Exercise for Women With or at Risk for Breast Cancer-Related Lymphedema

1. Exercise for Women With or at Risk for Breast Cancer-Related Lymphedema Bicego D, Brown K, Ruddick M, et al. Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther. 2006 Oct; 86 (10): 1398-405 OPTIONALLOGO HERE OPTIONALLOGO HERE Abstract Introduction Results Article #1 and Evidence • Schmitz K, Ahmed R, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan C, Williams-Smith C, Greene Q. Weight Lifting in Women with Breast-Cancer-Related Lymphedema. N Engl J Med. 2009; 361: 664-673. • This randomized control trial supports the original articles conclusion that it is safe for patients with lymphedema to perform exercises even with the involved extremities. • The researchers not only found that it was safe to exercise, but it may actually be beneficial for patients. • The results of this article included “a decreased incidence of exacerbations of lymphedema, reduced symptoms and increased strength”, all of which are benefits for this patient population. Aim The purpose of this update is to review and critique recent studies investigating the effects of aerobic exercise and UE resistance training for women with or at risk for breast cancer–related lymphedema. The questions we will address are: (1) Does aerobic or resistance exercise lead to lymphedema in women who are at risk for the condition? and (2) Does aerobic or resistance exercise reduce or exacerbate pre-existing lymphedema? We begin by reviewing the prevalence, etiology and pathophysiology, and diagnosis of lymphedema and then review recent exercise studies. Background Management of lymphedema in women with breast cancer has been a subject of debate for many years. Treatment options include elevation, massage, compression garments, pneumatic compression pumps, and complex physical therapy. Traditionally, women who had been treated for breast cancer and those with pre-existing lymphedema were advised to avoid strenuous or repetitive activities that required effort with the affected UE because these activities were assumed to initiate or exacerbate lymphedema. Methods Studies were systematically retrieved from published articles from 2001-2005 included in CINAHL, EMBASE, MEDLINE, PEDro, and PubMed databases using the keywords “breast cancer”, “exercise”, and “lymphedema”. The articles were appraised by five individuals and then placed into hierarchical levels based off of Sackett’s rules of evidence rank studies. Results Eight studies were included in the review that directly related to breast cancer-related lymphedema and exercise. Exercise was found to neither initiate nor exacerbate lymphedema. Conclusions Additional research with larger samples, more rigorous designs (eg, randomized controlled trials), and more sophisticated outcome tools to measure lymphatic flow (eg, lymphoscintigraphy) is needed to address the safety and effectiveness of exercises for women with breast cancer–related lymphedema, one of the most concerning and prevalent secondary complications of breast cancer treatments. • This article helped to confirm the notion that physical activity for patients with breast cancer-related lymphedema is safe and should not increase their symptoms. • According to the authors, “Additional research with larger samples, more rigorous designs (eg, randomized controlled trials), and more sophisticated outcome tools to measure lymphatic flow (eg, lymphoscintigraphy) is needed to address the safety and effectiveness of exercises for women with breast cancer–related lymphedema” • Breast cancer is commonly treated by surgery (axillary dissection), chemotherapy, or radiation. • Axillary dissection or radiation can result in lymphedema due to obstruction, trauma, and inflammation of the lymphatic system. • “25% of patients develop lymphedema after breast cancer surgery, with an increase to 38% for those who also undergo radiation therapy” • Lymphedema has been defined as an abnormal accumulation of protein-rich fluid, edema, and chronic inflammation and can elicit pain, tightness, and heaviness in the upper extremity (UE), as well as lead to recurrent skin infections. • Management of lymphedema in women with breast cancer has been a subject of debate for many years. Treatment options include elevation, massage, compression garments, pneumatic compression pumps, and complex physical therapy. • Traditionally, women who had been treated for breast cancer and those with pre-existing lymphedema were advised to avoid strenuous or repetitive activities that required effort with the affected UE because these activities were assumed to initiate or exacerbate lymphedema. Article #2 and Evidence Clinical Significance • Chan D, Lui L, So W. Effectiveness of exercise programmes on shoulder mobility and lymphedema after axillary lymph node dissection for breast cancer: systemic review. Journal of Advanced Nursing. 2010 May; 66 (9): 1902-1914. • This systemic literature review supports the findings of the original article. • Among the six studies that measured the effect of exercise on lymphedema found no significant difference between the treatment group, which consisted of an exercise regimen, and the control group. • The authors found that exercise did not increase exacerbations of lymphedema and they also found that early implementation of exercise post-operatively prevents a decrease in shoulder ROM. • According to the review, “physical exercise may improve shoulder mobility, and it does not alter the severity of lymphedema.” • Considering the large number of women affected by lymphedema, physical therapists are highly likely to see a large number of breast cancer survivors who may be suffering from lymphedema complications so as healthcare providers we need to be aware of treatment techniques that are not contraindicated • This article refuted the notion that physical activity is unsafe for patients with lymphedema and would increase exacerbations. • As a PT it is important for us to stay up to date with the most current evidence and be aware of what interventions are no longer contraindicated with certain patient populations. This article makes us aware that we can incorporate exercise into our interventions and not be concerned about an increase in the patient’s symptoms. Methods and Materials • The authors searched the following databases: CINAHL, EMBASE, MEDLINE, PEDro, and PubMed. • Keywords used: “breast cancer”, “exercise”, and lymphedema • The search was limited to human, female and English-language studies • Five reviewers were used to critique the articles. • Exclusion criteria: review articles, clinical practice guidelines, studies in which exercise was not an independent variable, and studies in which the type of exercise therapy was not defined. • The authors found eight articles that directly related to breast cancer-related lymphedema and exercise. The years of publication ranged from 2001-2005. • The two categories of articles the authors researched included: effects of exercise for women with pre-existing lymphedema and the effects of exercise for those with lymphedema due to breast cancer. • The authors used Sackett’s rules of evidence rank studies in order to place the articles in a hierarchical level. The levels are ranked I to V: • I: large randomized controlled trail with low false positive or false negative errors • II: small randomized controlled trial with high false positive or false negative errors • III: nonrandomized, concurrent cohort comparisons • IV: nonrandomized, historical cohort comparisons • V: case series without controls • The majority (5 out of the 8 articles) of the research included in the article was level V (case series without control). The highest level of research included in this article was level II (small, randomized controlled trials), which only included three studies. Summary Conclusion • The most recent publications are refuting old beliefs that exercise is not indicated and may increase exacerbations in patients with lymphedema. • This new research is proving that not only is exercise safe and will not increase symptoms, but now this patient population (i.e. breast cancer survivors) can receive all the benefits from a weight lifting program, such as a reduction in body fat and improvement in their body mass index (BMI). • These results now give healthcare providers the confidence to prescribe an exercise program to this population and not be concerned with adverse effects. • Ashley Walker, DPT Student • The authors concluded that it is safe for individuals with breast cancer-lymphedema to perform PRE and the aerobic activity will. • However, the lack of high quality evidence led the authors to also conclude to more research needs to be performed in this area with higher research quality and larger patient populations. Purpose • To review and critique recent studies investigating the effects of aerobic exercise and UE resistance training for women with or at risk for breast cancer–related lymphedema. • (1) Does aerobic or resistance exercise lead to lymphedema in women who are at risk for the condition? and (2) Does aerobic or resistance exercise reduce or exacerbate pre-existing lymphedema