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Original Article 
Short-Term Effects Of Dry Heat Treatment 
(Fluidotherapy) In The Management Of Breast 
Cancer Related Lymphedema: A Randomized 
Controlled Study 
Burcu Duyur Çakıt, 1 Seçil Pervane Vural 2 
Abstract 
In this study, we aimed to investigate whether fluidotherapy added to complete decongestive therapy (CDT) 
would provide additional contribution to edema reduction in patients with breast cancer-related lymphedema 
(BCRL). CDT alone and CDT + fluidotherapy in combined manner performed daily for 3 weeks. Fluidotherapy 
added to CDT treatment provided more improvement in pain and edema severity compared to standard CDT in 
BCRL patients without any side effects. 
Background: To investigate whether fluidotherapy added to complete decongestive therapy (CDT) would provide 
additional contribution to edema reduction in patients with breast cancer related lymphedema (BCRL). Material and 
Methods: Thir thy-t wo patients with unilateral BCRL were randomly divided into 2 groups: standard treatment with 
CDT only (Group 1) and CDT + fluidotherapy (Group 2). All patients underwent phase 1 CDT, which included manual 
lymphatic drainage, multilayer bandaging, supervised exercises and skin care for a total of 15 sessions, 5 times a week 
for 3 weeks. Only Group 2 received a total of 15 sessions application of fluidotherapy. Before and after CDT, patients 
were evaluated for extremity volumes and excess volumes, according to circumferencial measurements of the extrem- 
ity. Arm pain was evaluated with Visual Analaogue Scale (VAS-Pain). Results: Seventeen patients in Group 1 and 15 
patients in Group 2 completed the study. Patients’ demographic data and volume measurements were similar at the 
beginning of the treatment. Limb volumes of both groups were significantly reduced after treatment ( Pmonths had
passed since the follow-up patients last received CDT. Patients had
either breast-conserving surgery or mastectomy. Written informed
consent was obtained from all patients and ethical approval was
obtained from the local ethics committee before the study. The
procedures followed were in accordance with the ethical standards
Clinical Breast Cancer July 2024
of the national human experimentation committee and the princi-
ples of the Helsinki Declaration of 1975, revised in 2008. Forty-five
volunteer female patients who developed stage 2-3 upper extrem-
ity lymphedema after breast cancer treatment were included in
the study. Inclusion criteria were unilateral lymphedema following
breast cancer treatment and a volume difference of more than 10%
or a circumference difference of more than 2 cm between the 2 arms.
Patients with the following characteristics were excluded: bilateral
breast cancer, bilateral lymphedema, distant metastases, acute deep
vein thrombosis, clinical or radiographic evidence of cancer, extrem-
ity too large to be placed in the curing cabinet. Five patients did
not meet the inclusion criteria. Using a random number table, 40
patients in the study were randomly divided into 2 groups: standard
treatment with CDT only (Group 1) and CDT + fluidotherapy
(Group 2). During the treatment of lymphedema, active infection
was detected in 3 patients, 3 patients were dropped out due to social
problems and 2 patients were dropped out for unknown reasons.
Therefore, 8 patients were excluded from the analysis. As a result, a
total of 32 patients were included in the final analysis ( Figure 1 ). 
Measurements 
The presence of lymphedema was assessed by inter-limb volume
difference ( > 10%) based on the serial circumferential measurements
in both affected and nonaffected extremities or a circumference
difference of more than 2 cm between the 2 arms. 19 During the
circumferential measurements, patients sat straight on a chair with
their arms relaxed by their sides and elbows straight. Measurements
were made in both arms at the beginning and at the end of the
3-week treatment. Circumferential measurements were performed
by a standard 1-inch retractable tape, starting at the level of ulnar
styloid, at 4 cm intervals along the arms and converted to an approx-
imate arm volume to enable estimation of volume. 20 , 21 Extrem-
ity volumes were calculated using the truncated cone formula. The
excess percentage limb volume was expressed in a percentage reduc-
tion in edema of the affected limb, which was calculated using
standard methods. Excess limb volume represented the difference
between both limbs and was expressed in mL. 21 
Each patient was assessed by a single researcher who was blinded
to the group allocation. 
The stages of lymphedema are determined according to Interna-
tional Society of Lymphology (ISL). 19 ISL staging ranges from 0 to
3 and involves 2 criteria: the “softness” or “firmness” of the limb
(reflecting fibrotic soft tissue changes) and the outcome after eleva-
tion. Within stages 1 through 3, severity based upon volume differ-
ences is determined as mild ( 40%). 
Patients were asked to report their ’average pain intensity in their
affected arm over the previous week by using Visual Analog Scale
(VAS-Pain) in which 0 indicates no pain, 10 indicates the worst
pain. 
Complete Decongestive Therapy 
All patients were included in the intensive phase of the CDT
protocol consisting of MLD, short stretch multilayer bandage,
skin care and lymphedema exercises. Patients received a total of
15 sessions of treatment 5 days a week for 3 weeks. First, MLD
Burcu Duyur Çakıt, Seçil Pervane Vural
Figure 1 Flowchart of the study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
was applied by the same physiotherapist according to the Vodder
technique for 45-60 minutes. After MLD, a nonelastic, short-
stretch, multilayer bandaging treatment was applied by the same
experienced physiotherapist. Multilayer compression bandages were
applied with the highest pressure to the distal regions and gradu-
ally decreasing the pressure towards the proximal regions. 22 After
bandaging, all patients underwent a 15-minute individualized active
exercise program under the supervision of the same physiothera-
pist. Exercises included neck and shoulder stretching, abdominal
breathing exercise and strengthening of the arm muscles to facilitate
lymphatic flow, increase strength, and range of motion. 23 Patients
were asked to keep the compression bandage on the arm for 22-23
hours a day. 
Fluidotherapy Application 
Before the application, the patient washed her upper extremities
and removed all jewelry. The patient was then positioned so that the
area to be treated was comfortable and relaxed. The affected limb
placed inside the sheath and closed tightly around the proximal arm
( Figure 2 ). Only the subjects Group 2 received a total of 15 sessions
(5 sessions per week) application of fluidotherapy device (Fizyoflug
by Fizyomed) which was used for fluidotherapy at a temperature
of 42 °C for 20 minutes in continuous mode before the CDT
program. 
Volumetric mesasurements and VAS-Pain evaluation were done
before CDT and end of the 15 treatment sessions. 
Statistical Analysis 
Statistical analysis was performed using the IBM SPSS version
22.0 software (IBM Corp., Armonk, NY, USA). Descriptive data
were presented in mean ± standard deviation (SD) or median
(min-max) for continuous variables or in number and percentage
for categorical variables. The chi-square or Fisher’s exact tests were
used for the difference of categorical variables between the groups.
The Kolmogorov-Smirnov and Levene’s tests were used to indicate
normal distribution and homogeneity of the variance, respec-
Clinical Breast Cancer July 2024 441
Term Effects Of Dry Heat Treatment (Fluidotherapy) In The Management
Figure 2 Application of fluidotherapy. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
442
tively. The differences between numerical variables of 2 indepen-
dent groups were assessed by the independent samples t-test or
MannWhitney U test. The Wilcoxon test was carried out to assess
differences between before and after treatment. A P value of value of
 .05). 
Lymphedema stages, disease duration, type of surgery, adjunctive
therapies, lymphedema volumes, and pretreatment pain levels were
similar in both groups ( P > .05). 
Limb volumes of both groups were significantly reduced after
treatment ( Pwe can say that fluidotherapy
added to CDT treatment provided more improvement in pain and
edema severity compared to standard CDT in BCRL patients. To
the best of our knowledge, this is the first study in which fluidother-
apy was used in addition to CDT in patients with BCRL. No
worsening of lymphedema volume or side effects were detected in
any of the patients. We observed that the addition of fluidother-
apy, which can be easily applied to the upper extremity, to CDT in
BCRL patients may provide additional benefit in pain and volume
reduction. 
Heat is a powerful therapeutic agent. It increases blood flow,
increases heart rate, reduces blood pressure, sedates, and provokes
healing by accelerating biochemical reactions. There are studies
using microwave as a thermotherapy modality in lymphedema. One
of them is the study by Gan et al. 11 In 40 of 45 postmastectomy
lymphedema patients, they found significant reduction in periph-
eral edema and secondary acute erysipelas attacks after microwave
therapy. They also reported improvement in skin elasticity. 11 One
of the largest and oldest studies investigating heat therapies for
lymphedema is the study by Liu et al. 24 In this study, microwave
and hot water immersion methods were used as heat modalities.
Skin biopsies were performed before and after treatment in patients
with lower extremity lymphedema and lymphoscintigraphy was also
performed to evaluate lymphatic flow. At the end of the study, they
found a decrease in limb circumference and volume, but no change
Burcu Duyur Çakıt, Seçil Pervane Vural
Table 1 The Demographic and Clinical Characteristics in Both Patient Groups 
Group 1 
CDT 
N = 17 
Group 2 
CDT + Fluidoterapy 
N = 15 
P 
Age (year) 59.23 ± 11.86 61.92 ± 12.41 > .05 
BMI (kg/m2 ) 29.33 ± 3.67 28.96 ± 9.54 > .05 
Type of surgery n(%) > .05 
Mastectomy 
Lumpectomy 
11 (64.7) 
6 (35.3) 
10 (66.6) 
5 (33.4) 
Adjunctive Therapies n(%) > .05 
Chemotherapy 
Radiotherapy 
Hormonal therapy 
12 (70.5) 
10 (58.8) 
14 (82.3) 
10 (66.6) 
9 (60) 
13 (86.6) 
Type of lymphedema n(%) > .05 
Subclinic 
Reversible 
Spontaneous Irreversible 
0 
4(23.5) 
13(76.4) 
0 
3(20) 
12(80) 
Elephantiasis 0 0 
Stage of lymphedema > .05 
1 Mild 
2 Moderate 
3 Severe 
3(17.6) 
13(76.4) 
1(5.8) 
2(13.3) 
12(80) 
1(6.6) 
Lymphedema disease duration (months) 17.47 ± 14.51 17.68 ± 14.53 > .05 
Lymphedema excess volume before 
treatment (ml) 
3245.11 ± 826.34 3190.61 ± 812.90 > .05 
Lymphedema excess percentage volume 
before treatment (%) 
33.88 ± 28.31 39.69 ± 25.77 > .05 
VAS-Pain before treatment 5.41 ±1.76 5.23 ± 1.64 > .05 
VAS = Visual Analogue Scale, CDT = Complete decongestive therapy, BMI = Body mass index. 
Table 2 The Extremity Volumes, VAS-Pain Mean Values After Treatment and the Mean Change in Volume in Both Patient Groups 
Measurements and VAS-Pain Score Before and After Treatment 
Group 1 
CDT 
N = 17 
Group 2 
CDT + Fluidoterapy 
N = 15 
P 
1 P 
2 P 
3 
Lymphedema excess volume after treatment 2801.17 ± 831.37 2525.61 ± 709.12 > .05 .0001 .001 
Lymphedema excess volume change 443.94 ± 235.62 665.00 ± 238.47 .028 
Lymphedema excess percentage volume after 
treatment 
21.80 ± 20.29 19.65 ± 19.97 > .05 .0001 .001 
Lymphedema excess percentage volume change 12.07 ± 9.95 20.03 ± 7.93 .001 
VAS-Pain after treatment 3.29 ± 1.79 1.84 ± 0.68 .039 .001 .001 
VAS-Pain change 2.11 ± 1.26 3.38 ± 1.26 .020 
P 1 : intergroup difference after treatment. 
P 2 : Group 1 P values before and after treatment. 
P 3 : Group 2 P values before and after treatment. 
VAS = Visual Analogue Scale, CDT = Complete decongestive therapy. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
in lymphatic flow evaluated by lymphoscintigraphy. Changes in skin
biopsies were similar in microwave and hot water immersion groups.
They showed that the most striking histopathologic changes after
hyperthermic treatment were reduction of perivascular cell infiltra-
tion, disappearance of free fluids (lymphatic lakes) in the tissues and
dilatation of blood capillaries in the subcutis. Microwave derives
from oscillating free charges or ions, rotating polar molecules, and
the quantum effect of excitation of molecules in the living system.
They hypothesized that these effects may alter large molecules and
make it easier for them to be mobilized or produce internal macro-
molecular rearrangement with denaturation and breakup. With
heat, increased capillary infiltration of liquid may be greater than
that of protein with an overall decrease in viscosity of tissue fluid. As
a result, the polarized fragments of macromolecules and other wastes
Clinical Breast Cancer July 2024 443
Term Effects Of Dry Heat Treatment (Fluidotherapy) In The Management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
444
may more easily be transported into blood capilleries. They hypoth-
esized that regional heating causes an altered immune response,
changes in extracellular matrix protein composition, and greater
elasticity of tissues leading to reduced edema. 24 In our study, we
found that BCRL patients benefited more from heat therapy added
to CDT than CDT alone. We think that the addition of heat thera-
pies to CDT may potentialize the effects of CDT. Our results, in
accordance with the literature, suggest that increased perfusion in
tissues with the effect of heat does not increase lymphatic load, on
the contrary, it may decrease it. 
Based on these theories, we suggest that fluidotherapy may
similarly stimulate ion release by creating vibrational effects, which
may lead to denaturation of macromolecules and degradation of
proteins. Then, smaller pieces of macromolecules can be easily
absorbed by tissues. This effect may provide an inflammation-
reducing effect in the treatment of lymphedema, which in-turn may
reduce the severity of lymphedema. However, further histopatho-
logic studies are needed to prove these theories. 
Fluidotherapy is a heat modality consisting of finely divided
solid particles suspended in a heated air providing a dry whirlpool
system. Borrell et al. reported that hand fluidotherapy treatment
at 46.2 °C resulted in a 6-fold increase in blood flow and a 4-fold
increase in metabolic rates (measured by oxygen uptake) in a healthy
young man. In their study, they compared the effect of fluidother-
apy with other superficial heat modalities using in vivo temperature
measurements. The greatest temperature increase was obtained with
fluidotherapy (9 °C and 5.7 °C) compared with articular capsule
and muscle temperature paraffin (7.5 °C and 4.5 °C) and hydrother-
apy (6 °C and 4.3 °C), respectively. Dry whirlpool (fluidotherapy)
provides much more heat than paraffin or hydrotherapy because
higher temperatures can be tolerated in a dry environment. Data
from the Borrell et al. study shows that surface heating methods
are much more effective at generating high temperatures than ultra-
sound therapy or diathermy at depths of up to 1.2 cm. 25 In the light
of these informations, we chose fluidotherapy as a heat modality
in BCRL patients because we think that it may be more effective in
increasing blood flow and raising hand temperature in the treatment
of lymphedema in the skin-subcutaneous area. We found that it is
effective in the treatment of edema and pain when added to CDT
in the treatment of BCRL. Patient compliance was very good and
ease of use was among the advantages of fluidotherapy. 
Fluidotherapy not only increases tissue temperature but also
provides tactile stimulus to the treated extremity. Thanks to this
tactile stimulus, according to Melzack and Wall’s gate control
theory, activation of large diameter cutaneous afferent nerve fibers
by bombardment with synthetic cellulose fragments canreduce
pain transmission to the brain. 26 Cellulose particles, which form
a fluidized bed, are circulated around the extremities by hot air.
Fluidotherapy provides 3 times more heat transfer than copper bars
and heats muscle tissue 20%-50% more than warm water or wax
baths. Patients’ tolerance of high temperatures in a fluidized bed
(fluidotherapy) may be due to convective air movement and the
high thermal conductivity of cellulose particles. Increased temper-
ature tolerance occurs because cellulose particles over-stimulate skin
thermoreceptors and mechanoreceptors, reducing pain sensitivity.
Clinical Breast Cancer July 2024
Moreover dry heat reduces thermal irritation at high tempera-
tures. 27 In our study, BCRL patients tolerated the high tempera-
tures provided by fluidotherapy very well. When this dry heat was
applied in addition to CDT treatment, BCRL patients experienced
a decrease in limb volume rather than an increase in limb volume.
Contrary to popular belief, we think that the increase in venous
return by heat effect may not increase the lymphatic load; on the
contrary, the increase in venous return may decrease the lymphatic
load. 
Özcan et al. used fluidotherapy in patients with subacute
poststroke complex regional pain syndrome. A total of 15 sessions,
40 °C 20 minutes in continuous mode, were used in addition to the
conventional rehabilitation program. They evaluated limb volumes
using a water displacement method. They reported a more signif-
icant decrease in limb volumes in the group receiving fludother-
apy compared to the group receiving only conventional treatment. 18
In a similar study, Han et al. evaluated the effect of fluidotherapy
on activities of daily living, dexterity and edema in stroke patients.
They reported that fluidotherapy causes a decrease in edema and this
decrease can contribute to activities of daily living. 17 Neurogenic
inflammation, nociceptive sensitization, vasomotor dysfunction has
been blamed as the cause of edema in complex regional pain, but the
pathophysiology has not been fully elucidated. 28 Lymphatic stasis
and edema may also be seen in CRPS due to disuse, primary pathol-
ogy, or surgery for primary pathology. Therefore, the beneficial
effects of fluidotherapy on CPRS edema made us think that it may
produce similar improvement in lymphedema. In addition, the case
report showing that MLD, the main component of CBT, is benefi-
cial in the treatment of edema of the hand and upper extremity
complex regional pain syndrome 29 and the benefit of post-traumatic
edema from MLD 
30 and fluidotherapy 31 suggest that similar treat-
ments can be used in treatment and fluidotherapy may be beneficial
in both edema. We used the dose and duration of fluidotherapy
at the doses and durations used in the CPRS studies and obtained
positive results in BCRL patients. 
Another treatment that has been tried in BCRL patients is far-
infrared ray (FIR) therapy. It has been reported that FIR poten-
tially reduces extremity fluid volume and extremity diameter, and
also reduces dermatolymphangitis attacks. There were no differ-
ences in cancer recurrence rates or tumor markers when BCRL
patients who received FIR treatment were compared to controls
after 1 year. Furthermore, the in vitro experiment indicated that
FIR radiation does not affect viability, proliferation, cell cycle, and
apoptosis of fibroblasts, human breast adenocarcinoma cells. 32 The
conclusion we may draw from these studies is that heat treatments
are oncologically safe, do not worsen lymphedema, on the contrary,
they can reduce edema and make an additional contribution to
CDT. Today, when lymphedema treatments do not provide a cure
and medical and surgical modalities are insufficient, we think that
thermal treatments may be promising modalities, and especially the
use of fluidotherapy in this field may have the potential to make
an additional contribution to neuropathic pain. We believe that it
may provide significant clinical benefits, especially in patients with
neuropathic complaints who cannot tolerate multilayer bandages
and compression garments during CDT. 
Burcu Duyur Çakıt, Seçil Pervane Vural
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Limitations 
The main limitations of this study were the small number of the
study group and the lack of long-term follow-up. We evaluated the
patients before and after the 3-week CDT program, and we could
not follow the patients due to the Covid 19 pandemic. Another
important limitation was that majority of the patients had moder-
ate (stage 2) lymphedema. Because we could not include extremi-
ties that were too large to be placed in the cure cabin. So we could
not generalize the outcome of our study to patients with all stage
lymphedema. We also could not apply sham-fluidotherapy to the
control group. Other limitations were the lack of an objective upper
extremity function assessment method and ultrasonographic skin-
subcutis measurements. 
Conclusion 
Fluidotheray added to CDT reduced pain and edema severity
more than standard CDT in the patients with BCRL. As a noninva-
sive, novel, and effective method, fluidotherapy may be promising
treatment modality for the treatment of lymphedema. Therefore,
thermotherapy modalities should not be considered contraindicated
in the treatment of lymphedema and may have additional benefits
with promising results. Further larger randomized controlled trials
with long follow-up are needed to demonstrate the effects of
fluidotherapy. 
Clinical Practice Points 
International guidelines recommend that patients with
lymphedema take certain precautions to prevent treatment
symptoms and complications. One of these precautions is to
avoid temperature changes. It was believed that warming the
extremity would increase venous return and increase lymphatic
load. However, studies have reported improvement rather than
increase in lymphedema with heat therapies, such as microwave,
FIR, hot blanket, therapeutic ultrasound. Fludotherapy is a dry heat
modality. It has been used in the of CRPS and has been reported to
be beneficial in edema. In the light of this information, we applied
it to our patients in addition to CDT treatment in BCRL patients.
Compared to CDT treatment alone, the reduce in extremity
volumes and pain of patients receiving CDT + Fluidotherapy
was more significant. There was no increase in lymphedema or
side effects. To our knowledge, our study is the first in which
fluidotherapy was applied to BCRL patients. As a noninvasive,
novel, and effective method, fluidotherapy may be promising
treatment modality for the treatment of lymphedema. Therefore,
thermotherapy modalities should not be considered contraindicated
in the treatment of lymphedema and may have additional benefits
with promising results. 
Funding 
This research did not receive any specific grant from funding
agencies in the public, commercial or not-for-profit sectors. 
Disclosure 
No competing financial interest exists. 
CRediT authorship contribution 
statement 
Burcu Duyur Çakıt: Writing – review & editing, Methodology,
Investigation, Formal analysis, Data curation, Conceptualization.
Seçil Pervane Vural: Writing – original draft, Project administra-
tion, Methodology, Investigation. 
Acknowledgments 
None. 
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https://doi.org/10.1016/j.wem.2015.02.005
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	Short-Term Effects Of Dry Heat Treatment (Fluidotherapy) In The Management Of Breast Cancer Related Lymphedema: A Randomized Controlled Study
	Introduction
	Material and Methods
	Patients
	Measurements
	Complete Decongestive Therapy
	Fluidotherapy ApplicationStatistical Analysis
	Results
	Discussion
	Limitations
	Conclusion
	Clinical Practice Points
	Funding
	Disclosure
	CRediT authorship contribution statement
	Acknowledgments
	References