Table 1.

Characteristics of the Included Studies

Study/country	Study design sample size	Objectives related to body image	Intervention details	Program design—individual or group	Body image tool used and fitness measures	Study results	Considerations
Speck et al.16/United States	• RCT n = 234 BCS with or without lymphedema • Treatment group n = 113 • Control group n = 121	Examine the effects of weight training on body image in PAL trial (primary objective)	• 1-year weight-lifting 2 × /week at the YMCA 13 weeks supervised and then the rest unsupervised • Control group on a 1-year waiting list	Small groups (2–6 people) for first 3 months. Individual and unsupervised for remaining 9	• BIRS • Baseline and 12 months • Anthropometry, 1-RM bench and leg press • Strength measurements: 10-RM chest press and 1-RM leg press	• Significant between-group difference in BIRS by 12% after 1 year in favor of intervention group compared with 2% increase in the control group (p < 0.0001) • Significant improvements in 1-RM bench press and leg press (p < 0.0001) after 1-year • No significant change in QOL	• Also measured general QOL (SF-36) • No association observed between lymphedema status and lower BIRS values
Beidas et al.17/United States	Hybrid type 1 effectiveness-implementation trial n = 84. With or without lymphedema	• Determine if modifying the PAL a trial would still prove to be effective and safe for survivors • Qualitatively assess barriers and facilitators to implementing this design by interviewing key stakeholders	4 small group training sessions led by a physiotherapist and 2 × /week strength training at home	4 supervised small-group training sessions, the remaining unsupervised individual	• BIRS • 1-RM bench and leg press	• Significant within-group improvement in body image from baseline to 12 months (p < 0.001) • Significant within-group improvement in muscular strength (p < 0.001)	Used the same measures as the PAL trial
Benton et al.18/United States	• Nonrandomized 8-week trial n = 20 • n = 12, YRT • n = 8, ORT	To evaluate the effect of age on changes in body image and overall QOL after a resistance training program (primary objective)	Both YRT and ORT groups 2 × /week for 8 weeks identical supervised resistance training sessions	Individualized supervised exercise program	• BIRS • Arm-curl test, 30-second chair-stand test, 10-RM bench press, 1-RM leg press	• Significant within-group improvement in BIRS total scores (p < 0.001) • Significant between-group difference in BIRS total scores, with a greater improvement in the YRT group compared with the ORT group (p < 0.01) • Within-group improvements in strength and function (p < 0.001)	• The program brought awareness to functional decline in older participants but was too short in duration to show improvements and benefits of being active • The ORT group was less susceptible to noticing improvements in fitness compared with the YRT group
Musanti et al.15/United States	• Prospective RCT 12-weeh duration with or without lymphedema • Flexibility n = 12 • Aerobic n = 10 • Resistance n = 9 • Aerobic and resistance n = 11	To determine which exercise modality has the most significant impact on self-esteem (attractive body is a component measured)	Participants were assigned to a home-based 12-week exercise program A 3 × /week, R 3 × /week, AR 4–5 × /week, or F as the control	Individualized home-based exercise program	• PSPP measure of self-esteem has a component measuring attractive body • Submaximal Bruce protocol treadmill test, 6-RM chest press and leg press, YMCA bench press, and shoulder/hip flexibility	• Significant within-group improvement in attractive body in Resistance group only (p < 0.000) • Significant within-group improvements in muscular strength (chest press p = 0.032 and curls p = 0.013 in Resistance, Aerobic and Resistance, and Flexibility groups)	• Did not report between-group differences for body image scores • Other measures include: Rosenberg Self-Esteem Scale, Piper Fatigue Scale, and Hospital Anxiety and Depression Scale to measure fatigue and mood
Paulo et al.19/Brazil	• RCT n = 36 postmenopausal women between ages 50–80 years • Resistance and aerobic group n = 18 • Control group n = 18	Evaluate exercise program on QOL of BCS aged 50–80 years undergoing aromatase inhibitor therapy (body image is a component of QOL)	• Supervised resistance and aerobic exercise 3 × /week for 9 months and health education session 1 × /month • Control group invited to participate in stretching and relaxation 2 × /week for 45 minutes for 9 months	Supervised group exercise	EORTC QLQ-BR23	• Significant within-group improvement in body image in both exercise and control groups after 3 months compared with baseline (p < 0.001) and after 6 months compared with 3 months	• Used other QOL measures (EORTC QLQ-C30, SF-36) • Did not measure physical changes in fitness
Stan et al.20/United States	Prospective, interventional, one-arm, open-label study n = 15 with or without lymphedema	• Assess feasibility of Pilates exercises after mastectomy (primary outcome). • Changes in shoulder range of motion, neck flexibility, posture, lymphedema, height, QOL, mood, and body image (secondary outcome)	36 45-minute sessions of Pilates mat classes over a 12-week period	Participants could choose to come into the exercise facility and do a group class or do a DVD at home	MBSRQ	• Statistically significant within-group improvements in health evaluation (p = 0.049) and body area satisfaction (p = 0.017) • Shoulder mobility significantly improved in abduction (p = 0.002) and internal rotation (p = 0.028)
Eyigor et al.21/Turkey	• RCT n = 52 without lymphedema • Hospital exercise program n = 27 • Control group home exercise program n = 25	Determine the effect Pilates has on BCS' functional capacity, flexibility, depression and QOL (body image as a component of QOL)	• Supervised Pilates exercise 1 hour 3 × /week for 8 weeks • Control group was instructed to do home exercises that were given to everyone in a handout	Group Pilates class	• EORTC QLQ-BR23 • 6 MWT, and modified sit and reach test	• Significant within-group improvement in body image as BR23 functional scores significantly improved in exercise group from pre- to postvalues (p < 0.05) • Significant between-group improvement in 6 MWT in exercise group compared with control (p = 0.00)	Additional psychological measures: Beck Depression Test, Brief Fatigue Index, EORTC QLQ-30
Svensk et al.22/Sweden	• RCT n = 41 • Art therapy n = 20 • Control group n = 20	Evaluate art therapy intervention on self-rated QOL among BCS (body image as a component of QOL)	• Randomized into art therapy 1 × /week for 5 weeks or control group, which had no art therapy • QOL assessments before intervention, 2 and 6 months later	Individual sessions with art therapist	EORTC QLQ-BR23	• Significant within-group improvement in art therapy group for body image between baseline and 6-month measurement (p = 0.027)	• Additional Measures: QOL measures: WHOQOL-BREF (Swedish version)

AR, aerobic and resistance exercise; BCS, breast cancer survivors; BIRS, Body Image and Relationship Scale; DVD, digital versatile disc; EORTC QLQ-BR23, European Organization for Research and Treatment-QOL questionnaire and breast cancer-specific module; MBSRQ, Multidimensional Body-Self Relations Questionnaire; MWT, minute walk test; ORT, ages 60-80 years group; PAL, physical activity and lymphedema; PSPP, physical self-perception profile; QOL, quality of life; RCT, randomized control trial; RM, repetition maximum; SF, Short Form Health Survey Questionnaire; WHOQOL-BREF, World Health Organization Quality of Life Instrument; YMCA, Young Men's Christian Association; YRT, ages 40–59 years group.