Table 2.
Studies considering the preventive effect of exercise on secondary lymphedema
| Authors, year [ref.] | Subjects | Design and measuring point | Intervention | Outcome |
|---|---|---|---|---|
| Schmitz et al., 2010 [11] | - n = 154 (134) – age 36–75 years – included: 1–5 years post unilateral non-metastatic BC with radiation and/or chemotherapy; currently cancer-free, no medical conditions that limit participation; surgery: ALND: ≥2 lymph nodes (range: 2–26; IG: Ø 8; CG: Ø 9); ≥5: 94 women |
- randomized controlled equivalence trial – at baseline and 12 months |
IG: 1 year progressive weight lifting – first 13 weeks supervised instruction, followed by 9 months unsupervised exercise: 2/week for 90 min; 3 sets of each exercise, 10 repetitions/set – 10 min cardiovascular warm-up; range of motion stretching of major muscle groups; – 5–15 min resistance training to stabilize spinal and deep abdominal muscles: 9 strength training exercises with resistance machines and free weights (chest, back, shoulders, quadriceps, hamstrings, gluteal, biceps, triceps); end of session: stretching (held 30 s). – upper body exercises: seated row, supine dumbbell press, lateral or front raises, bicep curls, triceps pushdowns; dumbbells/variable resistance machines: start: no weight or 1 pound, next week: 0.5–1 pound increase, 1 set of 0.5 pound wrist weights and 2 pairs of dumbbell in 1 pound increments (up to 10 pounds) – lower body exercises: leg press and leg curl, back and leg extension; progressive, lift maximum weight that can be lifted in each exercise 8–10 times/set, up to 3 sets/exercise over first 3–4 weeks – increasing weight (without symptoms) CG: no exercise |
- incident lymphedema onset (≥5% increase in inter-limb volume difference): IG 11%; CG 17% (p = 0.003) – ≥ 5 lymph nodes removed: incident lymphedema onset: IG 7%; CG 22% (p = 0.001) – clinical defined lymphedema onset: IG: 1 woman (1.5%); CG: 3 women (4.4%); (p = 0.12) – IG became stronger and had lower percentage of body fat than CG |
| Sagen et al., 2009 [12] | - n = 204 – Ø age 55 ± 10 years (32–75 years) – included: early-stage BC surgery: mastectomy or breast-conserving with ALND; with or without radiotherapy, chemotherapy, hormone treatment |
- prospective randomized controlled trial – at baseline, 3, 6, and 24 months after surgery |
IG (n = 104): 6 months no activity restrictions (NAR) in daily living and moderate resistance exercise program: – progressive resistance training, 2–3/week with trainer for 45 min (first 2 weeks: 0.5 kg weights, 15 repetitions/set; individual weight increase) CG (n = 100): 6 months activity restrictions (AR) program with usual care program: – avoid heavy strenuous activities; no lifting or carrying >3 kg – low-dose physical therapy program (6 techniques of passive manual stretching emphasizing flexibility and light massage to the affected shoulder, arm, scar; 1/week for 45 min) |
- no significant difference between IG and CG in arm volume, difference in volume between affected arm and control arm, or lymphedema at 3, 6, or 24 months – lymphedema development from baseline to 2 years increased significantly in both groups (p < 0.001) – lymphedema: IG 5%; CG 7% at 3 months to 13% at 2 years for both groups – arm volume and arm lymphedema increased with time in both groups (p = 0.05) – home physical exercise rate significantly higher at 3 and 6 months in IG (p < 0.001) but did not differ at 2 years |
| Torres Lacomba et al., 2010 [5] | - n = 120 (116) – included: unilateral surgery with ALND, and adjuvant chemotherapy |
- randomized single-blinded clinical trial – 4 weeks (shortly after completion of intervention), 3, 6, 12 months after surgery |
IG (n = 60) (59): physiotherapy program (3 weeks; 3/week): – MLD technique used for treatment of postoperative edema (modification of strokes described by Leduc) – progressive massage of scar tissue (progressing from Jacquet and Leroy pincer to Wetterwald pincer) – stretching exercises for levator scapulae, upper trapezius, pectoralis major, medial and lateral rotators muscles of the shoulder – progressive active and action-assisted shoulder exercises – educational therapy (printed information about lymphatic system; concepts of normal load vs. overload; secondary lymphedema: source and preventive interventions; possible precipitating factors) CG (n = 60) (57): educational therapy only |
- statistically significant difference in diagnosis of lymphedema (>2 cm increase in arm circumference): CG 14 (25%); IG 4 (7%) (p = 0.010) - 1-year follow-up volume ratio between affected arms increased by 5.1% in CG and 1.6% in IG (p = 0.0065) - lymphedema diagnosed 4 times faster in CG (p = 0.010) - better survival rate in IG than in CG |
| De Rezende et al., 2006 [13] | - n = 60 – Ø age 54 years – included: first surgery for invasive BC, modified radical mastectomy or quadrant-ectomy with ALND; (neo-)adjuvant chemotherapy; 3 exercises started 1 day, others 48 h after surgery |
- prospective randomized controlled clinical trial |
IG: kinesiotherapy: – flexion, extension, abduction, adduction, internal and external rotation; 19 exercises: 10 repetitions (60-s interval between exercises) CG: biomechanical physiologic movements of the shoulder: – flexion, extension, abduction, adduction, internal and external rotation without defined number of repetitions or sequence; duration: 40 min, 3/week for 42 days |
- significantly better shoulder mobility in IG – no significant difference in lymphedema or arm circumference between IG and CG – statistically significant increase in circumference 7.5 cm above humeroradial joint in CG (p = 0.0332) |
| Zimmermann et al., 2012 [14] | - n = 67 – age 34–81 years (Ø IG: 60.3 years, Ø CG: 58.6 years) – breast-conserving therapy (n = 40) or modified mastectomy (n = 27) – SLND (n = 32) (Ø 2) – ALND (n = 35) (Ø 17) – adjuvant therapies, radiation, chemotherapy, or endocrine therapy |
- randomized controlled study – before surgery, at 2, 7, 14 days, and at 3, 6 months |
for all subjects from day 2: standard physiotherapy program (exercises of limb and chest physical therapy) IG (n = 33): MLD: 5/week during first 2 weeks; 2/week from day 14 to 6 months after surgery CG (n = 34): self-applied drainage |
- CG: mean values of arm volume measurements on operated side increased continually from 2nd day of surgery – IG: mean values increased on day 2 after surgery and started to resolve by day 7 – 6 months after surgery: CG: significant increase in arm volume on operated side (p = 0.0033); IG: no statistically significant increase in volume of upper limb on operated side – intergroup differences in mean values of volume of lymphedema: noticeable from day 7 after surgery and still evident at study end – 3 months after surgery: CG: 6% volume increase, up to 10% at 6 months; IG: ULL on operated side did not occur |
IG = Intervention group; CG = control group; BC = breast cancer; ALND = axillary lymph nodes dissection; SLND = sentinel lymph node dissection; MLD = manual lymph drainage; ULL = upper limb lymphedema; Ø = average.