the Kinesio Taping Method in 1973, and

he believed kinesio tape could help open up lymphatic pathways and keep the pathways open to improve lymphatic
uptake.11,12
We describe a patient with unilateral secondary malignant
BCRL and arteriovenous (A-V) fistula for hemodialysis in the
same arm, in whom we used kinesio taping to substitute for
short stretch bandaging, because no pressure could be applied
to the A-V fistula.

1
Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua, Taiwan
2
Department of Physical Medicine and Rehabilitation, Changhua Christian
Hospital, Changhua, Taiwan
3
School of Medicine, Chung Shan Medical University, Taichung, Taiwan

Corresponding Author:
Su-Fen Liao, MD, Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, No. 135 Nanxiao Street, Changhua 500, Taiwan.
Email: sueliao3@gmail.com

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American Journal of Hospice & Palliative Medicine 30(5)

504

Figure 2. Kinesio taping rerouting lymph flow from the left arm
through the back watershed to the right axillary area.

Figure 1. Left arm lymphedema after 3 sessions of therapy.

Case Report
A 48-year-old female with a medical history of end-stage
renal disease treated with 3 hemodialysis sessions every week
since 1999 using an A-V fistula in the left elbow and also left
breast cancer (stage T3N1M1) diagnosed in 2007. She refused
surgery and had received regular chemotherapy since 2007.
She underwent radiation therapy (3500 cGy) from the 6th cervical spine to the 3rd thoracic spine for bony metastasis in
September 2009. She visited our clinic on September 29,
2011, due to progressive swelling and fibrosis of the left arm
lasting for months that disturbed her activities of daily living.
She was undergoing weekly chemotherapy with paclitaxel
(60 mg/m2) due to liver and lung metastasis at that time. On
physical examination, stage II lymphedema and fibrosis of the
left forearm and arm was found (Figure 1). A complete
laboratory work-up and imaging studies were unremarkable
for infection or venous obstruction of the left arm. The positron emission tomography and computed tomography of the
chest revealed bilateral axillary lymph nodes and mediastinal
lymph node metastasis.
We arranged 3 therapy sessions every week to coordinate
with her hemodialysis schedule, for a total of 12 sessions including 45 minutes of MLD, and kinesio taping from the left arm to
the right axillary area, following Dr Kase instructions

(Figure 2),11 remedial exercise to facilitate venous and lymphatic flow, and instructions for skin and nail care. The kinesio tape
was kept on for 3 days and replaced at the next visit.
Circumferential measurements were taken at the metacarpophalangeal joint and the wrist, and repeated for every 10 cm proximally from the tip of the third digit to the top of the arm (axillary
fold). The volume of each limb was calculated from the circumference using the truncated cone formula.13 The severity of lymphedema was defined as the percentage of excess volume (PEV)
or the excess lymphedema volume relative to the healthy arm
(VH), PEV (VL  VH)/VH  100%. The response to the therapeutic intervention was quantified as the percentage reduction
of excess volume (PREV), PREV 100%  (posttreatment
VL  baseline VL)/excess volume.
The initial circumference difference was 37.6 cm, excess
volume was 992 mL, and the lymphedema severity-baseline
PEV was 79.15%, which was severe lymphedema based on
the definition of International Society of Lymphology.14 After
the 12 therapy sessions, the circumference was reduced 19.8
cm, excess volume decreased 536 mL, and PEV was
36.43%. The therapeutic efficacy, PREV, was 54%,
meaning that the edema volume could be reduced 54% in
12 sessions of therapy (Table 1).
The patient continued with a further 4 sessions of therapy
but the PEV and PREV did not show a reduction after the extra
sessions. She tolerated the entire treatment course well, except
the pruritus and wound production in the kinesio taping area.
She refused continuation of the kinesio taping because of the
skin lesions induced by the kinesio tape and felt more
comfortable after therapy.

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Chou et al

505

Table 1. Lymphedema Characteristics.

Variable
Excess circumference, cm
Post-t/x decreased circumference, cm
Excess volume (EV), mL
Post-t/x decreased EV, mL
PEV, %
PREV, %

Baseline

Post-6-Time Treatment

Post-12-Time Treatment

37.6

24.8
12.8
632
360
50.43
36.28

17.8
19.8
456
536
36.43%
54.75%

992
79.15

Abbreviations: PEV, percentage of excess volume; PREV, percentage reduction of excess volume.

Discussion
This patients lymphedema was not a typical BCRLit was
caused by tumor infiltrating the left axillary lymph nodes. It
is classified as a secondary malignant lymphedema. SoucekHadwiger et al15 reported that both tumor-specific therapy and
an early start to complex physical oedematherapy are necessary
to stabilize disease without symptoms of secondary malignant
lymphedema.
This patients PEV improved from 79.15% to 36.43% after
therapy or from severe lymphedema to moderate
lymphedema.14 The lymphedema reduction was 54% after
12 sessions of therapy, so lymphedema treatment was
successful using Ramoss definition.8 We wanted to know
which component played a major role in the therapy.
Many studies have shown that the CDP program can reduce
PEV.1,5,7,8,16 The role of MLD is still controversial in BCRL
studies. Williams et al17 reported MLD could further reduce
PREV by 9.7% compared with simple lymphatic draining, but
McNeely et al9 found an additional benefit to the application of
MLD only in mild early-stage lymphedema. Didem et al compared CDP efficacy with standard physiotherapy (SP), SP
group treated by bandage, head-neck and shoulder exercise,
and skin care, and the efficacy of CDP group was 19.7% greater
than SP group.18 But Anderson found MLD did not contribute
significantly to the reduction of lymphedema volume when
compared with compression sleeves and exercise.19 Based on
previous studies, we could conclude that MLD worked well
in early-stage lymphedema (duration <12 months)9 as this
patient and that kinesio tape helped to reduce the greater edema
volume, because MLD and remedial exercise alone did not
have such a prominent effect. After the 12-session treatment,
the efficacy reached a plateau and longer treatment did not
further reduce the lymphedema volume. This also was the case
with CDP, as most lymphedema reduction occurred during the
first 10-session intensive treatment, and the fibrosis tissue did
not resolve in a 12-session protocol.9,10,13,20 Kinesio tape did
not work in fibrosis tissue but compression treatment with specific padding could improve fibrotic tissue in the CDP
program.10,13
Kinesio taping has been widely used with athletes due to its
flexibility, comfort, and waterproof characteristic since it was
developed in 1973.21-23 Dr Kase believed kinesio taping could
improve lymphatic uptake and also help in the routing or
rerouting of lymph in superficial lymphatic vessels.11 In the

only one study to investigate the effect of kinesio taping in

BCRL, Tsai et al12 concluded that kinesio tape could replace the
bandage in CDP and could be an alternative choice for BCRL
with poor bandage compliance after a 1-month intervention.
This was an interesting study because both the CDP and kinesio
taping groups showed there was no difference in volume and circumference when comparing the preintervention data with the 3month follow-up results; both interventions showed subjective
symptoms improvements only after the 3-month follow-up. The
volume and circumference were significantly reduced after a 4week intervention only in the bandaging group, although the
patients wore the bandages for only 7.8 hours (it was supposed
to be worn for 16 hours) in the daytime. In contrast, the kinesio
taping group showed improved only forearm circumference and
water composition after the intervention. In other words, Tsai
study showed the intensive phase of the CDP program is still
effective, even in patient with poor compliance. The effect of
compression therapy is stronger than that of kinesio taping.
Kinesio tape is not a substitute for bandaging, but it could be
another choice if compression therapy is contraindicated.
Wounds production is a major problem with kinesio tape as
Tsai12 noted, because the integrity of the skin is important in
preventing infection in lymphedema care. This patient
developed wounds and pruritus at the taping area although the
tape was carefully removed by the therapists. We think this was
because of the adhesive characteristics of the kinesio tape, and
that xerosis, pruritus, and fragile skin are common mucocutaneous disorders in patients with uremia.24 The putting on and
taking off of kinesio tape in lymphedema therapy requires
attention. In the future, the avoidance of wound production
when using kinesio tape with lymphedema patients will be a
major concern.
The use of MLD, kinesio taping, remedial exercise, and skin
care had an excellent effect in this case of secondary malignant
BCRL combined with an A-V fistula arm. We do not think that
kinesio taping can replace short stretch bandaging, but it can be
another choice for patients in which pressure therapy is contraindicated and in hospice care, and we need to pay attention to
wounds induced by kinesio tape. The long-term effect and real
role of kinesio taping in lymphedema need further evaluation.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

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American Journal of Hospice & Palliative Medicine 30(5)

506
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.

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