title: A systematic review of axillary web syndrome (AWS).
abstract: BACKGROUND
  Axillary web syndrome (AWS) can result in early post-operative and long-term difficulties following lymphadenectomy for cancer and should be recognised by clinicians. This systematic review was conducted to synthesise information on AWS clinical presentation and diagnosis, frequency, natural progression, grading, pathoaetiology, risk factors, symptoms, interventions and outcomes.
  
  
  METHODS
  Electronic searches were conducted using Cochrane, Pubmed, MEDLINE, CINAHL, EMBASE, AMED, PEDro and Google Scholar until June 2013. The methodological quality of included studies was determined using the Downs and Black checklist. Narrative synthesis of results was undertaken.
  
  
  RESULTS
  Thirty-seven studies with methodological quality scores ranging from 11 to 26 on a 28-point scale were included. AWS diagnosis relies on inspection and palpation; grading has not been validated. AWS frequency was reported in up to 85.4 % of patients. Biopsies identified venous and lymphatic pathoaetiology with five studies suggesting lymphatic involvement. Twenty-one studies reported AWS occurrence within eight post-operative weeks, but late occurrence of greater than 3 months is possible. Pain was commonly reported with shoulder abduction more restricted than flexion. AWS symptoms usually resolve within 3 months but may persist. Risk factors may include extensiveness of surgery, younger age, lower body mass index, ethnicity and healing complications. Low-quality studies suggest that conservative approaches including analgesics, non-steroidal anti-inflammatory drugs and/or physiotherapy may be safe and effective for early symptom reduction.
  
  
  CONCLUSIONS
  AWS appears common. Current evidence for the treatment of AWS is insufficient to provide clear guidance for clinical practice.
  
  
  CONCLUSIONS
  Cancer survivors should be informed about AWS. Further investigation is needed into pathoaetiology, long-term outcomes and to determine effective treatment using standardised outcomes.
authors: Department of Physiotherapy, Princess Alexandra Hospital, Metro South Hospital and Health Service, Ipswich Road, Brisbane, QLD, 4102, Australia. iwa.yeung@health.qld.gov.au.
authors: W M
authors: WM
authors: Yeung
authors: Principal Research Fellow, School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia.|Centre for Functioning and Health Research, Metro South Hospital and Health Service, Brisbane, QLD, Australia.
authors: S M
authors: SM
authors: McPhail
authors: Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, QLD, Australia.|School of Allied Health Sciences, Griffith Health Institute, Griffith University, Gold Coast, QLD, Australia.
authors: S S
authors: SS
authors: Kuys
mesh_terms: D000328:Adult; D001365:Axilla / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000009:adverse effects* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000473:pathology / Q000601:surgery; D026741:Physical Therapy Modalities; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D016059:Range of Motion, Articular / Q000502:physiology; D012307:Risk Factors; D020069:Shoulder Pain / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D017741:Survivors / Q000706:statistics & numerical data; D013577:Syndrome
keywords: Axillary lymphadenectomy; Axillary web syndrome; Breast cancer; Melanoma; Pain; Post-operative morbidity