Sliding-cupping along meridian for lymphedema after breast cancer surgery: A randomized controlled trial

Sliding-cupping along meridian for lymphedema after breast cancer surgery: A randomized controlled trial

World Journal of Acupuncture – Moxibustion 29 (2019) 179–185 Contents lists available at ScienceDirect World Journal of Acupuncture – Moxibustion jo...

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World Journal of Acupuncture – Moxibustion 29 (2019) 179–185

Contents lists available at ScienceDirect

World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam

Clinical Research

Sliding-cupping along meridian for lymphedema after breast cancer surgery: A randomized controlled trial ✩ Zhi-feng XIONG (), Ting WANG (), Hong-lin WANG (), Yong-yue WANG (), Lin GAN (), Gang Lǚ ()∗ Breast Thyroid Department of Chongqing Traditional Chinese Medicine Hospital, Chongqing 400021, China (,  400021, )

a r t i c l e

i n f o

Article history: Available online 20 August 2019 Keywords: Sliding-cupping Along meridian Postoperative breast cancer surgery Lymphedema Randomized controlled trial

a b s t r a c t Objective: To observe the clinical efficacy difference between sliding-cupping along meridian combined with short-stretch elastic bandage wrapping and comprehensive detumescence therapy in treating lymphedema after breast cancer surgery. Methods: Sixty patients with lymphedema after breast cancer surgery were randomly divided into the sliding-cupping group and the comprehensive detumescence therapy (CDT) group, with 30 cases in each one. The sliding-cupping group used the sliding-cupping along meridian therapy, and the sliding-cupping was applied along the three yin meridians and three yang meridians on the hand of the affected-side upper limbs, continuing for 25–30 min. After the sliding-cupping was finished, the affected limb was wrapped with the short-stretch elastic bandage. The CDT group was treated with comprehensive detumescence therapy (CDT). Both groups were treated once a day, with14 times as one course of treatment, and there was totally 1 course of treatment. The changes of circumferences before and after treatment of the affected limb were measured by a flexible ruler, and the efficacy was evaluated. The subcutaneous tissue thickness and the full skin layer thickness of the patients with moderate to severe edema in sliding-cupping group were measured by color Doppler ultrasound. Results: After treatment, the circumferences at the cubital crease, 5 cm above olecranon, and 10 cm above the olecranon of the affected limbs in the sliding-cupping group were (26.02 ± 2.42) cm, (28.43 ± 3.13) cm, and (30.05 ± 2.80) cm respectively, which were all reduced compared with the pre-treatment circumference (27.95 ± 3.00) cm, (30.80 ± 3.38) cm, and (32.17 ± 2.96 cm). In the sliding-cupping group, the post-treatment subcutaneous tissue thicknesses at 5 cm above the olecranon, 10 cm above the olecranon and 5 cm below the olecranon, and full skin layer thickness at 10 cm below the olecranon of the 15 patients with moderate to severe edema were (8.71 ± 2.83) cm, (8.53 ± 2.4) cm, (6.46 ± 1.38) cm, and (1.61 ± 0.17) cm respectively, which were all reduced compared with pre-treatment (11.90 ± 3.56) cm, (11.84 ± 3.27) cm, (9.12 ± 1.84) cm, and (1.87 ± 0.23) cm, and the difference was statistically significant (all P < 0.05). The total effective rate of the sliding-cupping group was 86.6%, and the total effective rate of the CDT group was 80%, and the difference was statistically significant (P < 0.05). Conclusion: Compared with CDT, the sliding-cupping along meridian combined with short-stretch elastic bandage wrapping for the treatment of lymphedema after breast cancer surgery was more effective. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.

Introduction The incidence of breast cancer is currently the highest among female malignant tumors worldwide. The number of new breast cancer cases worldwide is about 1.6 million per year, and it is growing at a rate of 3–4% per year [1]. Breast cancer-related ✩ Supported by Performance Incentives and Special Project of Chongqing Scientific Research Institutes: cstc2017jxj1130 0 09. ∗ Corresponding author. E-mail address: [email protected] (G. Lǚ).

lymphedema (BCRL) is the most common complication of postoperative breast cancer, and it is shown from the foreign study that the incidence rate is 13.5–41.1% [2]. Lymphedema after breast cancer surgery is due to blockage of lymphatic drainage channels caused by surgery, radiotherapy and chemotherapy, or lymph fluid production and drainage imbalance in the affected area. As the disease progresses, the function of lymphatic vessel deteriorates gradually, and the function of transporting the lymphatic fluid is lost, and the accumulation of lymphatic fluid leads to dermal backflow. The clinic manifestations include edema of the affected limb, thickening of the skin, deterioration of elasticity, and there are even

https://doi.org/10.1016/j.wjam.2019.08.005 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.

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Z.-f. XIONG, T. WANG and H.-l. WANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 179–185 Table 1 Comparison of general data of patients with lymphatic edema after breast cancer surgery between the two groups (mean ± SD). Groups

Sliding-cupping group CDT group

Cases

30 30

Age (years)

53.43 ± 11.87 52.47 ± 11.27

unbearable painfulness and movement disorders, which cause great pain to the body and mind of patient. According to the China Anti-Cancer Association Breast Cancer Diagnosis and Treatment Guidelines and Regulations (2017 Edition) [3], it is determined that if the circumference at any point of the affected-side upper limb is longer than the same part of the healthy-side upper limb, it is edema, and if the circumference is less than 3 cm, it is mild edema, and if the circumference is 3–5 cm, it is moderate edema, and if the circumference is longer than 5 cm, it is severe edema. Lymphedema after breast cancer surgery is difficult to reverse, and there is a trend of deterioration [4]. The complex decongestion therapy (CDT) [5] for the treatment of lymphedema is used abroad, and it needs technology training of foreign professional institutions, and domestic therapists know very little about it, and therefore, how to treat lymphedema under existing conditions is a question worth considering. In this study, sliding-cupping along meridian was applied on the affected-side upper limbs of patients to treat lymphedema after breast cancer surgery, and it is reported below. Clinical data General data A total of 60 cases of patients with lymphedema after breast cancer surgery in breast thyroid department outpatient and ward of Chongqing Traditional Chinese Medicine Hospital from March 2018 to March 2019 were collected. The patients were all women with unilateral breast cancer, and they had completed routine breast cancer surgery with radiotherapy and chemotherapy having been over for 3 months. They were randomly divided into an sliding-cupping group and a CDT group by random number table method, with 30 cases in each group. The age of the patients in the sliding-cupping group was between 31 and 71 years old, with an average of (53.43 ± 11.87) years old; the course of disease was between 0.3 and 10 years, with an average of (3.18 ± 2.30) years. The age of the patients in the CDT group was between 29 and 73 years old, with an average of (52.47 ± 11.27) years old; the course of disease was between 0.3 and 9 years, with an average of (3.03 ± 2.24) years. In the sliding-cupping group before treatment, 15 cases showed mild degree of edema, 10 cases showed moderate edema, and 5 cases showed severe edema. In the CDT group before treatment, 16 patients showed mild edema, 10 patients were moderate, and 4 patients were severe. There were no significant differences in age, course of disease and degree of edema between the two groups (all P > 0.05) (Table 1). Diagnostic criteria According to the China Anti-Cancer Association Breast Cancer Diagnosis and Treatment Guidelines and Regulations (2017 Edition), pathological diagnosis met the diagnostic criteria for unilateral, single lesion, and primary breast cancer. Modified radical mastectomy or breast-conserving surgery had been performed. Armpit lymph node dissection had been performed during operation, and the affected-side upper limb showed local edema after operation.

Course of disease (years) 3.18 ± 2.30 3.03 ± 2.24

Degree of edema (cases) Mild

Moderate

15 16

10 10

Severe 5 4

The circumference of any point on the affected-side upper limb was longer than the same part of the opposite upper limb, and the patient with the length difference <3 cm was mild edema, and the patient with the length difference ≥3 cm and <5 cm was moderate edema, and the patient with the length difference ≥5 cm was severe edema. Inclusion criteria

 1 Age between 18 and 75 years old.  2 No distant tissue metastasis of upper and lower region of clavicle, cervical lymph nodes and lung, bone, liver, and brain, etc.  3 Radiotherapy and chemotherapy had been over for at least 3 months.  4 Expected survival period were more than 12 months. Exclusion criteria

 1 Patients with second primary tumor or local recurrence or metastasis occurring during diagnosis, treatment or follow-up.  2 Patients with severe damage of heart, liver and kidney or hematopoietic dysfunction, and arteriovenous color Doppler ultrasound of upper limb, arteriovenous color Doppler ultrasound of neck, and color Doppler ultrasound of heart suggesting cardiovascular disease.  3 Patients with a history of major trauma to the upper limb or neck, and a history of surgery. Drop-out criteria

 1 Patients who did not undergo treatment according to the prescribed treatment protocol or patients who were undergoing other treatments during the trial.  2 Patients with affected limb allergies, erysipelas or other serious adverse events that could not continue treatment during the trial.  3 Patients who withdrew from the trial due to other various reasons when the treatment was not over, or patients who were lost of follow-up or died. Treatment methods Sliding-cupping group The affected limb of the patient was treated with slidingcupping along meridian, and then a short-stretch elastic bandage was applied, as follows. The therapist used a common glass cup, and examined the local skin of the affected-side upper limb to make sure there was no red swelling, rash, and damage etc. before applying the sliding-cupping, and then the sliding-cupping was applied along the transmission route of the three yin meridians and the three yang meridians of the hand of the affected-side upper limbs. Along the distal end to the proximal end, the sliding-cupping was moved to the shoulder joint transiting to the shoulder-back region, continuing for about 25–30 min until the skin was reddish and there were slightly spots of rash. The treatment stopped for 5–10 min after the sliding-cupping was over, until the affected limb had no obvious pain and discomfort, and the red skin gradually returned to normal color. Then the therapist trained by the international lymphedema therapist applied the short-stretch elastic bandage wrapping to the affected

Z.-f. XIONG, T. WANG and H.-l. WANG et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 179–185

limb (manufactured by Hartmann, Germany), the appropriate length of high-elastic seamless tube-type bandage was applied to the affected limb as a bottom padding layer to protect the skin. The high-elastic plastic bandage was used to add pressure wrapping the fingers of the affected side. The soft cotton pad was wrapped around the tube-type bandage to balance the pressure of the bandage and to protect the nerve and blood vessels. Then the short-stretched ultra-thin elastic bandage was used to carry out gradient pressure dressing on the affected limb, and the distal end pressure of the limb was larger than the proximal end, thereby forming a pressure gradient. After dressing, the patient performed appropriate functional exercise under the guidance of the physician. The patient performed passive movement of the shoulder joint and wrist joint at a moderate speed, and performed circular motion for 20–30 times each, moving the shoulder and the scapula to promote the return of lymph to the jugular vein. The affected upper limb and the contralateral lower limb performed flexed and stretched exercises at the same time. The upper limb was lifted up and touched the head for stretching training, and the breathing exercise was performed by opening chest. The training time was about 30 min, and the daily wrapping time was not less than 12 h, and then the patient removed the bandage by herself. The treatment was applied once a day, with 14 times as a course of treatment, and there was a total of 1 course of treatment.

CDT group Comprehensive decongestion therapy (CDT) was used. The qualified therapist trained by the international lymphedema therapist applied manual lymphatic drainage (MLD). The patient lay in a supine position. The affected limb was horizontal with the long axis of the heart. The lymphatic pathway was first opened to allow the patient to be in a state of complete relaxation, and the therapist used the index finger, the middle finger and the ring finger that were closed together to massage the superficial lymph nodes in a stationary-revolving manner, and the movements were gentle, with the order was successively the cervical lymph node area, the clavicular lymph node area, the preauricular and retroauricular lymph node area, and the lymph node area of the contralateral axilla, and the inguinal lymph node area. Then, lymphatic drainage was performed, and the massage was performed by manipulations of the circular propulsion, the rotary propulsion, and the scoop-like propulsion etc. to massage. The sequence started from the chest wound, and the upper lymph of the chest wound was drained to the lymph nodes of the contralateral axilla or the upper and lower region of clavicle, and the lower lymph of the wound of chest was drained to the ipsilateral inguinal lymph nodes. The lymph from the medial upper arm in front of the body was drained to the outside of the upper arm until the supraclavicular lymph nodes, the lymph from the medial upper arm in the back of the body was transmitted to the outside of the upper arm and then drained to the back or drained to the ipsilateral inguinal lymph nodes via the dorsal body. The lymph from the back of the hand, the palm of the hand, the forearm, and the cubital fossa was drained to the outside of the upper arm. The manipulations were mainly lightly, gently, shallowly, and rubbing-manner massaging, and the force should not be too large. After the end of the manipulation drainage, the short-stretch elastic bandage was applied on the affected limb. After the wrapping, the functional exercise of appropriate intensity was performed under the guidance of the physician. The specific wrapping and exercise methods were the same as the sliding-cupping group. The daily wrapping time was not less than 12 h, and then the patient removed the bandage by herself. The treatment was applied once a day, with 14 times as a course of treatment, and there was a total of 1 course of treatment.

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Therapeutic effect Observation indicators Before and after treatment, the total 12 circumferences at the wrist crease, cubital crease, 5 cm above olecranon, and 10 cm above the olecranon, 5 cm below olecranon, and 10 cm below the olecranon of the double upper limbs were measured with a soft ruler. During the measurement, the patient took a seat or a standing position, and the arms naturally hung down. Then PHILIPS EnVisor color Doppler ultrasound diagnostic instrument was used, and the frequency of high-frequency linear array probe was 3–12 MHz. In the sliding-cupping group, the subcutaneous tissue thicknesses and full skin layer thickness at 5 cm above the olecranon, 10 cm above the olecranon, and 5 cm below the olecranon, and 10 cm below the olecranon on the double upper limbs of the moderate to severe patients before and after treatment were measured. The patient was placed in the supine position, the upper limb was close to the trunk, and the palm was down or naturally vertical. Standard of therapeutic effect The standard of therapeutic effect was drawn up according to the reference [6]. The calculation formula was: effective index = (circumference of the affected arm before treatment – circumference of the affected arm after treatment) ÷circumference of the affected arm before treatment × 100%. The effective indexes of each measurement point were calculated separately and then the average value was taken. The average effective index being greater than or equal to 90% meant markedly effective, and the effective index being 10% to 90% meant effective, and the effective index being less than or equal to 10% meant ineffective. Statistical analysis The statistical software SPSS 19.0 was used for analysis. The enumeration data was expressed by the percentage. The total effective rate of treatment between the two groups was measured by χ 2 test. The measurement data were expressed by mean ± standard deviation (Mean ± SD), and the t-test was used for comparison between groups. The difference was statistically significant when P < 0.05. Results (1) Comparison of circumference between affected upper limbs and healthy upper limbs pre-treatment of patients with lymphedema after breast cancer surgery in the two groups Before treatment, there were no statistically significant differences in each part circumference of the healthy side in the two groups (all P > 0.05). There were no statistically significant differences in each part circumference of the affected side in the two groups (all P > 0.05). There were statistically significant differences respectively in each part circumferences of the affected and the healthy side in the two groups (all P < 0.05). See Table 2 for details. (2) Comparison of circumference of the affected limbs of patients with lymphedema after breast cancer surgery in the two groups between the pre-treatment and post-treatment There were no statistically significant differences in each part circumference of the patients in the two groups before treatment (all P > 0.05). In the sliding-cupping group, the circumferences at the cubital crease, 5 cm above olecranon, 10 cm above olecranon became shorter than those before treatment, and the differences were statistically significant compared with pre-treatment

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Table 2 Comparison of circumference between affected upper limbs and healthy upper limbs of patients with lymphedema after breast cancer surgery in the two groups before treatment (Mean ± SD, cm). Groups

Cases

Upper limb

Wrist crease

Sliding-cupping group CDT group

30

Healthy side Affected side Healthy side Affected side

15.65 17.45 15.77 17.38

a

30

± ± ± ±

0.86 1.80a 0.77 2.30a

Cubital crease 24.33 27.95 24.52 27.56

± ± ± ±

1.56 3.00a 1.78 3.33a

5 cm above olecranon 10 cm above olecranon 5 cm below olecranon 10 cm below olecranon 26.03 30.80 26.43 30.16

± ± ± ±

2.25 3.38a 2.20 3.47a

28.40 32.17 27.93 31.50

± ± ± ±

2.20 2.96a 2.76 3.25a

23.99 28.12 23.99 27.76

± ± ± ±

1.59 3.70a 1.59 3.43a

22.21 26.35 22.31 25.69

± ± ± ±

1.87 3.78a 1.91 3.75a

Compared with the healthy side upper limb circumference of the same parts in the same group, P < 0.05.

Table 3 Comparison of circumference of the affected limbs of patients with lymphedema after breast cancer surgery in the two groups between the pre-treatment and post-treatment (Mean ± SD, cm). Groups

Cases Time point

Wrist crease

Sliding-cupping group CDT group

30

17.45 16.55 17.38 16.78

a b

30

Pre-treatment Post-treatment Pre-treatment Post-treatment

± ± ± ±

1.80 1.31 2.30 1.69

Cubital crease 27.95 26.02 27.56 26.11

± ± ± ±

3.00 2.42a 3.33 2.71

5 cm above olecranon 10 cm above olecranon 5 cm below olecranon 10 cm below olecranon 30.80 28.43 30.16 28.88

± ± ± ±

Upper limb

5 cm above olecranon

10 cm above olecranon

5 cm below olecranon

10 cm below olecranon

Healthy side Affected side

6.38 ± 2.07 11.90 ± 3.56a

6.96 ± 1.72 11.84 ± 3.27a

4.83 ± 1.40 9.12 ± 1.84a

4.82 ± 1.73 8.70 ± 1.78a

Compared with the same part of the healthy side, P < 0.05.

Table 5 Comparison of full skin layer thickness at different parts of 15 patients with moderate to severe edema in the sliding-cupping group between healthy and affected side (Mean ± SD, mm). Upper limb

5 cm above olecranon

10 cm above olecranon

5 cm below olecranon

10 cm below olecranon

Healthy side Affected side

1.20 ± 0.19 2.22 ± 0.54a

1.21 ± 0.24 2.13 ± 0.48a

1.22 ± 0.24 1.93 ± 0.44a

1.11 ± 0.19 1.87 ± 0.23a

a

32.17 30.05 31.50 29.23

± ± ± ±

2.96 2.8a 3.25 3.03b

28.12 26.46 27.76 26.30

± ± ± ±

3.70 3.11 3.43 2.90

26.35 24.98 25.69 24.27

± ± ± ±

3.78 2.78 3.75 3.21

Compared with the same part in the same group before treatment, P < 0.05. Compared with the same part in the sliding-cupping group at the same time point, P < 0.05.

Table 4 Comparison of subcutaneous tissue thickness at different parts of 15 patients with moderate to severe edema in the sliding-cupping group between healthy and affected side (Mean ± SD, mm).

a

3.38 3.13a 3.47 3.50

Compared with the same part of the healthy side, P < 0.05.

(all P < 0.05). After treatment, the circumference at 10 cm above olecranon on the affected limb in the sliding-cupping group was longer than the CDT group, and the difference was statistically significant (P < 0.05). See Table 3 for details. (3) Thickness comparison between the healthy side and the affected side of the subcutaneous tissue and full skin layer at different parts of 15 patients with moderate to severe edema in the sliding-cupping group There were 15 cases of patients with moderate to severe edema in the sliding-cupping group. There were statistical differences in the subcutaneous tissue thicknesses at 5 cm above olecranon, 10 cm above olecranon 5 cm below olecranon, and 10 cm below olecranon between the healthy side and the affected side (all P < 0.05), see Table 4. There were statistical differences in the full skin layer thicknesses at 5 cm above olecranon, 10 cm above olecranon, 5 cm below olecranon, and 10 cm below olecranon between the healthy side and the affected side (all P < 0.05), see Table 5. (4) Thickness comparison of subcutaneous tissue and full skin layer in 15 patients with moderate to severe edema in the sliding-cupping group between pre-treatment and posttreatment

In the sliding-cupping group, there was statistically significant difference in subcutaneous tissue thickness and full skin layer thickness at 5 cm above olecranon, 10 cm above olecranon 5 cm below olecranon and 10 cm below olecranon on the affected limbs of the 15 patients with moderate to severe edema between pretreatment and post-treatment (all P < 0.05), see Tables 6 and 7. (5) Comparison of clinical effects of the patients with lymphedema after breast cancer surgery between the two groups In the sliding-cupping group, 7 cases were markedly effective, 19 cases were effective, and 4 cases were ineffective, the total effective rate was 86.6%. In the CDT group, 2 cases were markedly effective, 19 cases were effective, and 6 cases were ineffective. The total effective rate was 80.0%. The effective rate of the slidingcupping group was higher than that of the CDT group, but there was no significant difference in the efficacy between the two groups (P > 0.05). See Table 8. Discussion Lymphedema after breast cancer surgery is an independent predictor of the decline in life quality for patients with breast cancer, causing great pain to patients. At present, there is no completely unified standard for the diagnosis, treatment and efficacy assessment etc. of lymphedema after breast cancer surgery in China and abroad. The International Society of Lymphology divides upper extremity edema into 4 periods [5]. This period dividing is suitable for primary lymphedema and secondary lymphedema, but the boundaries between the periods are not clear and do not reflect the severity of edema in the same period. The current diagnosis and evaluation methods for lymphedema include circumference measurement, volumetric exchange method, infrared photoelectric sensor (Perometer), bioimpedance spectroscopy (BIS), etc., and CT and MRI [7] and color Doppler ultrasound, lymphangiography for local tissue detection and other methods can also be used. Each method has its own advantages and disadvantages, such as volumetric exchange method can more accurately reflect the degree of limb swelling, but the operation process is relatively complicated, and tends to aggravate infections of the limbs with local skin damage, and therefore, it has not been widely used in clinical practice. The circumference measurement method determines the edema and its degree by comparing the circumferences of the same parts between the affected side and the healthy side. It is

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Table 6 Comparison of the thickness of subcutaneous tissue layer in 15 patients with moderate to severe edema in the sliding-cupping group before and after treatment (Mean ± SD, mm). Cases

Time point

5 cm above olecranon

10 cm above olecranon

5 cm below olecranon

10 cm below olecranon

15

Pre-treatment Post-treatment

11.90 ± 3.56 8.71 ± 2.83a

11.84 ± 3.27 8.53 ± 2.43a

9.12 ± 1.84 6.46 ± 1.38

8.70 ± 1.78 7.25 ± 1.39

a

a

Compared with the same part pre-treatment, P < 0.05.

Table 7 Comparison of the full skin layer thickness in 15 patients with moderate to severe edema in the sliding-cupping group before and after treatment (Mean ± SD, mm). Cases

Time point

5 cm above olecranon

10 cm above olecranon

5 cm below olecranon

10 cm below olecranon

15

Pre-treatment Post-treatment

2.22 ± 0.54 2.00 ± 0.37

2.13 ± 0.48 1.92 ± 0.36

1.93 ± 0.44 1.79 ± 0.40

1.87 ± 0.23 1.61 ± 0.17a

a

Compared with the same part pre-treatment, P < 0.05.

Table 8 Comparison of clinical efficacy of the patients with lymphedema after breast cancer surgery between the two groups(cases). Groups

Cases

Markedly effective

Effective

Ineffective

Total effective rate (%)

Sliding-cupping group CDT group

30 30

7 2

19 22

4 6

86.6 80.0

generally believed that a 2 cm increase in the same part circumference of the affected limb compared with the healthy limb can be diagnosed as lymphedema [8]. This method is objective and simple, but the circumference measurement method has differences in the selection of limb measurement points. It is reported from the literature that 10 cm above and below the olecranon are selected as measurement points, and one position for each of the forearm and upper arm is used as the measurement point, and it cannot comprehensively reflects the degree of limb edema, and the body shape, bones, development and other aspects of the foreign women are very different from Chinese women. Based on this, the study added the measurement points. Six total positions including wrist creases, cubital creases, 5 cm above the olecranon, 10 cm above the olecranon 5 cm below the olecranon, and 10 cm below the olecranon were selected as the measurement points, involving the upper arm, forearm, wrist joint, elbow joint and other parts, and the assessment and control of the overall affected limb edema were more comprehensive and specific. It was demonstrated from this study that lymphedema after breast cancer was not a simple edema of upper arm or forearm, and when the condition developed to a certain extent, the entire affected limb edema would appear. At present, there are many clinical reports on the treatment of lymphedema after breast cancer surgery, and the treatment methods are different. There is no unified treatment specification and consensus in China and abroad. The treatment of lymphedema in modern medicine is mainly divided into conservative therapy and surgical therapy. With the development of microsurgery, the lymphatic venous anastomosis and other surgical operation were used to treat lymphedema in some countries, and the clinical efficacies are quite different [9], and the curative effect is related to the surgical procedure, the level of surgery and the degree of edema etc. The functions of lymphatic vessels lymphedema patients at progressive stage are degenerated. It is agreed in China and abroad that surgery is ineffective for progressive-type lymphedema, and the cost of surgical treatment is high, the trauma is large, the complications are numerous, the long-term curative effect is poor, and meanwhile, it requires high-precision surgical techniques and operations, and the patient acceptance is low, and therefore, its clinical application was greatly limited. Conservative treatment is nonsurgical treatment, mainly including drug treatment and physical therapy. The drug treatment from the earliest diuretics to later

coumarin-type drugs, as well as the drugs that are still used in recent years, such as diosmin [10], and interferon [11] etc. can all relieve edema to a certain extent. However, the drug treatment works slowly, needs to take medication for a long time, and has certain side effects, and therefore, it is only selected to use as an auxiliary means in clinical treatment. With the traditional Chinese medicine understanding lymphatic edema after breast cancer surgery gradually deepens, Chinese herbal decoction has achieved certain curative effect in the treatment of lymphedema [12], however, doctors from various regions have some differences in the syndrome differentiation in traditional Chinese medicine of lymphedema, and there is no consensus on the rationale for the use of therapeutic medication, which limits the clinical application of traditional Chinese medicine. Physical therapy includes manual massage, functional exercise, limb air pressure therapy device, acupuncture [13], moxibustion, etc. The therapeutic effect has been recognized by clinicians and patients, and they currently tend to be combined to increase curative efficacy. At present, western medicine uses complex decongestion therapy (CDT) to treat lymphedema. CDT includes 4 steps including skin care, manual lymphatic drainage (MLD), short-stretch elastic bandage compression wrapping and rehabilitation exercise [14], and among them, manual lymphatic drainage is the most basic and important component. The manual lymphatic drainage is based on the structural features of the lymphatic system. It gently massages the skin along a certain direction, and pulls the anchoring filament of the lymph capillary by massage to promote the entry of macromolecules such as proteins into the lymph capillary, and moreover, it stimulates smooth muscle cells in the lymph capillary wall by means of manipulation to promote its contraction and expansion, and accelerate lymph return. This kind of lymphatic drainage method is quite different from the traditional Chinese medicine massage method. It needs to be trained by foreign professional institutions. Our department introduced this technology in 2018, and the therapist obtained the qualification of international lymphedema therapist. However, this kind of treatment requires professional lymphedema therapist to operate, and very few medical institutions in China have mastered this technology. In the CDT group, after the manual lymph drainage for the affected limb, it was wrapped by the short-stretched elastic bandage, and then appropriate mild domestic exercise was performed. After one course of treatment, the results showed that the CDT had a

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Fig. 1. Comparison of the edema degrees in the affected limb of a patient in the sliding-cupping group before and after treatment sliding-cupping group.

certain effect, which were basically the same as the results reported in foreign literature. Ancient books have no clear disease name for upper extremity edema after breast cancer surgery. According to their symptoms and signs, they can be classified as edema. If the limb has a cordlike hard object with pain, it belongs to the category of “pulse bì”. In 3rd century (Jin Dynasty), Wang Shu-he’s Mài J¯ıng (The Pulse Classic) contains the words “the overflow is water, and the retention is expansion”, indicating that the edema is caused by inhibited water flow and retention. In addition, during the operation, the arteries and veins are damaged, the operation consumes qi and blood, it makes the one in deficiency more deficiency, and what is in excess more excessive. The blood out of vessel accumulates inside, and cause edema. Xuèzhèng Lùn (Treatise on Blood Syndromes) mentioned: “If the blood is accumulated for a long time, it can also lead to edema caused by fatigued water,” indicating that upper extremity edema is inseparable from blood stasis. Blood stasis and edema are related to each other, and the two are reciprocal causation with one as blood and the other as fluid, and fluids and blood are from the same source in essence debilitation of water and grain. The blood stasis cause poor water flow, and then the blood flow is blocked, and the two interact, and therefore the edema is formed. As a traditional medicine therapy in China, the sliding-cupping has the effect of invigorating blood and dissolving stasis, and dredging the meridians and unblocking the collaterals. They are developed on the basis of ancient slidingcupping therapy, and they are widely used in parts of large areas and thick muscles such as shoulder and back diseases [15–16]. The manual lymphatic drainage in CDT therapy must be drained in a specific direction. In this particular direction, there is a medical term of drainage divide. The drainage divide has no clear anatomical positioning like the meridians and collaterals in traditional Chinese medicine. In this study, the sliding-cupping group used the sliding-cupping along meridian therapy for the affected limb, and the sliding-cupping was applied along the three yin meridians and three yang meridians on the hand of the affected-side upper limbs. The sliding-cupping along the lymphatic channel in the axilla was

interrupted because of surgical injury. For each meridian and collateral, when the sliding-cupping moved to the proximal shoulder joint, it continued to move to the shoulders and back, promoting to constructing the collateral branches of lymphatic vessels in the shoulder and back. In addition, a certain amount of negative pressure generated during sliding-cupping, pulling the anchoring filament at the end of the lymph capillary to open and close, prompting the liquid to enter the lymphatic vessel, and finally promoting lymphatic return, and the clinical effect was better (see Fig. 1). In the sliding-cupping group, the results showed that the differences in pre-treatment and post-treatment circumferences at the wrist crease, 5 cm below olecranon, and 10 cm below the olecranon of the affected limbs was not statistically significant, and indicating that there was no obvious regression after the treatment of the forearm edema. The differences in pre-treatment and posttreatment circumferences at the cubital crease, 5 cm above olecranon, and 10 cm above the olecranon of the affected limbs was statistically significant, and indicating that the upper arm was obviously improved after treatment of the edema. In the CDT group, only the difference in the circumference at 10 cm above the olecranon was statistically significant, indicating that the sliding-cupping group was better than the CDT group, and the total effective rate of treatment of 86.6% was higher than the CDT group with 80%. However, there was no statistically significant difference in the total effective rate between the two groups, and it was considered that these results were related to sample size of inclusion and treatment course. In addition, the study also conducted a statistical analysis of the subcutaneous tissue thickness and full skin layer thickness and of the affected limbs for 15 patients with moderate to severe edema in sliding-cupping group, and the results showed that the subcutaneous tissue thickness and full skin layer thickness of the affected limbs were significantly thicker than the healthy side for patients with moderate to severe edema before treatment. After treatment, the thickness of 5 cm above olecranon, and subcutaneous tissue layer at 10 cm above the olecranon, and full skin layer at 10 cm below the olecranon was thinner, indicating that the sliding-cupping therapy can reduce the thickness of the full skin

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layer and subcutaneous tissue layer to a certain extent, and it was considered that the sample size was small, and further research was needed. Because the wrist crease and cubital crease were located at the place of joint motion, and the thicknesses of the subcutaneous tissue layers in these two parts were obviously thinner than other parts, and therefore, the two parts were not measured during the color Doppler ultrasound measurement. The CDT group had little change in the circumference of each measurement point before and after treatment, and it was considered that there were not statistically significant differences in the thicknesses of the full skin layer and subcutaneous tissue layer before treatment and after treatment with color Doppler ultrasound measurement, and therefore, the two parts were not measured. The diagnosis and treatment strategy of lymphedema after breast cancer surgery should be based on prevention. Early postoperative functional exercise and prevention education are extremely important. Once edema occurs, the majority of patients can only temporarily relieve symptoms after treatment. The edema is easy to recur and difficult to be complete cured. The manual lymphatic drainage requires professional lymphedema therapist to operate, and is highly professional. This study has used sliding-cupping along meridian to treat lymphedema. The results show that this therapy can obtain the effect of manual lymphatic drainage. This study has used traditional glass fire cupping for sliding-cupping treatment. The manipulation required to repeat the practice and to master certain skills. Different size of fire cups were selected according to the degree of swelling in the affected limbs, and the diameter of the opening of the cup should be within 3 cm, and if the opening was too large, it was easy to leak gas and fall off the cup. The negative pressure of the sliding-cupping should not be too high. If the negative pressure was too high, there would be pain and it might even cause local skin damage. It should be based on the tolerance of the patients, and stop when the skin was reddish and there were slightly spots of rash. After the end of slidingcupping, the skin was observed to examine if there was damage and bleeding, etc. In the course of the manipulation, we considered whether we can do some improvements. We intended to invent a sliding-cupping device that was suitable for limb lymphedema, and it was able to manually generate negative pressure and control the magnitude of negative pressure to a certain extent. Finally

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