Avoidance of Lifting Weight

Avoidance of Lifting Weight

PEP Topic 
Lymphedema
Description 

Weight lifting is a physical activity in which the individual tones and builds muscle strength by using muscles to lift weight against gravity. Weight lifting has been evaluated related to risks and benefits for patients at risk for or with lymphedema and historically patients with lymphedema had been advised to avoid lifting weight in usual daily activities, such as carrying items weighing more tha a few pounds. Recent studies in lymphedema among patients with breast cancer have shown that weight lifting does not appear to exacerbate lymphedema. It should be noted that research in this area has involved training patients how to safely lift weights and, in some cases, the exercises are supervised.

Effectiveness Not Established

Research Evidence Summaries

Ahmed, R.L., Thomas, W., Yee, D., & Schmitz, K.H. (2006). Randomized controlled trial of weight training and lymphedema in breast cancer survivors. Journal of Clinical Oncology, 24(18), 2765–2772.

doi: 10.1200/JCO.2005.03.6749
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Study Purpose:

To examine associations between exercise and lymphedema in breast cancer survivors

Intervention Characteristics/Basic Study Process:

The study and all protocols were approved by the University of Minnesota.

Sample Characteristics:

  • The study sample (N = 85) was comprised of female breast cancer survivors who were recruited from October 2001–June 2002.
  • Forty-two women were randomly selected for the intervention group, 23 of which had undergone axillary dissection.
  • Forty-three women were randomly selected to the control group, 23 of which had also had axillary dissection.
  • All participants gave signed informed consent.

Setting:

The study took place in the Minneapolis-Saint Paul greater metropolitan area in Minnesota.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Arm circumference measurements were taken on both arms at the level of the metacarpophalangeal joints, just distal to the ulnar styloid process, 10 cm distal to the midpoint of the lateral epicondyle, and 10 cm proximal to the midpoint of the lateral epicondyle. During measurements, participants lay prone with their arms at their sides and elbows straight. A cloth measuring tape was placed around the arm so that there was no slack and no indentation of the tissue. Participants who wore compression sleeves removed them one hour before measurements were taken. The mean of two measurements was used. The outcome measure was the calculated difference in each circumference measure between the ipsilateral and contralateral arms.
  • A validated survey measured self-report of lymphedema diagnosis, symptoms, and treatment over the past three months. The survey had a specificity of 0.90 and sensitivity of 0.86–0.92 for diagnosing lymphedema (difference in arm circumferences of 2 cm), compared with clinical assessment by a physical therapist with training in lymphedema. Symptoms of lymphedema included whether or not a patient had noticed that her hand or lower or upper arm on the side of the cancer was larger than the side of the opposite arm and if the difference was mild, moderate, or severe. Additionally, other symptoms included altered fine motor function, puffiness, swelling, or pain of the hand or arm.
  • A patient was a self-reported “incident” case of lymphedema if she self-reported a clinician diagnosis of lymphedema at six months but not at baseline. A patient was a self-reported “prevalent” case if she self-reported a clinician diagnosis of lymphedema. A participant was considered to have lymphedema symptoms if she reported any lymphedema symptoms in the survey.

Results:

After dropouts and loss to follow-up, 78 women completed baseline and six-month measurements of arm circumference. A twice-a-week weight training for a period of six months did not increase arm-circumference measurements or exacerbate symptoms of lymphedema in survivors of breast cancer compared with nonintervention controls.

Limitations:

  • Six months may not have adequately captured acute or transient changes in circumferences or symptoms that may result from exercise.
  • They did not measure change in volume, which is correlated with circumference measures but may be more sensitive to change.
  • Few of the women randomly selected at baseline had lymphedema.

Brown, J.C., Troxel, A.B., & Schmitz, K.H. (2012). Safety of weightlifting among women with or at risk for breast cancer-related lymphedema: Musculoskeletal injuries and health care use in a weightlifting rehabilitation rrial. The Oncologist, 17(8), 1120–1128.

doi: 10.1634/theoncologist.2012-0035
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Study Purpose:

To compare the risk of musculoskeletal injury in women with or at risk for lymphedema between a weight-lifting program and standard care

Intervention Characteristics/Basic Study Process:

Women were randomized to receive twice weekly weight lifting or standard care for one year. Patients in both groups attend one hour of education on lymphedema. Women in the weight-lifting group received twice weekly group-based supervised instruction on proper biomechanics. Sessions lasted 90 minutes and included upper- and lower-body exercises and 10 minutes of aerobics and static stretching. If there were no changes in arm symptoms at a given weight, the weight was increased by 1 lb.  There was no upper limit on maximum weight lifted over one year. Patients with lymphedema wore a custom-fitted compression garment during exercise. Data were compared to weight-lifting injury rate data among a general population.

Sample Characteristics:

  • The study sample (N = 243) was comprised of female patients with breast cancer.
  • Mean age was 55.8 years.
  • Time since cancer diagnosis ranged from 39–88 months.
  • Fifty-nine percent of patients had stage I disease.
  • Eight percent of patients were taking tamoxifen at the time of the study.
  • The majority of patients had at least some college education and were White; 37% were Black.

Setting:

The study took place in the eastern United States.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a radonmized controlled trial design with epidemiological analysis comparison.

Measurement Instruments/Methods:

  • Patients completed the International Physical Activity Questionnaire.
  • Anthropometric measures were used.
  • Strength measurements were taken.
  • Patients were interviewed regarding adherence.
  • Self-reported healthcare use rates were reported.
  • Arm volume was measured via bioimpedence monthly.
  • Cirumferences and water displacement volume were measured.

Results:

Strength was better in the weight-lifting group at 12 months compared to usual care controls (p = 0.03). Patients with lymphedema had greater odds of a musculoskeletal injury compared to controls (OR 19.9, 95% CI 5.1–77, p = 0.001). Patients at risk for lymphedema in the weight-lifting group did not have higher odds of injury. Injury rate per 1,000 reported exercise sessions among patients who did the weight-lifting was less than weight-lifting injury rates among a comparison group of premenopausal women. Six women in the weight-lifting group reported shoulder injuries, one had a wrist injury, and three had lower-body injury. Healthcare use in the control group was not reported.

Conclusions:

Weight lifting in women with and at risk for lymphedema appears to be safe, with no more frequent injury rates than those seen in other women; however, musculoskeletal injuries did occur. This points to the need for supervision and communication with professional healthcare providers when delivering a weight-lifting program.

Limitations:

  • The study has a risk of bias because no blinding was done.
  • Measurement validity and reliability are questionable.
  • No information about any changes in lymphedema were provided in the report (reported elsewhere with main study findings) and healthcare use data was only provided for patients who were involved in weight lifting. 
  • Injury findings were not fully discussed, in terms of likelihood of being caused by weight lifting. The method of injury measurement was based on patient recall on a survey done at 12 months—patients may not have remembered all injuries. 
  • It is not clear if patients adhered to schedule of weight lifting, and comparable activities in the control group were not described or discussed

Nursing Implications:

Findings suggest that women with or at risk for lymphedema can safely do weight lifting, although, as with women without these problems, musculoskeletal injuries can occur. It appears that shoulder injuries were most common. These results point to the importance of supervision and monitoring by appropriate professionals during any weight-lifting program.

Cormie, P., Galvao, D.A., Spry, N., & Newton, R.U. (2013). Neither heavy nor light load resistance exercise acutely exacerbates lymphedema in breast cancer survivor. Integrative Cancer Therapies, 12, 423–432.

doi: 10.1177/1534735413477194
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Study Purpose:

To examine the acute impact of upper-body resistance exercise on lymphedema symptoms in women with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

After four sessions of exercise to familiarize patients with exercise routines over a two-week period, patients were instructed to perform five upper-body resistance exercises. Both low- and high-load exercises involved moderate to high intensity. Patients were to complete two sets of all exercises. High-load sessions involved lifting as much weight as possible for 6-8 repetitions. Low-load exercises involved lifting as much weight as possible for 15–20 repetitions. Load was prescribed and progressed individually. Patients were randomly assigned to which load condition was performed first, and then, after a 10–12 day washout period, crossed over to the other load condition. An exercise physiologist supervised all sessions.  Participants chose whether or not to wear compression garments during exercise. Study outcome measures were obtained prior to exercise, immediately after exercise, and at 24 and 72 hours after exercise. Patients were instructed to maintain usual self-care management and physical activities.

Sample Characteristics:

  • The study reported on 17 patients.
  • Mean age was 61.2 with a range of 52.1–70.3.
  • The sample was 100% female.
  • All patients had breast cancer-related clinical diagnosis of lymphedema. All had surgical treatment with an average of removal of 13 lymph nodes. Most of patients (88%) had received previous radiation therapy.
  • Participants were generally overweight or obese.
  • Average time since diagnosis was 5.4 years.
  • Average arm circumference difference was 18.7% (SD = 11.9).

Setting:

This was a single-site, outpatient study conducted in Australia.

Phase of Care and Clinical Applications:

This study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized crossover design.

Measurement Instruments/Methods:

The following tools were used.

  • Impedance spectorsopy
  • Dual energy X-ray absorption
  • Arm circumference measurements
  • Brief Pain Inventory
  • Visual analog scale (VAS) for pain, heaviness, and tightness

Results:

No significant differences were observed in lymphedema measures of affected arms across most time points in the study, and no differences were found between high- and low-load conditions. No significant changes were found in arm volume or circumference, and no differences were found between load conditions. No significant differences were found in severity of pain, heaviness, or tightness across all study time points.

Conclusions:

Neither low- nor heavy-load resistance upper-body exercises had any acute impact on lymphedema symptoms.

Limitations:

  • The sampel size was small with fewer than 30 patients.
  • Use of compression garments during exercise varied. Other activities were not described. 
  • This study only looked at short-term, acute effects; longer-term effects with ongoing resistance exercise are not known.

Nursing Implications:

Findings showed that prescribed and supervised moderate- to high-intensity, upper-body exercise with low and high loads did not acutely exacerbate lymphedema. Traditional conservative guidelines have recommended avoidance of excessive upper-body exercise with resistance or weight to avoid exacerbation of lymphedema. Findings from this study suggest this may not be necessary. Of note, however, is that exercise done here was supervised and only examined immediate acute effects.  Long-term chronic response needs to be examined.

Cormie, P., Pumpa, K., Galvao, D.A., Turner, E., Spry, N., Saunders, C., … Newton, R.U. (2013). Is it safe and efficacious for women with lymphedema secondary to breast cancer to lift heavy weights during exercise: A randomised controlled trial. Journal of Cancer Survivorship, 7, 413–424.

doi: 10.1007/s11764-013-0284-8
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Study Purpose:

To compare the effects of high and low weight load resistance exercise on lymphedema severity, symptoms, physical function and quality of life in women with breast cancer

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to one of three groups: high load resistance exercise, low load resistance exercise, or a wait list usual care control group. Both exercise programs involved six exercises targeting the major upper body muscle groups. Intensity was moderate to high on the Borg scale. Sessions were done for 60 minutes once per week for three months and were supervised by an exercise physiologist. Patients chose whether or not to wear compression garments during exercise. Patients were instructed to maintain usual self care and activity.  Outcome measures were obtained at baseline and at three months post intervention.

Sample Characteristics:

  • The study consisted of 60 patients with a mean age of 57 years.
  • The sample was 100% female.
  • Time since diagnosis ranged from an average of 5.9 years in the high load group to 9.5 years in control patients.
  • The majority of patients (97%) had surgery. Overall, a mean of 15.4 lymph nodes were removed.
  • The amount of patients who had received radiotherapy was 85%.
  • Most patients had grade I or II lymphedema.

Setting:

This was a single-site, outpatient study conducted in Australia.

Phase of Care and Clinical Applications:

This study has clinical applicability for late effects and survivorship.

Study Design:

This was a single-blind, randomized controlled trial.

Measurement Instruments/Methods:

The following measurement tools were used.

  • Bioimpedance
  • Dual energy x-ray absorption measurement
  • Arm circumference measurement
  • Disability of the arm, shoulder, and hand questionnaire (DASH)
  • Brief Pain Inventory (modified)
  • Functional Assessment of Chronic Illness-Breast cancer (FACT-B)
  • European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QOL) questionnaire
  • Short Form Health Survey (SF-36)
  • Hand dynamometry for grip strength
  • Maximal muscle endurance testing

Results:

No lymphedema exacerbations or adverse events were reported. No differences across groups were found in change of swelling outcome measures or symptom severity. A nonsignificant trend toward greater improvement in grip strength was noted. Significant improvement was reported in upper body muscle endurance in both exercise groups compared to controls (p=.001). Physical functioning measurement showed significant improvement in both exercise groups compared to controls, in which the measure showed decline (p = 0.04). A fourth of the patients used compression garments during exercise.

Conclusions:

Findings showed that women with breast cancer-related lymphedema can safely lift weight at both low and high relative load. Moderate- to high-intensity exercise may be beneficial to improve physical functioning.

Limitations:

  • The sample size was small with fewer than 100 patients.
  • A risk of bias exists because the study did not have an appropriate attentional control condition.

Nursing Implications:

This study adds to the growing body of evidence that weight lifting and high or low load resistance exercise can be safe for patients with lymphedema. Of note, the evidence in this area includes only supervised weight lifting.

Hayes, S.C., Speck, R.M., Reimet, E., Stark, A., & Schmitz, K.H. (2011). Does the effect of weight lifting on lymphedema following breast cancer differ by diagnostic method: Results from a randomized controlled trial. Breast Cancer Research and Treatment, 130(1), 227–234.

doi: 10.1007/s10549-011-1547-6
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Study Purpose:

To identify the baseline prevalence of lymphedema in the PAL cohort according to three standard diagnostic methods commonly used in clinical practice and/or research, and to compare the effect of the weight-lifting intervention on lymphedema outcomes using these same three diagnostic methods.

Intervention Characteristics/Basic Study Process:

The study evaluated the women’s lymphedema status at baseline and 12 months using four independent standardized methods: volumetric, sum of arm circumferences, bioimpedance spectroscopy, and validated self-report survey.  In the PAL trial women were randomized to progressive weight lifting or usual care.

Sample Characteristics:

  • The study sample was comprised of 295 female patients who were randomly allocated to the weight-lifting (n = 148) or control (n = 147) group.
  • Mean age for the weight-lifting group was 55 years and mean age for the control group was 57 years.
  • Patients were included in the study if they had
    • A history of unilateral nonmetastatic breast cancer
    • A body mass index of less than or equal to kg/m²
    • At least one excised lymph node
    • No recurrence of breast cancer and no clinical signs or symptoms of breast cancer
    • Stable lymphedema, defined as greater than or equal to 10% inter-limb discrepancy in volume or circumference at point of greatest visible difference
    • Swelling or obstruction of the anatomic architecture on close inspection
    • Pitting edema
    • Prior diagnosis of lymphedema, having had any prior intensive lymphedema therapy on the affected arm
    • Self-reported clinical diagnosis of lymphedema that was later confirmed by study measurements or by qualified clinician.
  • Patients were defined as having lymphedema or not according to the Physical Activity Lymphedema (PAL) Trial definition.
  • Patients were excluded from the study if they had
    • Unstable lymphedema defined as needing intensive lymphedema therapy within three months before entry into study
    • 10% change in volume or circumference of affected arm that had lasted at least seven days within three months before entry into study
    • Lymphedema-related infection that required use of antibiotics within three months before entry into study
    • Required a change in activities of daily living in response to exacerbation of lymphedema within three months before entry into study.

Setting:

The study took place across multiple settings in Pennsylvania.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a secondary analysis of a randomized controlled trial design.

Measurement Instruments/Methods:

  • Arm volume was measured using the water displacement method.
  • Arm circumference was measured.
  • Bioimpedance spectroscopy was used.
  • Patients provided a self-reported that was validated.
  • Statistical analysis included Chi square test and Fisher’s exact test to compare categorical variables, continuous variables compared with Student’s t test, and Wilcoxin rank sum test.

Results:

There were no clinical or statistical differences in personal and treatment characteristics between the weight-lifting and control group. The authors identified that irrespective of the lymphedema diagnostic criteria used, weight lifting did not initiate nor exacerbate lymphedema. The PAL Trial’s definition for lymphedema identified 48% of the 295 participants as having lymphedema. When specific diagnostic criteria were independently applied to the cohort, lymphedema was clinically evident between 22% (sum of circumferences) and 52% (Norman survey). When all four criteria were applied, only 19% were considered to have lymphedema.

Conclusions:

It is important to consider that the variations in lymphedema cohort and intervention studies may be reflected by these different diagnostic methods. It is important to consider the strengths and limitations of each criteria in light of the cohort being assessed. The results of the study may change the previous recommendations of restricting repetitive exercise; this study highlights that women should be encouraged and not restricted to participate in programs. Results also suggest large differences in reported lymphedema incidence based on the definitions used.

Limitations:

Unintended interventions or applicable interventions were not described and would influence results.

Nursing Implications:

Findings suggest that progressive weight lifting does not exacerbate lymphedema. Still, we should caution that women in the PAL Trial were supervised and closely monitored for changes in signs or symptoms of lymphedema. The study was not powered to evaluate whether weight lifting could prevent lymphedema.

Johansson, K., Klernas, P., Weibull, A., & Mattsson, S. (2014). A home-based weight lifting program for patients with arm lymphedema following breast cancer treatment: A pilot and feasibility study. Lymphology, 47, 51–64.

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Study Purpose:

To determine whether an at-home weight lifting program was feasible and effective in patients with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

Prior to the start of the intervention, all participants wore compression garments according to their usual protocols (determined from the previous three months, day and night or day only) for two weeks. All garments had to be less than one month old and be of at least Compression Class (CCL) II. At the end of the control period, patients introduced resistance exercises over a four-week period, beginning with five repetitions and ending with 10 repetitions maximum. If lymphedema was not exacerbated, weights were increased by .5–1 kg every other session until the 10-repetition maximum was reached. After the four-week introduction period, patients were provided with flexible dumbbells ranging from .5–12 kg and were asked to exercise three times per week with at least one day between sessions. Patients performed four sets of the following exercises in this order, resting one to three minutes between each set: 1) shoulder flexion in a standing position, 2) shoulder adduction, 3) elbow extension in a supine position, and 4) elbow flexion in sitting position. Patients used 50% of the recommended weight for the first set and the full weight for the remaining three sets. Weight resistance levels were individually adjusted according to guidelines by the American College of Sports Medicine. Patients completed a minimum of eight repetitions per set when possible, and weight was increased by .5 kg when patients could complete more than 12 repetitions per set. Participants were not required to wear a compression garment during the exercises, but they were to put it on immediately following the exercises. Data were collected at baseline and at the end of the 12-week intervention.

Sample Characteristics:

  • N = 23 (10 women participated in an additional study)
  • AVERAGE AGE = 58 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients had to be less than 70 years old 

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Home    
  • LOCATION: Sweden

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Study Design:

Pre/post pilot study

Measurement Instruments/Methods:

  • Log book (i.e., wearing compression garment, completing exercises per protocol)
  • Water displacement method
  • Bioelectrical impedance spectroscopy 
  • Magnetic resonance imaging (MRI)
  • Body weight
  • Isometric muscle strength device

Results:

All patients in the study followed the minimum criteria for the protocol (exercise at least two times per week). All patients who participated had lymphedema (mean lymphedema relative volume was 19.6%, SD = 11.7%, range = 5.1%–53.5%). No significant changes in arm volume were observed during the control period. At the completion of the intervention, there was a significant reduction in absolute volume from 448 ml to 427 ml (p < .03) and relative volume from 19.2% to 18% (p < .005). Multiple muscle groups showed an improvement in strength at the conclusion of the study period (shoulder flexors p = .001, shoulder adductors p = .001, elbow flexors p = .003, and elbow extensors p = .002). Ten additional participants took part in a study with an MRI. There was no significant reduction in arm volume for these participants after the intervention.

Conclusions:

This home-based weight lifting program did not exacerbate or worsen lymphedema in this study. Participants saw some improvement in absolute arm volume and relative arm volume at the conclusion of the 12-week study period. Additional improvements were seen in the strength of multiple muscle groups. Overall, patients found the study to be feasible, and the majority of patients were at least minimally compliant with the exercise protocol.

Limitations:

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)  
  • Other limitations/explanation: It is unclear how much the participants exercised prior to the intervention.

Nursing Implications:

A home-based exercise program was acceptable for women with lymphedema following breast cancer treatment. Women were able to complete the minimum requirements of the protocol and exercise at least twice per week for 12 weeks. Nurses should assess women for readiness to participate in home-based exercise programs and provide appropriate recommendations for those who are motivated to participate in such a program. Home-based weight lifting is safe for patients with lymphedema and does not make lymphedema worse. In addition, weight lifting improves the strength of multiple muscle groups.

Katz, E., Dugan, N.L., Cohn, J.C., Chu, C., Smith, R.G., & Schmitz, K.H. (2010). Weight lifting in patients with lower-extremity lymphedema secondary to cancer: A pilot and feasibility study. Archives of Physical Medicine and Rehabilitation, 91(7), 1070–1076.

10.1016/j.apmr.2010.03.021
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Study Purpose:

To assess the feasibility of recruiting and retaining cancer survivors with lower-extremity lymphedema in an exercise intervention study and to determine preliminary estimates of the safety and efficacy of the intervention
 

Intervention Characteristics/Basic Study Process:

Patients participated in slow, progressive weight lifting two times weekly, supervised for two months, then unsupervised for three months. Participants were instructed in warm-up, stretching, breathing, weight training and additional stretching exercises by a certified fitness professional. Exercises were performed using variable resistance machines, free weights, and ankle weights.

Sample Characteristics:

  • The study sample was comprised of three male and seven female patients; five patients completed the intervention.
  • The study had an upper-age limit of 90 years old.
  • Patients had lower-limb lymphedema, with at least 6% discrepancy in the affected limb and did not have an infection.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a pre-post design with no control.

Measurement Instruments/Methods:

  • A Perometer was used to calculate limb volume.
  • Multiple leg circumference measurements were taken.
  • Patients completed a lymphedema survey.
  • A visual analog scale assessed associated pain.
  • Patients completed the 36-Item Short Form Health Survey (SF-36).
  • Patients took six-minute walks.
     

Results:

All but one person attended at least 81% of supervised sessions. Five patients did not complete the study because of cellulitis that occurred early in the study, progression of cancer, and inconvenience. There were no significant differences in lower-limb volume. Strength increased and the six-minute walk increased.

Conclusions:

The study was too small to draw any conclusions, and the number of drop outs for various reasons makes the feasibility of this approach for patients with lower-limb lymphedema questionable.

Limitations:

The sample size was small, with less than 30 participants.

Nursing Implications:

 The study is one of few that begins to address lower-limb lymphedema. Further study on the safety and potential benefits of exercise and weight training for this condition are needed.

Schmitz, K.H., Ahmed, R.L., Troxel, A.B., Cheville, A., Lewis-Grant, L., Smith, R., . . . Chittams, J. (2010). Weight lifting for women at risk for breast cancer-related lymphedema: A randomized trial. JAMA: The Journal of the American Medical Association, 304(24), 2699–2705.

doi: 10.1001/jama.2010.1837
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Study Purpose:

To evaluate the onset of lymphedema after a one-year weight-lifting intervention versus no exercise among breast cancer survivors at risk for lymphedema

Intervention Characteristics/Basic Study Process:

Patients were randomized to the weight-lifting intervention group or control group, who were to have no change in level of exercise. The weight-lifting intervention included a gym membership and 13 weeks supervised instruction with a remaining 9 months unsupervised. Specific equipment varied but provided upper-body exercises (i.e., seated row, supine dumbbell press, lateral or front raises, bicep curls, triceps pushdowns) and lower-body exercises (i.e., leg press, back extension, leg extension, and leg curl), 3 sets of 10 repetitions. Weights were increased for each exercise by the smallest possible increment after two sessions of completing 3 sets of 10 reps with no change in arm symptoms. Trainers called patients who missed more than one session per week. Those who missed two consecutive sessions were asked to reduce resistance and rebuild per protocol. All participants in the intervention or control group who developed lymphedema were given a custom compression garment and were required to wear garments during weight-lifting sessions. Certified fitness professionals employed by the centers received a three-day training course regarding exercise protocol and overview of lymphedema prevention, symptoms, and treatment.

Sample Characteristics:

  • The study sample (N = 134) was comprised of female patients who had a diagnosis of unilateral nonmetastatic breast cancer one to five years prior.
  • Mean age of participants was 54–56 years.
  • Patients were included in the study if they
    • Had a body mass index of less than or equal to 50
    • No medical conditions limiting exercise
    • No weight lifting in year prior to study
    • No plans for surgery or absence for a month during the study
    • A stable weight
    • Were not trying to lose weight
    • No prior lymphedema diagnosis
    • No evidence of current lymphedema.

Setting:

The study took place across multiple community fitness centers in Philadelphia, PA.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized controlled equivalence trial design.

Measurement Instruments/Methods:

  • Patients self-reported demographics and treatment history.
  • Surgical pathology reports were used to study removed lymph nodes.
  • Weight and height (baseline only) were recorded.
  • Whole-body dual-energy x-ray absorptiometry scan measured bone mineral density to avoid misrepresenting changes in relative fat mass because of changes in bone density.
  • Physical activity outside of weight lifting was assessed using the International Physical Activity Questionnaire.
  • Diet was assessed using the Diet History Questionnaire
  • Water volume displacement measured lymphedema.
  • Clinical laboratory technicians at Penn Therapy used standardized clinical evaluation based on Common Toxicity Criteria version 3.0.
  • Participants were sent for evaluation of change for symptoms lasting one week or longer by fitness trainers or if three-month interval measurements by measurement staff indicated a change in treatment-arm volume of at least 5% inter-limb difference.
  • Strength was measured at baseline and 12 months based on the maximum amount of weight patients could lift at once.
  • Intervention adherence was evaluated by attendance logs kept by fitness trainers.
  • Statistical analysis was performed using the Statistical Analysis System (SAS) version 9.2.
     

Results:

Women in the weight-lifting group became stronger with lower percentage body fat compared with the no exercise group. Lymphedema onset (5% or more increase in inter-limb volume difference during the 12 months) was 17% (n = 13) in the control group and 11% (n = 8) in the weight-lifting group.

Conclusions:

The findings demonstrates that slowly progressive weight lifting will not increase the risk of lymphedema in breast cancer survivors, the primary objective of testing the safety of the weight-lifting intervention. 

Limitations:

  • Key sample group differences could influence results.
  • Replication to other fitness settings was limited by availability of instructors.
  • Patients had limited access to clinical laboratory technicians for immediate evaluation and treatment.
  • Garments to be provided to patients was not covered by insurance.

Nursing Implications:

Additional research is needed to determine if weight lifting prevents lymphedema. Nurses should use caution in stating that exercise does not increase onset of lymphedema based on just this study, as it was conducted in a controlled environment, with careful instruction and observation of correct use of equipment and evaluation of arm symptoms and volume changes.

Schmitz, K.H., Ahmed, R.L., Troxel, A., Cheville, A., Smith, R., Lewis-Grant, L., . . . Greene, Q.P. (2009). Weight lifting in women with breast-cancer-related lymphedema. New England Journal of Medicine, 361(7), 664–673.

doi: 10.1056/NEJMoa0810118
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Study Purpose:

To assess the effects of controlled weight lifting for breast cancer survivors with lymphedema

Intervention Characteristics/Basic Study Process:

For the first 13 weeks, participants in the intervention group received supervised 90-minutes session twice weekly led by certified fitness professionals employed by the fitness centers, who received three days of training. There was no upper limit on weight lifting. Participants were given a custom-fitted compression garment at 6 and 12 months and were required to wear the garments during weight lifting.

Sample Characteristics:

  • The study sample (N = 130) was comprised of female patients who had a history of unilateral, nonmetastatic breast cancer 1–15 years before the study.
  • Patients were included in the study if they had a body mass index of less than or equal to 50, at least one lymph node removed, and clinical diagnosis of stable breast cancer-related lymphedema.

Setting:

The study took place at community fitness centers near participants' homes in Philadelphia, PA.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Lymphedema was measured using water volume displacement.
  • Percentage body fat was measured.
  • Physical activity level was measured using metabolic equivalent of task.

Results:

Weight lifting did not significantly affect the severity of breast cancer-related lymphedema. Weight lifting reduced the number and severity of arm and hand symptoms, increased muscular strength, and reduced the incidence of lymphedema exacerbation. Median attendance at exercise sessions was 79%. The proportion of women who experienced at least 5% increase in limb volume was 17% in the control group and 11% in the weight lifting group. Among women who had five or more lymph nodes removed, 7% in the weight-lifting group and 22% in the control group had more than 5% increase in limb volume.

Conclusions:

The results of this study should reduce concerns that weight lifting will worsen arm and hand swelling with lymphedema in breast cancer survivors.

Limitations:

  • Evaluations for exacerbations were not completed by a single therapist, although the six lymphedema therapists followed a standardized algorithm for evaluation.
  • The study had no blinding.

Nursing Implications:

Nurses need to review current handouts and information regarding exercise therapy. The findings of this study support the potential benefits of a slowly progressive weight-lifting program, with appropriate use of compression garments and close monitoring for arm and hand swelling.


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