COMPARISON OF MANUAL LYMPH DRAINAGE THERAPY AND

CONNECTIVE TISSUE MASSAGE IN W O M E N W I T H

FIBROMYALGIA: A RANDOMIZED CONTROLLED TRIAL

Gamze Ekici, PT, PhD,^ Yesim Bakar, PT, PhD,*" Turkan Akbayrak. PT, PhD," and Inci Yuksel, PT.

ABSTRACT

Objective: This study analyzed and compared the effects of manual lymph drainage therapy (MLDT) and connectivetissue massage (CTM) in women with primary fibromyalgia (PFM).Methods: The study design was a randomized controlled trial. Fifty women with PFM completed the study. The patientswere divided randomly into 2 groups. Whereas 25 of them received MLDT, the other 25 underwent CTM. The treatmentprogram was carried out 5 times a week for 3 weeks in eaeh group. Pain was evaluated by a visual analogue scale andalgometry. The Fibromyalgia Impact Questionnaire (FIQ) and Nottingham Health Protile were used to describe healthstatus and health-related quality of life (HRQoL). Wilcoxon signed rank test and Mann-Whitney U test were used toanalyze the data.

Results: In both groups, significant improvements were found regarding pain intensity, pain pressure threshold, andHRQoL {P<.05). However, the scores of FIQ-7 {P = .006), FIQ-9 (P = .006), and FIQ-total {P = .0\0) were significantlylower in the MLDT group than they were in the CTM group at the end of treatment.Conclusions: For this particular group of patients, both MLDT and CTM appear to yield improvements in terms ofpain, health status, and HRQoL. The results indicate that these manual therapy techniques might be used in the treatmentof PFM. However, MLDT was found to be more effective than CTM according to some subitems of FIQ (morningtiredness and anxiety) and FIQ total score. Manual lymph drainage therapy might be preferred; however, further long-term follow-up studies are needed. (J Manipulative Physio! Ther 2009;32:127-133)Key Indexing Terms: Fibromyalgia; Massage: Pain; Quality Of Life; Randomized Controlled Trial

W hen chronic pain becomes widespread(ie, involving most ofthe body), which patientscommonly attribute to originating in their

muscles, it is caWedßbmniyalgia (FM).' It is an enigmaticdisorder that is usually referred to as a syndrome in view ofthe fact that these patients often have multiple othersymptoms such as musculoskeietal aches, pain, stiffiiess,

" Assistant Professor, School oí Physical Therapy and Rehabi-litation, Ahi Evran University, Kirsehir, Turkey.

'' Assistant Professor, School of Physical Therapy and Rehabi-litation, Abant Izzet Baysal University, Bolu, Turkey.

' Associate Professor, Faculty of Health Science, Department ofPhysical Therapy and Rehabilitation, Hacettepe University, Ankara.Turkey.

Professor, Faculty of Health Science, Department of PhysicalTherapy and Rehabilitation. Hacettepe University, Ankara, Turkey.

Submit requests for reprints to: üamze Ekici. PT, PhD, AssistantProfessor, Ahi Evran Üniversitesi Fizik Tedavi ve Rehabil i tasyonYüksekokulu, Merkez Kampus, Tenne, Kirsehir, Turkiye{e-rmW: fztgamze@yahoo.com).

Paper submitted April 16, 2008; in revised form September 25,2008; accepted October 25, 2008.

0161-4754/$36.00Copyright © 2009 by National University of Health Sciences.doi: 10.1016/j.jmpt.2008.12.001

and exaggerated tenderness at specific sites.'" An abnormalautonomie nervous system may explain the multisystemsymptoms of FM.'' ' There is also mounting evidence forcentral pain processing abnormalities in almost all FMpatients.^ The perceived symptoms and disability in FM canimpact the person's activities, abilities, and .self-esteem. Tnother words, it atTects negatively every dimension of life,especially health-related quality of life (HRQoL).*-'

The lack of specific disease mechanisms is reflected in thefact that no cure has been found for the disease. Thus, themany interventions that are advocated in FM are targetedagainst the more general characteristics of pain anddisability. Current pharmacologie interventions have limitedefñcacy. There is an increasing consensus that therapyshould also include nonpharmacologic approaches.'

According to the literature about nonpharmacologictreatment approaches for FM, there are different manage-ment approaches such as exercise, electrotherapy, patienteducation,** manual therapy techniques, acupuncture, spatherapy, cognitive-behavioral therapy, and chiropracticcare. ' Nonpharmacologic treatment for patients withchronic pain aitns to enhance body functions, activity, andoverall health.'' These treatment approaches also focus ontemporary alleviation of symptoms."'^

127

1 2 8 EkicieialManual Therapy in Fibromyalgia

Manual therapy techniques are composed of a variety ofprocedures directed at the musculoskeletal structures in thetreatment of pain. Two major subcategories exist: those thatproduce joint motion and those that do not. The firstsubcategory includes manipulation, mobilization, and man-ual traction. The second subcategory involves both general-ized soft tissue therapies, such as the many types of massage,and focal son tissue therapy. '

The development of manual lymph drainage therapy(MLDT) by the Vodder method for lymph edema in cancertreatment has recently been described.'^ In this technique,the lymph vessels are gently massaged to mobilizelymphatic fluid. It stimulates the lymphatic system, helpsregulate the immune system and clears blockages, elim-inates metabolic waste and toxins from the body, andreduces excess fluid.

According to Kurz,'^ when the skin is stroked duringMLDT near the pain stimulus, touch receptors in the skinperceive this. After switching stations in the spinal cord,the impulse goes from there to the cerebrum and registersthe touch, which we then consciously perceive. However,in the spinal cord, the nerve fiber has collateral (lateralpathway) to an inhibitory cell. This inhibitory cell isconnected to the switch-cell of the pain pathway. If theinhibitory cell receives an impulse, it passes this on as aninhibition. In this technique, several neighboring touchreceptors are stroked in succession. Each of thesereceptors sends action potentials at the beginning andend of contact. Each of these action potentials causes aninhibition of the pain transmission. Therefore, withMLDT, the "stroking" can cause a reduction in pain.'"*Unfortimately, there appears to be only 1 article about theeffects of MLDT on FM. This preliminary study showedpain relief effect of MLDT."'

There are few studies about sensory treatments (such asmassage).** Connective tissue massage (CTM) is a reflextherapy that uses a shear force at connective tissue interfacesin the skin in a specific sequence. Stimulation of tbemechanoreceptors by CTM may also close the "pain gate"via pre- and postsynaptic inhibition. Moreover, it has beenfound to induce release of endogenous opiates.'''•'^ Con-nective tissue massage leads to reduced tension in theautonomie nervous system with secondary increased circula-tion, giving a sense of warmth, muscle relaxation, pain relief,and increased mobility by inducing segmental and supraseg-mental reflex.'*'""

Consequently, there is currently no recognized effectivetreatment for FM patients.""^ In addition, there are a limitednumber of studies dealing with the effect of manual therapytechniques on FM. Although there are some studies aboutMLDT'" and C T M ' " " ' in FM, there do not appear to be anystudies comparing the effects of MLDT and CTM. In thisstudy. MLDT and CTM were tised for primary fibromyalgia(PFM); these are included in the second subcategory ofmanual therapy techniques.

Journal of Manipulative and Physiological Therapeuticsl-'ebmary 2009

16Based on positive results of some studies about MLDTand CTM'"•""' in FM. this study was planned to test andcompare the effects of M LDT and CTM in women with PFMusing a randomized controlled trial.

METHODS

SubjectsThe Ethics Committee of Haeettepe University, Faculty of

Medicine, Ankara, Turkey, approved the protocol; and thestudy was conducted in accordance with the niles of theDeclaration of Helsinki. It was also registered with theclinical trial registry. Before any volunteer participated inthis study, written informed eonsent was obtained after allprocedures had been fully explained. The study began inJune 2006 and ended in October 2007.

Patients were eligible for the study if they (a) werefemale outpatients, (b) were at least 25 years or older, (c)met the criteria for PFM as defmed by the American Collegeof Rheumatology." (d) had moderate pain {>4 based onvisual analogue scale [VAS]) before the baseline visit, (e)had pain in the neck or shoulder region, (/) had never beentreated for PFM. and (g) volunteered to participate inthis study.

Exclusion criteria included the following: (a) pain fromtraumatic injury or structural or regional rheumatic disease,(b) chronic infection, (c) fever or an increased tendency tobleed, (d) severe physical impainnent, (e) signs of tendinitis.(/) eardiopulmonary disorder, (g) inflammatory arthritis orautoimmune disease, (h) uncontrolled endocrine disorder, (/)allergic disorder, (/) pregnancy or breast-feeding, (k)malignancy, or ([) unstable medical or psychiatric illnessor medication use. They were asked not to use antidepres-sants. myorelaxants, and nonsteroid anti-inflammatorydrugs during the 3 days before the first appointment andduring the treatment sessions and the evaluation processafter the treatment.

Treatment Procedure for MLDTIn this study, MLDT was applied by a trained

physiotherapist (second author), who used specialized handmovements in a range of different sequences.^^ Thetreatment was carried out as very light, completely pain-free, rhythmical translational movements of the skin in theflow direction of the lymph vessels."' The subject was in thesupine position with knees bent. The MLDT started withabdominal lymph drainage. Afterward, central lymphstimulation was performed; and neck and head manuallymph drainage was applied consecutively. Later, bystimulating bilateral axillar lymph nodes, manual lymphdrainage was applied to both the anterior and posterior sidesof the trunk. Bilateral inguinal and cervical lymph nodeswere also treated. The treatment session lasted approxi-mately 45 minutes. After MLDT, a moisturizing cream was

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129

Table I. Demographics ofthe sample (mean ± SD)

Age (y)BMÍ (kg/m-)Education (y)

MLDT group (n

38.84 ±6.3824.15 ±2.6413.32 ±3.H0

BMI indicates body mass index.• P<.05.

= 25) CTM

36.9622.3714.96

group (n =

±8.88±3.19±3.61

25) P

.395

.038*

.155

applied to decrease the tension ofthe skin. The MLDT wasapplied daily (Monday-Friday) for 3 weeks.

Treatment Procedure for Q HIn the CTM group, the treatment procedure focused on 5

different regions that were especially painful. The treatmentstarted in (a) the lumbosacral area (basic section) andprogressed to (b) the lower thoracic area, (c) the scapulararea, (d) the interscapular area, and (e) the cervicooccipitalarea,̂ "' performed by a trained physiotherapist (first author),according to the vascular response ofthe connective tissue. Itlasted 5 to 20 minutes depending on the treated area.Connective tissue massage was also applied to the back ofthe subject daily. 5 times a week (Monday-Friday), for 3weeks. During the treatment, the subject was sitting erect,with 90° flexion of the hips., knees, and ankles. The thighsand feet were fully supported. A pillow was placed on thesubject's lap for forearm support. The back was unclothedand straight for optimal tension ofthe connective tissue. Forcreating traction between the cutaneous tissues, the middlefingers of both hands were used.̂ *'

We investigated in this randomized trial firstly whethersymptoms disappeared after applying the MLDT or CTM;secondly, we compared the effects of MLDT and CTM inwomen with PFM.

• j > t •I

Measures 'All patients underwent an assessment for a diagnosis by a

physiatrist. At the first appointment, they were evaluated interms of pain intensity and pain pressure threshold (PPT)using a VAS and algometry, respectively. On the same day.they completed the demographic data sheet and the self-report questionnaires, including the Nottingham HealthProfile (NHP) and the Fibromyalgia Impact Questionnaire(FIQ). The same researcher (fourth author) repeated thequestioning and measurements after the treatment withoutknowledge of the patient group. The demographics of thesample are shown in Table 1.

Primary Outcome Measures : , ,hin ¡ntetisity. The VAS was used to measure the mean pain

intensity over the previous 3 days (average of rest andactivity). The lO-cm scale was marked with "0" (no pain)and "10" (worst imaginable pain), and the patients wereinstructed on how to use the scale.^^

Secondary Outcome MeasuresTbe PPT. The PPT was determined with a hand-held

algometry (J Tech, Salt Lake City, Utah) mounted with a 1-cnr probe and calibrated in kilopascals. The reproducibilityof pressure algometry to evaluate deep somatic tissuesensitivity has been demonstrated previously.̂ ** To assessthe PPT, the probe was held perpendicular to the skin oftheupper part of musculus trapezius bilaterally, which is one ofthe tender points used for diagnosis in FM."""** The pressurewas applied at a constant rate of 30 kPa/s. The PPT wasdefined as the pressure when the perceived sensationchanged from pressure to pain. The PPT measurementswere conducted 3 times, and the mean ofthe measurementswas calculated.̂ **

Health-Related Quality of LifeThe NHP is a widely used generic tool to measure

HRQoL. It contains 38 items divided into 6 dimensions:NHP-energy, NHP-pain. NHP-emotional reactions, NHP-sleep, NHP-social isolation, and NHP-physical mobility. Allthe parameters are summed as NHP-total. The respondentanswers "yes" if the statement adequately reflects thecurrent status or feeling, or "no" otherwise.^' Dimensionscores range from 0 (no problems) to 100 (maximumproblems). The Turkish version was administered, and ithas been shown to be valid and cross-culturally equivalentto the original.^"

Health StatusHealth status was assessed using the Turkish version of

the FIQ.^^ The FIQ is a brief lO-item self-adminisieredinstrument developed for persons with FM."''' In the revisedversion ofthe FIQ,"'*̂ the first item focuses on the patient'sability to carry out muscular activities, in the next 2 items,patients are asked to circle the number of days in the pastweek that they felt good and how often they missed work.Finally, the last 7 questions (job ability, pain, fatigue,moming tiredness, stiffness, anxiety, and depression) aremeasured by VAS. The FIQ score ranges from 0 to 100, and ahigher value indicates a higher impact ofthe disorder."'''•^^

The selection of the treatment procedure for the firstparticipant was detennined by a closed envelop including aletter. Firstly, there were 2 letters including difTerenttreatment approaches: MLDT or CTM. The researcher(third author) chose a letter that included instructions, oneof the treatment procedures and the name of the treatmentprovider. For the first selection, the third researcher did notknow which treatment was selected by the participant. Shethen wanted the participant to read her therapy group. Af\crthis, women who met the entry criteria were randomlyassigned in a 1:1 ratio to I of 2 treatment groups: MLDT orCTM, respectively. They were also given a letter; but thistime, the third researcher had knowledge about the content ofthe letters. However, the other researchers (first, second, and

130 Hkicí ct alManual Therapy in Fibromyalgia

Journal of Manipulative and Physiological TherapeuticsFebruary 2009

Potenii.iily eligibleindividuals:

n = 87

F.xcliiüeü - noi mee ling iheinclusion cnteria: n = 34(age<25 years (n - 6). pain<4 andpainless neck/shoulder (n = 2|. breastfeeding (n = 2). men (n = 9). drugusage (n = 4), traunialic injury (n = 3).iilher reasons In = 6),Pregnancyfn - I ). Maiignancy(n = 1 ))

Discontinuedinlerveiilion

n = l

Discontinuedintervention

n = 2

Analyzed Analyzedn = 25

Fig I. Study flowchart.

fourth) did not have any information. Thus, both the otherresearchers and the subjects were blinded during theselection of inten'ention group.

StatisticsStatistical analyses were done usitig the Statistical

Package for the Social Sciences version 11.5 (SPSS Inc,Chicago, ill), including descriptive statistics. Data arepresented as mean {±SD) in the text. The Wilcoxon ranktest was used to analyze the data obtained before and after thetreatments for each group. The outcomes were comparedusing the Mann-Whitney U test to detect significantdifTerences between the groups. The level of statisticalsignificance was set at .05.

RE5ULTS

The sample was derived from a population of S7 PFMoutpatients. Finally, 50 outpatients participated in the currentstudy prospectively (Fig 1 ).

According to the baseline data ofthe groups, statisticallysignificant differences were found only in body mass index(Table ! ) and 2 subitems of FTQ (Table 2). Whereas the score

for FIQ-2 (feel good) (P = .036) was higher, the score forFIQ-9 (anxiety) (P = .019) was lower in the MLDT groupthan in the CTM group (Table 2). Except for these itemsabove, before the treatment, no significance was foundbetween the groups (P > .05).

Both treatment methods led to significant and progressiveimprovements based on NHP (Table 3). VAS (Table 4), PPT(Table 4), and FIQ-total (Table 2) at the end ofthe treatmentprogram. In the CTM group, no differences were foundbetween baseline and end of treatment data for FIQ-l(physical impairment) and FlQ-3 (work missed) (P > .05)(Table 2), The MLDT group showed more improvements;and statistical significances were found in FIQ-7 (rested)(P = .006), FIQ-9 (anxiety) (F = .060), and FIQ-total {P =.010) vs the CTM group (Table 2).

DISCUSSION

The present study was performed to assess and comparethe effects of MLDT and CTM in a sample of PFM patients.The results demonstrate that MLDT and CTM might beeffective in improving several key problems of PFM,including pain intensity. PPT, health status, and HRQoL.This study is important because it is the first to compareMLDT and CTM in women with PFM. in addition, theeffectiveness and the useftilness of these manual therapyapproaches are shown herein. These techniques, especiallyMLDT, are not commonly used in the treatment of FM, aprevalent chronic pain disease. Because FM is a femalepredominant syndrome.*' our sample included only seden-tary female patients. Neither MLDT nor CTM requiresactive participation.

Asplund"* used MLDT by the Vodder method in FMtreatment. Improvements were detennincd regarding pain,stifïhess, sleep problems, and well-being. The preliminaryresults ofthe same study also indicated that MLDT can be avaluable alternative approach for patients with FM. Simi-larly, the results ofthe MLDT group in our study showed thatthis technique may be used to improve pain, health status,and HRQoL in women with PFM.

in 1991, Goats and Keir̂ '̂ determined that CTM increasesblood flow and gives pain relief Furthennore, McKechnie etal̂ *" showed that CTM reduces tension and anxiety.Similarly, Brattberg^^ stated that CTM gave pain relief,decreased depression, and increased quality of life in patientswith FM. In the same study, it was also reported that theanalgesic effect appeared gradually with the first 15treatments. Connective tissue massage has positive effectson autonomie responses. ' " ' ''"̂ ' •"" It has been suggested thatabnormalities in the autonomie nervous system may play animportant role in the pathogenesis of FM.̂ Pain in FM isconsistently felt in the musculature and is related tosensitization of central nervous system pain pathways.^^Connective tissue massage is thought to be an effective

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131

Table 2. Fibromyalgia Impact Questionnaire scores of groups (mean ± SD)

FIQ

FIQ-! physical impairmentFIQ-2 days fell goodFlQ-3 work mis.sedFlQ-4 work impairmeniFlO-5 painFlQ-6 fatigueFlQ-7 moming tirednessFlO-8 stiffnessFlO-'i anxietyFlQ-10 depressionriQ-total

MLDT group baselinevalue (n = 25)

2.22 ±1.065.89 ±2.410.80 ±1.495.84 ± 2.967.36 ± 1.806.38 ± 2.436.18 ±2.395.26 ± 2.284.14 ±2.84 .3.44 ± 2.48

47.81 ± 15.59

CTM group baselinevalue (n = 25)

2.57 ± 1.824.23 ± 2.750.68 ± 1.546.14 ±2.506.36 ± 2.546.48 ± 2.746.46 ± 2.785.70 ±3.216.14 ±2.735.00 ± 2.97

49.51 ±20.99

P

.580

.036*

.654

.740

.156

.922

.558

.459

.019*

.050

.961

MLDT group end oftreatment (n = 25)

1.19 ±0.58^2.40 ± 1.28̂0.34 ± 0.74^2.20 ± 1.48^2.10 ±1.49^2.76 ±1.41^2.36 ± 1.51*2.38 ± 1.75^1.62 ±1.34*1.52 ± 1.31*

18.88 ±8.30*

CTM group end ol"treainient (n = 25)

1,92 ± 1.51*2.86 ± 1.97̂0.31 ± 1.05^2.46 ± 2.25^3.00 ±2.21^3.82 ± 2.47'4.28 ± 2.67*3.46 ± 2.67^3.66 ± 2.79*2.86 ± 2.36^

28.55 ± 13.46*

P

,094.417.346.852.235.227.006*.170.006*.054.010*

/'<.O5.P < .05, the difference between before and after the treatment in MLDT group.P<.05, the difference between before and aller the treatment in CTM group.P > .05, the difference between before and after the treatment in CTM group.

Table 3. Nottingham Health Profile .scores of groups (mean ± SD)

NHPMLDT group baselinevalue (n = 25)

CTM group baselinevalue (n = 25)

MLDT group end oftreatment (n = 25)

CTM group end ofIreatment (n = 25)

EnergyPainHmotionai reactionsSocial isolationSleepPhysical mobilityN HP-total

54.49 ±27.3153.68 ±28.1424,10 ±23.98

7.37 ± 12.8335.89 ± 29.8222.20 ± 13.81

198.95 ±96.63

51.04 ±31,3953.37 ± 28.4335,19 ±32,8514.07 ± 24.5327.72 ± 30.7218.71 ± 16.21

201.22 ± 129.16

.777

.869

.334

.432

.278

.403

.977

18.72 ±9.66 ±

7.28 ±

3.20 ±4.44 ±9.39 ±

52.93 ±

19.73*

9.52*

9.75*7.56*8.66*10.61*31.61*

27.26 ± 33.63*17.10 ± 13.84^11.93 ±15.42'3.34 ± 9.68*4.38 ± 8.26*

I2.86± 13.18*76.89 ±63.21*

.531

.057

.366,784.869.315.383

P<.05.P < .05, the difference between before and after the treatment in MLDT group.P < .05. the difference between before and after the treatment in CTM group.

Table 4. Pain intensity (VAS) and PPT scores

MLDT group baselinevalue (n = 25)

VAS(O-lOcm) 6.98 ± 1.91R.PPT (kg/cm-) 1.68 ±0.57L.PPT (kg/cm^) 1.66 ±0.47

of groups (mean ± SD)

CTM group baselinevalue (n = 25)

6.52 ± 2.291.64 ±0.561.91 ±0.94

P

.466

.961

.391

MLDT grouptreatment (n ~

1.49± 1.19*2.82 ± 0.72*2.95 ± 0.78*

end of^25)

CTM grctuptreatment (n

2.59 ± 2.05^2.41 ± 0.74*2.66 ± 1.04̂

end of= 25) P

.071

.066

.137

R.PPT indicates right side; L.PPT, left side.* P < .05, the difference between before and after the treatment in MLDT group.* P < .05, the difference between before and after the treatment in CTM group.

method because it produces genera! body relaxation,, reducesmuscle spasm and connective tissue tenderness, andincreases plasma (S-endorphins.'"

In this study, according to the data obtained from theCTM group, decreased pain intensity, increased PPT, andimproved health status and HRQoL were in agreement withthe literature.'"'"

The pain in FM is commonly perceived as arising fromthe muscles; and there are typically 1 or 2 locations that arethe major pain foci, although sites of pain often shin andfluctuate in intensity over days and weeks. Most FM patientsreport pain and stiffness in the neck-shoulder muscles; andmost develop FM from localized or regional muscle painconditions, such as trapezius myalgia.̂ '*" '̂' Fibromyalgia

patients exhibit lower thresholds for mechanical pain(allodynia) and show exaggerated pain response to noxiousstimuli (hyperalgesia). In addition to this information fromthe literature, our experiences also show that the neck-shoulder region was stiff and painful in FM patients. Becausethese areas are highly painftil, the trapezius muscle waschosen bilaterally for PPT testing in this study. Conse-quently, in both groups, after the treatment, the PPT scoreswere increased significantly. These were valuable data forchoosing and planning treatment approaches.

In both groups, the baseline mean scores on the subscalesof the HRQoL using NHP indicated that participantsreported greater improvements in terms of energy, pain,emotional reactions, steep disturbances, social isolation, and

132 Ekici ct alManual Therapy in Fibmiiiyalgia

Journal of Manipulative and Physiological TherapeuticsFebruary 2009

physical mobility than the scores obtained at the end ofthe treatment.

As is the case with other rhcumatologic diseases, FMpatients may be further scored in terms of disease impact bythe FIQ."*' In support of previous fmdings, negative affectwas significantly predictive of poorer health status; andpositive affect was significantly associated with better healthstatus in FM."*' This work emphasized that health status asdetemiined by FIQ was significantly improved in bothgroups. However, in the MLDT group, the patients felt morerested when they got up in the morning, less tense, and lessnervous/anxious than the CTM group. In addition, thebaseline score for FlQ-9 (anxiety) was higher in the CTMgroup than in the MLDT group.

Both CTM and MLDT had a calming effect on thepatients due to the soothing effect of hands-on therapy andthe social interaction with a therapist for 20 to 45 minuteson a daily basis. In addition, the MLDT treatment sessionslasted about 45 minutes; and the CTM treatment sessionsonly lasted about 5 to 20 minutes as described in the"Methods" section. When substantially different amountsof time and attention are given to patients during MLDTand CTM, patients may be expected to respond differently.This may be a potential confounding variable in thestatistical analysis and should be taken into consideration.The source of these differences may also be the use ofdifferent pressure applications in CTM and MLDT.Whereas MLDT is applied by light massage, traction ofconnective tissue is necessary for the reflex response inCTM. In addition, touching the skin in itself has positiveeffects by decreasing stress hormones and muscle tension,and increasing PPT."" Manual lymph drainage therapylight massage may be preferred by physiotherapists forimproving the symptoms in terms of feeling rested andemotional problems in PFM.

CONCLUSION

Manual lymph drainage therapy and CTM might behelpful in tentis of reducing pain intensity, increasing PPT,supporting the HRQoL, and improving the health status inpatients with PFM. However, it is not clear which approach ismore beneficial for PFM. Both methods used in this trialseemed to be useful, although a placebo effect cannot be ruledout. When selecting a physiotherapy program for patientswith PFM, we can hannonize the approaches according to thepatients* needs for obtaining the optimal outcome. In thissample of patients, MLDT had a greater effect on health statusthan CTM based on FIQ. Therefore, MLDT using lightmassage may be preferred by physiotherapists. It can beconcluded that the MLDT and CTM may be safe and valuabletreatment methods for symptom relief in patients with thissyndrome. They are both efficient in reducing pain andincreasing PPT, thus enhancing patients' quality of life, lnlight of these findings, these methods are thought to be

worthy of investigation in further studies including largernumber of groups, men, and long-term follow-up results.

Practical Applications

• Manual lymph drainage therapy might be used inthe treatment of PFM.

• Connective tissue massage and MLDT may affectsthe HRQoL positively m PFM patients.

ACKNOWLEDGHENT

The authors thank Erkan Sümer, MD, from HacettepeUniversity, Ankara, Turkey, for meaningful contributions tothis study.

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