Exercise

Exercise

PEP Topic 
Lymphedema
Description 

Exercise is physical activity that involves repetitive bodily movement done to improve or maintain one or more of the components of physical fitness—cardiorespiratory endurance (aerobic fitness), muscular strength, muscular endurance, flexibility, and body composition. Exercise interventions in patients with cancer have been provided as home-based, patient self-managed programs, and supervised and unsupervised individual or group exercise sessions of varying duration and frequency, and can include combinations of aerobic and resistance types of activities. Exercise has been studied in patients with cancer for anxiety, chemotherapy-induced nausea and vomiting, depression, lymphedema, sleep-wake disturbances, pain, and fatigue. Users of this information are encouraged to review intervention details in study summaries, as the exercise interventions studied and their timings in the trajectory of cancer care vary, and these differences can influence effectiveness.

Likely to Be Effective

Research Evidence Summaries

Anderson, R.T., Kimmick, G.G., McCoy, T.P., Hopkins, J., Levine, E., Miller, G., . . . Mihalko, S.L. (2012). A randomized trial of exercise on well-being and function following breast cancer surgery: The RESTORE Trial. Journal of Cancer Survivorship: Research and Practice, 6(2), 172–181.

doi: 10.1007/s11764-011-0208-4
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Study Purpose:

To determine the effectiveness of early exercise intervention programs on the quality of life, physical function, and arm volume for breast cancer survivors immediately following breast cancer surgery

Intervention Characteristics/Basic Study Process:

Participants were randomized into a control group and an intervention group. The control group received patient education only (tips about lymphedema awareness and prevention exercises from a general newsletter). The intervention group underwent a tailored comprehensive program (the RESTORE program), which consisted of a structured exercise regimen, a lymphedema prevention module, patient and diet education, and counseling sessions. The intervention occurred every 3 months, beginning from 4–12 weeks after breast cancer treatment. The final session occurred at 18 months.

Sample Characteristics:

  • The sample (N = 82) was comprised of female patients.
  • Mean age was 53.6 years with a range of 32–82 years.
  • Patients were within 4–12 weeks of surgery and had stage I–III breast cancer.
  • Of the sample, 46% had breast-conserving surgery, 79% had axillary node dissection, 59% received chemotherapy, 64% received radiation, and 71% had a mass body index of equal or greater than 25 kg/m2.

Setting:

The study took place across multiple in-patient and home settings in association with Wake Forest University Health Center.

Phase of Care and Clinical Applications:

Patients were undergoing transition from breast cancer treatment to active treatment for lymphedema.

Study Design:

The study used a single, blinded, randomized controlled design.

Measurement Instruments/Methods:

The effectiveness of the RESTORE program was measured using the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B), distance traveled during a six-minute walk (measured by a pedometer), and arm volumes measured at three-month intervals using the water displacement method. The FACT-B was a survey that assessed physical, social, and functional well-being of the participants.

Results:

Those in the exercise intervention had a significantly higher distances walked in the six-minute walk test than in the control group by the end of all the study (p = 0.00098). However, there was no statistical difference between the average FACT-B scores from the control and intervention groups. (p = 0.57). There also was no statistical significance between groups in terms of arm volume when compared with measurements at baseline and 18 months (p = 0.54).

Conclusions:

There appears to be a positive correlation between the RESTORE program and physical function in individuals immediately after breast cancer treatment. Unexpectedly, this did not translate into a decrease in lymphedema-related symptoms (like edema) or social perceptions of the disease.

Limitations:

  • The sample was small (N < 100).
  • The intervention was expensive, impractical, or required extensive training for a long period of time.
  • Subject withdrawals were greater than or equal to 10%.

Nursing Implications:

Nurses should be aware of the symptoms that patients can present with after breast cancer remission. Nurses should encourage their patients to seek regular visits to their healthcare providers because this study showed that physical function can improve with more vigorous self-maintenance and early intervention. Further research should be conducted to determine the effectiveness of the RESTORE program as a standalone therapy.

Box, R.C., Reul-Hirsch, H.M., Bullock-Saxton, J.E., & Furnival, C.M. (2002). Physiotherapy after breast cancer surgery: Results of a randomised controlled study to minimise lymphoedema. Breast Cancer Research and Treatment, 75(1), 51–64.

doi: 10.1023/A:1016591121762
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Intervention Characteristics/Basic Study Process:

The purpose of the study was to evaluate the incidence of lymphedema after axillary dissection to determine the effects of prospective monitoring and early physiotherapy intervention

Sample Characteristics:

The study sample (N = 65) was comprised of a treatment group and a control group.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

Both arms of patients were measured for circumference, volumetry, and multi-frequency bioimpedance analysis preoperatively and 5 days and 1, 3, 6, 12, and 24 months postoperatively.

Results:

A small number of women detected with clinically significant lymphedema (n =12); 91% of women completed measures at two years after surgery. Two women had bilateral surgeries within the first month after enrollment. At 24 months, three times as many women in the control group compared to treatment group showed secondary lymphedema (except for volume criteria). Using volume criteria, a trend toward increased lymphedema in patients with mastectomy complete with breast conservation therapy existed. Hand or arm dominance did not influence lymphedema by these measurements. Logistic regression used to determine risk factors for development of lymphedema included

  • Axillary dissection by level
  • Number of lymph nodes removed
  • Number of lymph nodes affected with disease
  • Wound infection
  • Body mass index
  • Total wound drainage
  • Seroma
  • Age
  • RT
  • Occupation
  • Clinical.

Clinical incidence of lymphedema in the study was 21% at two years.

Conclusions:

The study was very well done and well designed.

Limitations:

  • The sample size was small; however, the data are useful in that they suggest a preventative approach with ongoing monitoring to prevent and minimize risk in a population with high-risk criteria for development of symptoms.
  • Anecdotal evidence of some specific cases.

Nursing Implications:

Nurses should advocate ongoing measurement to detect changes early and intervene.

Cinar, N., Seckin, U., Keskin, D., Bodur, H., Bozkurt, B., & Cengiz, O. (2008). The effectiveness of early rehabilitation in patients with modified radical mastectomy. Cancer Nursing, 31(2), 160–165.

doi: 10.1097/01.NCC.0000305696.12873.0e
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Study Purpose:

To evaluate the effects of the early onset rehabilitation program on shoulder mobility, functional capacity, lymphedema, and postoperative complications in patients who had modified radical mastectomy

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to either the treatment group (n = 27) or home exercise program group (n = 30). In the treatment group, specific shoulder-hand-elbow range-of-motion exercises were performed under the supervision of a physiotherapist until the drains were out, then participants followed a physiotherapy program for eight weeks. In the home exercise program group, patients received a form that demonstrated how to perform the exercises by themselves after removal of the drains. Each exercise was taught by a physiotherapist until the exercise was performed properly. Both groups were informed about skin care and other issues that they should pay attention to during daily living activities. Each patient was assessed preoperatively and then postoperatively on the fifth day and one, three, and six months after by another physiotherapist who was blinded to the groups of the patients.

Sample Characteristics:

  • The sample size consisted of 57 female patients with 27 in the intervention group and 30 in the comparison group.
  • Patients were about 50 years of age.

Setting:

The setting was a single site in Turkey that included inpatient and outpatient.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Circumferential measurements were used to assess lymphedema.
  • Range of motion of the operation-side shoulder joint was measured by Myrin goniometry while the patients were sitting in a chair.
  • A functional questionnaire was used.

Results:

There were statistically significant time-related changes in all range-of-motion measurements and functional questionnaire scores in both groups. The differences over time in flexion, abduction, and adduction movements were significantly better in the treatment group compared with the home exercise program group  (p < 0.01, p < 0.001, p < 0.005, respectively). The mean range of flexion and abduction returned to almost preoperative values more quickly in the treatment group compared with the home exercise program group. The recovery of upper-extremity functional questionnaire score was also significantly better in the treatment group compared with the home exercise program group  (p < 0.05). There was no statistically significant variance in circumferential difference between the groups.

Conclusions:

Early rehabilitation started on the first postoperative day did not have an adverse effect on local infection, hematoma, and seroma formation and did not cause an increase in duration and amount of lymphatic drainage.

Limitations:

  • The sample was small (N < 100).
  • The follow-up time for the late effect of breast cancer treatment, lymphedema, was shorter (only six months).

Nursing Implications:

Nurses and clinicians should remember to refer patients with breast cancer to a rehabilitation specialist. During the postoperative period, patients should be closely monitored to increase their adaptation and compliance to an early onset exercise program.

de Rezende, L.F., Franco, R.L., de Rezende, M.F., Beletti, P.O., Morais, S.S., & Gurgel, M.S. (2006). Two exercise schemes in postoperative breast cancer: Comparison of effects on shoulder movement and lymphatic disturbance. Tumori, 92(1), 55–61.

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Intervention Characteristics/Basic Study Process:

The study compared the effects on shoulder movement and lymphatic disturbance of two exercise schemes after surgery in patients with breast cancer. Subjects were randomly assigned to two exercise groups based on kinesiotherapy: directed group guided by a physiotherapist with a regimen of 19 exercises (exercises were performed 10 times with 60-second intervals between exercises) and free group, which had no defined sequence or number of repetitions. Both groups began with three exercises beginning on the first day after surgery. Exercises were performed in outpatient physiotherapy department. The study was reviewed by the Research Commission and Ethics Committee of the faculty of medical sciences. Patients participated in a 40-minute session three times weekly for a period of 42 days.

Sample Characteristics:

  • The study sample (N = 60) was comprised of female patients who had undergone modified radical mastectomy or quadrantectomy with axillary dissection for breast cancer.
  • Patients were excluded from the study if they
    • Underwent immediate reconstruction
    • Had bilateral breast surgery
    • Had greater than 2 cm difference in arm circumference before surgery
    • Experience any limitation of limb movement prior to surgery
    • Had greater than 20° difference in flexion and abduction before surgery.
    • Were unable to understand proposed exercises.

Setting:

Patients were recruited from State University of Campinas, Brazil.

Measurement Instruments/Methods:

  • Manual goniometer (no passive support given) was used to measure range of motion.
  • Arm circumference was measured using a universal tape measure; measurement points were 7.5 cm above the humeroradial joint and 7.5 cm below the humeroradial joint, at ulnar styloid at wrist, and at metacarpophalangeal joints.
  • Demographic data collected along with age, BMI, number of lymph nodes, and number of PT sessions.

Results:

No difference in groups was found in terms of individual characteristics and clinical-surgical characteristics. Incidence of infection was similar in both groups. Lymphatic disturbance showed no statistical difference between groups. Incidence of seroma was not statistically different between groups. The directed exercise group had more recovery of range of motion in shoulder in flexion, abduction, and external rotation compared with the free group. Patients who received directed exercises achieved better function and return to premorbid function than those patients who did free exercise.

Limitations:

  • The small sample size limits generalizability.
  • Access, time, and cost could be patient barriers.
  • Comorbidities are not addressed or described.

Gautam, A.P., Maiya, A.G., & Vidyasagar, M.S. (2011). Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy patients: Pre-post intervention study. Journal of Rehabilitation Research and Development, 48(10), 1261–1268.

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Study Purpose:

To determine the effectiveness of a home-based independent exercise regimen, comprised of upper-limb resistance exercises and deep breathing exercises, in relieving lymphedema symptoms and improving quality of life

Intervention Characteristics/Basic Study Process:

Participants received education from a qualified physiotherapist on how to perform the at-home exercise regimen for the first few sessions. Once satisfactory performance of the exercises had been completed, the patients received a handout about the exercise program and a log book to journal their progress. The exercise regimen was to be performed five days a week. Deep breathing exercises were to be performed between each set. It was recommended to only increase the weight if 2 sets of 15 repetitions became very easy to perform. The exercise regimen consisted of scapular retraction, shoulder extension, scapular protraction, scapular depression, elbow flexion, elbow extension, wrist flexion and extension, and ball squeeze. Patients were monitored weekly via telephone, and the fourth week all patients had a follow-up appointment with the investigators either in the home or at the hospital.  
 

Sample Characteristics:

  • The sample (N = 32) was comprised of female patients with breast cancer (stages I–II).
  • Mean age of the sample was 46.56 years.
  • All patients had underwent a unilateral mastectomy.
  • One and a half years before study participation, patients completed neoadjuvent chemotherapy and radiation (March 2006–February 2008).
     

Setting:

The study took place at multiple sites in Manipal, India.

Phase of Care and Clinical Applications:

Patients were transitioning between phases of care.

Study Design:

The study used a pre-post design. 

Measurement Instruments/Methods:

  • The arms were measured using two different methods, arm circumference and water displacement, to determine volumetric changes.
  • Quality of life was assessed using the 36-Item Short-Form Health Survey (SF-36).

Results:

A statistically significant reduction in upper-limb circumference was found at three measurements (p < 0.001) and in affected upper-limb volume (p<0.001). The mean volume reduction was 122 ml. The metacarpophalanfeal joint circumference reduction measurement was not found to be statistically significant (p = 0.04). A statistically significant change in quality-of-life score from the SF-36 was found after completion of the exercise regimen.

Conclusions:

The study has shown statistically significant improvements in limb volume and circumference reduction as well as improvement in QOL using this at-home exercise program.

Limitations:

  • The sample was small (N < 100).
  • The study did not have a control group or random assignment (all patients received the intervention).
  • Patient adherence to the exercise regimen can affect results.

Nursing Implications:

Because the findings from the study is statistically significant, it would be great for this research to be repeated with a more rigorous study design (i.e., randomized controlled trial) with a larger sample size to clarify effectiveness of the exercise regimen. If repeatedly proven that this exercise regimen is effective in reducing lymphedema, it would be a good program for nurses to teach their patients during discharge instructions because it is extremely simple and anyone can complete the exercises with common household items.

Hayes, S.C., Reul-Hirche, H., & Turner, J. (2009). Exercise and secondary lymphedema: Safety, potential benefits, and research issues. Medicine and Science in Sports and Exercise, 41(3), 483-489.

doi:10.1249/MSS.0b013e31818b98fb
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Study Purpose:

To investigate the effect of participating in a supervised, mixed-type exercise program on lymphedema status among women with lymphedema after breast cancer

Intervention Characteristics/Basic Study Process:

All measures were assessed before the intervention, immediately after the intervention, and at 12-week follow-up and were conducted by the same assessor who was blinded to participant group allocation. Participants were randomly allocated to the intervention group or the control group after being assessed before the intervention. The intervention involved a 12-week, mixed-type exercise program, including aerobic and resistance exercise.

Sample Characteristics:

  • The study sample (N = 32) was comprised of female patients with breast cancer.
  • Mean age of the sample was 59 years.
  • Patients were objectively measured by Perometer with greater than 200 ml differences.
  • Another 106 women who provided patient and treatment information were unable to participate because of the intervention requirements.

Setting:

The study took place in an outpatient setting in Queensland.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Lymphedema was assessed via bioimpedance spectroscopy and perometry.
  • Qualitative comments regarding the program and the lymphedema status provided by the women during exercise sessions were recorded.

Results:

There were no significant differences in lymphedema status at baseline or changes between testing phases observed between the intervention and control groups.

Conclusions:

Women with lymphedema can safely participate in this type of education.

Limitations:

  • The study had a small sample size (N < 100).
  • Intervention requirements caused many patients (N = 106) to be ineligible.
  • Generalizability for all the women treated for breast cancer should be cautioned.
  • The study reported on short-term follow-up only.

Nursing Implications:

Nurses should be aware that, at minimum, exercise does not exacerbate secondary lymphedema. Women with secondary lymphedema should be encouraged to be physically active, optimizing their physical and psychosocial recovery.

Jeffs, E., & Wiseman, T. (2012). Randomised controlled trial to determine the benefit of daily home-based exercise in addition to self-care in the management of breast cancer-related lymphoedema: A feasibility study. Supportive Care in Cancer, 21, 1013–1023.

doi:10.1007/s00520-012-1621-6
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Study Purpose:

To compare a home-based exercise program plus standard lymphedema self-care with self-care alone in the management of breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

Women were randomly assigned to self-care alone or self-care plus exercise groups. Self-care consisted of compression hosiery, skin care, and general activity. Regular hand pumping during any activity involving a closed handgrip was included as standard care. The exercise program combined a series of gravity resistive isotonic arm exercises in a specific sequence to simulate manual lymphatic drainage. Patients were assessed at baseline and at 4,12, and 26 weeks. Patients were instructed to do exercises taught daily for 10–15 minutes and provided pictures and written directions for the exercises.

Sample Characteristics:

  • N  = 23      
  • MEAN AGE =65
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had breast cancer
  • OTHER KEY SAMPLE CHARACTERISTICS:  Patients' duration of lymphedema ranged from 32–146 months.

Setting:

  • SITE: Single site  
  • SETTING TYPE: Home   
  • LOCATION: United Kingdon

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Study Design:

  • Randomized, controlled trial

Measurement Instruments/Methods:

  • Adherence to regimen evaluated via self report to open ended questions
  • Limb volume measurement with perometer optoelectronic measure
  • QuickDASH-9 questionnaire
  • Range of shoulder motion measured with goniometer

Results:

Out of 85 potential participants, only 23 consented to participate. Analysis showed significant arm volume reduction in the intervention group, no significant reduction in the control group, and no significant arm volume changes between groups by the end of the study. There was no improvement in quality of life or range of motion. Both groups reported high adherence to usual self care measures. Fifty-five percent of the intervention group reported adherence to daily exercise use.

Conclusions:

The exercise intervention appeared to have a positive effect in terms of limb volume lymphedema reduction. The study sample was likely too small to detect significant differences between groups at the end of the study.  Adherence to the exercise regimen was moderate.

Limitations:

  • Small sample (< 30)
  • Risk of bias (no blinding)
  • Unintended interventions or applicable interventions not described that would influence results
  • Questionable protocol fidelity
  • Other limitations/explanation: The intervention group had lower severity of lymphedema at baseline. Authors state they excluded patients with a history of non-adherence, but even with this exclusion only slightly more than half of those assigned to the exercise intervention used it consistently.

Nursing Implications:

Findings suggest that the exercise intervention used here in combination with standard lymphedema self-care may be beneficial in reducing arm lymphedema. This group of patients had long standing lymphedema, which can be more difficult to impact, so the approach may have promise. Findings suggest, however, that not a lot of patients wanted to participate in this, and that only about half actually completed the exercise as prescribed. Findings point to the challenge of maintaining patient adherence to such regimens and the need to develop effective strategies to support and facilitate patient adherence.

Johansson, K., Hayes, S., Speck, R.M., & Schmitz, K.H. (2013). Water-based exercise for patients with chronic arm lymphedema: A randomized controlled pilot trial. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, 92, 312–319.

doi: 10.1097/PHM.0b013e318278b0e8
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Study Purpose:

To evaluate the effect of a water-based exercise program on women with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

Women were randomly assigned to the exercise group or a wait list control group. The exercise intervention involved an initial instructional session followed by 30-minute sessions, three times per week for eight weeks, of specific exercises or swimming at moderate intensity on the Borg scale. After the initial instruction, sessions were unsupervised. Both groups completed weekly diaries of exercises performed. Measurement of outcomes was done at baseline and at the end of the study.

Sample Characteristics:

  • The study reported on 29 patients with a median age of 63 years (range = 56–74 years).
  • The sample was 100% female.
  • All patients had breast cancer-related lymphedema. Duration of lymphedema ranged from 32.8–101.7 months. Time since diagnosis ranged from 92–152 months. Lymphedema was defined as an arm volume difference of at least 5%.
  • Women who expressed interest after participating in another study were recruited.

Setting:

This was a single site study in an unspecified setting in Sweden.

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:

Perometry, bioimpedeance spectroscopy, local tissue water measurement via tissue dielectric constant measurement, shoulder range of motion (ROM) measures, and exercise diaries were used.

Results:

A quarter of the patients in the intervention group did not complete the interventions. No differences were found between groups in lymphedema. Some shoulder ROM measures were better in the exercise group (p ≤ 0.05).

Conclusions:

The water-based exercise used was feasible, but had no obvious impact on lymphedema severity. The water-based exercise regimen was associated with better shoulder ROM compared to controls.

Limitations:

  • The sample size was small, with fewer than 30 patients.
  • A risk of bias exists because no appropriate attentional control condition was included.
  • Unintended interventions or applicable interventions that were not described could influence results.
  • The study had a participant withdrawal rate of 10% or more.

Nursing Implications:

Water-based exercises and swimming may improve shoulder ROM but had no demonstrated effect on lymphedema severity in this study. In general, some evidence supports the benefit of exercise in lymphedema, but whether this type of water-based exercise is effective for actual lymphedema reduction is not clear.

Johansson, K., Tibe, K., Weibull, A., & Newton, R.C. (2005). Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology, 38(4), 167–180.

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Intervention Characteristics/Basic Study Process:

  • Patients performed low-intensity resistance exercises for arm lymphedema with or without a compression sleeve.
  • At least two weeks prior to start of the study, all participants had to wear a  compression sleeve according to their usual custom.
  • Prior to entering study, the compression sleeve had to be no older than three months.
  • The study had two training sessions, one with a compression sleeve and one without.

Sample Characteristics:

  • The study sample was comprised of 31 patients.
  • Patients were included in the study if they
    • Had unilateral arm lymphedema following breast cancer treatment
    • Measured at 10%–40% greater arm volume in the the lymphedema arm compared to the contralateral arm
    • Had an onset of edema more than three months after surgery that persisted for at least six months
    • Were younger than 70 years of age.
  • Patients were excluded from the study if they had recurrent cancer, another disease affecting the swollen limb, or language or cognitive limitations. 
  • Of the 42 eligible patients identified and randomly asked to participate in the study, four declined because of distance and seven did not reach the 10% volume criteria.

Setting:

The study took place at Lund University in Sweden.

Measurement Instruments/Methods:

  • Arm volume was measured using water displacement.
  • Multiple frequency bioelectrical impedance analysis was used to measure body composition.
  • Subjective sensations using a visual analog scale rated heaviness and tightness.
  • Perceived exertion was measured using the Borg scale.
  • The Physical Activity Questionnaire was used to assess level of weekly exercise, lasting 30 minutes over the past year.

Results:

Results showed no difference in arm volume between the the group without the compression sleeve (n = 15) and the group with the compression sleeve (n = 16). Controlled acute arm exercise program with low-intensity weights produced a slight arm volume increase that was transient and disappeared after 24 hours in the affected arm in patients with breast cancer experiencing lymphedema.

Conclusions:

Wearing compression sleeve during exercise did not influence arm volumes but should be worn as prescribed the rest of the time.

Limitations:

  • The sample size was small.
  • All patients in the study had mild-to-low-moderate lymphedema.

Nursing Implications:

More research is needed to validate results.

Jonsson, C., & Johansson, K. (2009). Pole walking for patients with breast cancer-related arm lymphedema. Physiotherapy Theory and Practice, 25(3), 165–173.

doi: 10.1080/09593980902776621
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Study Purpose:

To investigate the influence of pole walking on arm lymphedema following breast cancer treatment when using a compression sleeve

Intervention Characteristics/Basic Study Process:

Pole walking is a walking exercise with the addition of walking poles that simulates the arm motion of cross-country skiing during walking. Subjects participated in pole walking on one occasion for one hour outdoors in a park and on sidewalks for approximately 4 km. Each session was performed similarly and was supervised by the same person. Measurements were made before, immediately after, and 24 hours later.

Sample Characteristics:

  • The study sample was comprised of female patients aged less than 70 years.
  • Arm lymphedema was defined as the affected arm being 5% larger than the contralateral arm, including palpable thickness somewhere in the affected arm compared to the contralateral arm, and the patient's experience of tightness in the affected arm.
  • The edema had to be persistent for at least six months.

Setting:

The study took place at a single site in Sweden.

Study Design:

The study used a pre-post design.

Measurement Instruments/Methods:

  • Both arms were measured with the water displacement method and the contralateral arm was used as a control on each occasion.
  • Total arm volume was given in milliliters for both arms.
  • Lymphedema absolute volume was calculated as the volume difference between the arms.
  • The lymphedema relative volume was calculated in percentage.
  • Subjective lymphedema assessments of experience of heaviness and tightness in the affected arm while standing with their arms hanging and no arm sleeve on were used.
  • A 100-millimeter visual analog scale used the endpoints ‘‘no discomfort’’ (0 mm) and ‘‘worst imaginable".

Results:

The patients showed no significant difference in total arm volume in the edema arm immediately after pole walking or 24 hours later compared to before walking. Immediately after pole walking, a significant decrease in lymphedema absolute volume and in lymphedema relative volume was found compared to before pole walking. Twenty-four hours later, no differences were found compared to before walking. There were no significant differences in rating of heaviness and tightness on the visual analog scale immediately after pole walking or after 24 hours compared to the rating before pole walking.

Conclusions:

A controlled, short-duration pole-walking program can be performed by patients with arm lymphedema using a compression sleeve without deterioration of the arm lymphedema.

Limitations:

  • The study had a small sample size (N < 30).
  • Out of 42 candidates, 26 participated in the study.
  • Participation bias should be advised.

Nursing Implications:

Nurses and clinicians should be aware and encourage women with lymphedema to perform exercises, such as pole walking, which seems not to deteriorate arm lymphedema.

Jonsson, C., & Johansson, K. (2013). The effects of pole walking on arm lymphedema and cardiovascular fitness in women treated for breast cancer: A pilot and feasibility study. Physiotherapy Theory and Practice, 30, 236–242.

doi: 10.3109/09593985.2013.848961
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Study Purpose:

To investigate the effects on intensive pole walking on cardiovascular fitness, subjective assessment, and arm lymphedema in women who were treated for breast cancer

Intervention Characteristics/Basic Study Process:

Eight-week exercise period preceded by a two-week control period where subjects were asked not to change anything in daily living. Exercise was self directed 3–5 times/week for 30–60 minutes. Subject pace had to correspond to 70%–80% of estimated maximum heart rate (220-age). Warm up period of 10 minutes included pole walking and light arm exercises. Subjects wore compression garments during exercise and various measurements prestudy, at various intervals, and at the conclusion of the study.

Sample Characteristics:

N = 23  
MEAN AGE = 60 years
MALES: 0, FEMALES: 100%
KEY DISEASE CHARACTERISTICS: Patients with breast cancer with mean onset of lymphedema at 15 months post-op

Setting:

SITE:  Multi-site  

SETTING TYPE:  Outpatient  

LOCATION: Lymphedema unit at Skane University Hospital in Lund and Malmo, Sweden

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship
APPLICATIONS: Elder care, palliative care

Study Design:

Quasiexperimental

Measurement Instruments/Methods:

  • Pre-post design: 8 week exercise period preceded by a 2 week control period.
  • Arm volume bilateral measurements using the water displacement method and using unaffected arm as a control, cardiovascular fitness was assessed using sub-maximal bicycle ergometer test, which included heart rate monitoring. 
  • DASH questionnaire for symptom assessment 
  • Visual analogue scale for heainess and tightness in the affected arm
  • Two general well-being questions

Results:

Statistically significant reduction in total arm volume (p = 0.001), lymphedema absolute volume (p = 0.014), and lymphedema relative volume (p = 0.015), as well as decreased heart rate and rating of tightness in the arms. Both positive and negative influences on well-being were reported.

Conclusions:

Moderately intense exercise, such as pole walking, is feasible for patients with breast cancer with lymphedema. Standard precautions and use of compression garments during exercise is advisable. The effects of exercise on cardiovascular health and well-being are consistent with general public. Reduction in arm volume measurements post intervention should be further studied.

Limitations:

  • Small sample (< 30)
  • Measurement/methods not well described
  • Measurement validity/reliability questionable
  • Other limitations/explanation: Self reported adherence to intervention; measurement of well being and heaviness/tightness in affected arm—subjective assessment—reliability and validity of tools not addressed. Small n value. Further studies are needed.

Nursing Implications:

Patient education

Kilgour, R, Jones, D. Keyserlink, J. (2008). Effectiveness of a self-administered, home-based exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection: A preliminary study, Breast Cancer Research and Treatment, 109(2), 285–295.

doi: 10.1007/s10549-007-9649-x
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Study Purpose:

To study the effects of a self-administered home-based exercise video program designed to help women regain shoulder mobility immediately following surgery for modified radical mastectomy and axillary node dissection

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to usual care control or home-based exercise groups. Usual care consisted of standard written information on diet and skin care and a nine-page brochure entitled “Exercise Guide After Breast Surgery”. Participants were not encouraged to follow exercises, nor were they instructed not to do the exercises. The study was conducted during the immediate two-week recovery period following surgery. Over the next 11 days, women assigned to the home-based exercise intervention received the usual care education and followed the home-based exercise video program. Exercises involved upper-extremity movement designed to increase general range of motion, various neck movements, and stretches.

Sample Characteristics:

  • The study sample was comprised of female patients.
  • Mean age for the control group was 49.1 years and for the home-based exercise group was 50.6 years.
  • All patients had a modified radical mastectomy with axillary node dissection.
  • Patients were excluded from the study if they had a history or presence of shoulder dysfunction, were older than 65 years, or had sentinel node biopsy dissection only.

Setting:

The study took place at an outpatient setting in Montreal, Canada.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • The Oxford Manual Muscle Testing Scale
  • Hand-grip dynamometry
  • Circumferential tape measurements of both extremities
  • Participant self-report using the CR-10 Pain Scale and Borg's Category Scale for Rate of Perceived exertion

Results:

The experimental group demonstrated a significantly greater increase in flexion (p = 0.003) and abduction (p = 0.036) of shoulder. There was no significant difference in forearm circumference measurements, external rotation, grip strength, or pain. None of the patients in the home-based exercise group demonstrated any significant change in forearm circumference that would indicate lymphedema. Fifty percent of the patients in the home-based exercise group did not complete exercises because of pain at the shoulder joint and axillary swelling, 25% because of lack of support from family and others, 12.5% for no specific reason.

Conclusions:

Self-directed home exercise was associated with greater improvement in some range of motion over time and did not appear to aggravate lymphedema development. There was generally low adherence to the self-directed program.

Limitations:

  • The study had a small sample size (N < 30).
  • The study was short, with insufficient evidence about how the program might affect women at longer intervals.
  • Because the control group was aware of the exercise arm of the study, they may have completed more exercise than they otherwise would have, and no control was put in place to not exercise.
  • In the home-based exercise group, 50% did not adhere to the exercise program for a variety of reasons.
  • It is not clear if the exercise program contributed to join pain and axillary swelling experienced by 25% of patients.

Nursing Implications:

Poor adherence to the home based self-directed program point to the challenges associated with the approach described in the study.

Kim do, S., Sim, Y.J., Jeong, H.J., & Kim, G.C. (2010). Effect of active resistive exercise on breast cancer-related lymphedema: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 91(12), 1844–1848.

doi: 10.1016/j.apmr.2010.09.008
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Study Purpose:

To investigate the effects of complex decongestive physiotherapy with and without active resistive exercise on volume reduction of the upper limb and improvement of quality of life (QOL) in patients with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to the active resistive exercise (ARE) group or the the nonactive resistive exercise group. Both groups received complete decongestive physiotherapy (CDPT) led by a physical therapist once a day, five days a week, for two weeks. The nonactive resistive exercise group then continued self-administered CDPT for another six weeks. The ARE group performed shoulder stretching exercises followed by using dumbbells for 15 minutes while wearing a compression stocking or multilayer bandage.

Sample Characteristics:

  • The study sample was comprised of 40 patients.
  • Mean age of the ARE group was 50.5 years and for the nonactive resistive group 50.9 years.
  • Patients were included in the study if they had a greater than 2 cm circumference difference between the affected and normal arm or had lymphedema diagnosed via lymphoscintigraphy.
  • Patients were excluded from the study if they were aged 70 years or older; had cancer recurrence within six months from time of entering study; had lymphedema in both arms; had vascular disease; had any neurologic signs, such as decreased motor power, sensory changes, or decreased deep tender reflexes; or could not communicate

 

Setting:

The study took place in an outpatient setting at Kosin University Gospel Hospital in Korea.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Circumference was measured every 3 cm before and after eight weeks of treatment to determine limb volume.
  • QOL was measured using the 36-Item Short Form Health Survey Version 2 (SF-36v2) before treatment and after eight weeks of treatment.
     

Results:

Both groups showed significantly reduced volumes after treatment, but the difference between the reduced volume in the distal arm and that of the total arm was not significant. The ARE group showed a significantly reduced volume in the proximal arm. Although CDPT  is described as manual lymphatic drainage, compression therapy, and remedial exercise, description of the remedial exercises does not identify whether or not a compression garment or multilayer bandages were worn. Patients in the ARE group wore a compression stocking or a multilayer bandage to avoid aggravation of the lymphedema in the shoulder and arm while doing exercises.

Both groups had reduced QOL demonstrated by baseline values on the SF-36v2. After treatment, patients in the ARE group showed significant improvements in the SF-36v2 categories of physical functioning, role-physical, body pain-general and mental health. The nonactive resistive exercise group experienced improvements in physical functioning, role-physical, body pain, and mental health. By comparison, the ARE group showed significant improvements in role-physical and general health as compared with the nonactive resistive exercise group.
 

Conclusions:

ARE demonstrated volume reduction in the proximal arm, with no statistically significant reduction in the distal or overall measurement. More robust research focusing on the relationship between resistive exercise and lymphedema is needed.

Limitations:

  • The study had a small sample size (N < 100).
  • No binding was done for the study.
  • Findings not are not generalizable.
  • The study does not indicate if patients are male or female.
  • The age range of participants exceeds the exclusion criteron of older than 70 years, indicating that the sample size was potentially even smaller.

Nursing Implications:

Exercise, including ARE, appear to be beneficial for patients with BCRL.  It is important to note that all participants in this small study received CDPT, with self-administration techniques included. Nurses should encourage patients to speak with a therapist experienced in CDPT prior to initiating an exercise program.

Malicka, I., Stefańska, M., Rudziak, M., Jarmoluk, P., Pawłowska, K., Szczepańska-Gieracha, J., & Woźniewski, M. (2011). The influence of Nordic walking exercise on upper extremity strength and the volume of lymphoedema in women following breast cancer treatment. Isokinetics and Exercise Science, 19(4), 295–304.

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Study Purpose:

To examine the effect of Nordic walking on upper-extremity strength and lymphedema

Intervention Characteristics/Basic Study Process:

Participants were randomly assigned to the walking group or the control group, who did not participate in any rehabilitation program. The program consisted of two hour-long sessions each week for eight weeks. Sessions involved a 10-minute warm up and 40 minutes of Nordic walking at 85% of maximum heart rate, followed by 10 minutes of stretching and relaxation exercises.

Sample Characteristics:

  • The study sample was all female with a mean age of 62.8 years.
  • Patients had undergone radical mastectomy (79%) or breast-conserving surgery (21%). Mean time since surgical treatment was 7.6 years.
  • Most patients had received adjuvant therapy, chemotherapy, radiation therapy, or hormonal therapy.
  • No axillary dissection was reported.
  • Only 34% of patients had lymphedema.

Setting:

The study took place in an outpatient setting in Poland.

Phase of Care and Clinical Applications:

  • Patients were undergoing long-term follow-up care.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • An isokinetic dynamometer was used to test muscle strength.
  • Lymphedema volume was evaluated by measuring circumferences of both upper extremities with use of a tape measure at five levels.

Results:

A variety of changes in muscle strength were observed. No differences were found between groups in arm volume results.

Conclusions:

The study did not provide any evidence that Nordic walking improved lymphedema.

Limitations:

  • The sample size was small, with fewer than 100 patients.
  • The authors did not indicate if exercise was done alone or in groups. 
  • Only a third of patients had lymphedema.
  • High variability existed in the sample of time since surgery, which would be expected to influence observance of lymphedema. 
  • No other lymphedema risk factors were reported, and use of other prevention or treatment strategies were not discussed.
  • The study was not blinded.

Nursing Implications:

The study had several methodologic weaknesses and did not provide strong evidence either for or against the effects of Nordic walking on lymphedema after breast cancer treatment.

McClure, M.K., McClure, R.J., Day, R., & Brufsky, A.M. (2010). Randomized controlled trial of the Breast Cancer Recovery Program for women with breast cancer-related lymphedema. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 64(1), 59–72.

doi: 10.5014/ajot.64.1.59
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Study Purpose:

To determine effect of completion of a recovery program including gentle exercise and deep breathing on breast cancer-related lymphedma

Intervention Characteristics/Basic Study Process:

Patients assigned to the treatment group attended biweekly one-hour exercise and educational sessions for five weeks, then followed a three-month self-monitored home program. Those in the treatment group were instructed to complete use of a video and relaxation daily at home. Exercises included gravity-resistive arm movements incorporating shoulder flexion, abduction, and external rotation. Exercise and compression hose adherence was assessed with a self-report tool designed for the study. Control patients received usual care. Patients were assigned into four groups of treatment and controls.

Sample Characteristics:

The study sample (N = 32) was comprised of female patients aged 21–80 years with stage I or II unilateral breast cancer-related lymphedema.

 

Setting:

The study took place in an outpatient site in Pittsburgh, PA.

Study Design:

The study used a randomized controlled single blind trial design.

Measurement Instruments/Methods:

  • Bioimpedance differences were compared between the affected and unaffected arm.
  • The Beck Depression Inventory measured severity of depression.
  • The 36-Item Short Form Health Survey (SF-36) measured quality of life.
  • Cone girth was measured.

Results:

Bioimpedance mean differences of those in treatment compared with controls showed a positive main effect for treatment (p = 0.049). There was no significant effect on volume measures. Patients who complied with compression demonstrated improvement over time. Range of motion, mood, and quality of life improved in those in the treatment group.

Conclusions:

The program of combined exercise activity and self-directed practice related to coping and relaxation were associated with improvement in lymphedema and other symptoms.

Limitations:

  • The sample size was small (N < 100).
  • The study had no attentional control.
  • Limited information is provided regarding all aspects of the intervention.
  • Lack of participant binding poses potential for patient self-report measures.

Nursing Implications:

Findings support the positive benefit of patient upper-extremity exercises in the management of lymphedema.

Scaffidi, M., Vulpiani, M.C., Vetrano, M., Conforti, F., Marchetti, M.R., Bonifacino, A., . . . Ferretti, A. (2012). Early rehabilitation reduces the onset of complications in the upper limb following breast cancer surgery. European Journal of Physical and Rehabilitation Medicine, 48, 601–611.

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Study Purpose:

To clinically evaluate upper ipilateral limb function and the impact of certain post-surgical consequences arising after invasive or breast-conserving surgery for early breast cancer, by intervening, or not intervening, with an early rehabilitation program

Intervention Characteristics/Basic Study Process:

Group A received reoperative information verbally; did not begin physiotherapy during hospitalization. Group B received preoperative information in written form; treated by a dedicated physiotherapist during hospitalization from the day following surgery until the hospital discharge. One physiotherapy session per day, with each session lasting for 30–40 minutes. The exercises were initially focused on deep breathing, relaxation, stretching of the neck muscles, and then on elevation, abduction, external and internal rotation of the shoulder, flexion and extension of the elbows in a neutral position. The patients were instructed on how to position their shoulder-arm in bed and how to carry out exercises at home after discharge. The patients were given an exhaustive brochure containing pictures and explanations of the exercises to carry out at home. All patients were assessed at 15–30, 60, and 180 days after surgery. 

Sample Characteristics:

N = 83    
MEAN AGE = Group A: 49.6 (SD = 8.8); Group B: 52.1 (SD = 11.9)
MALES: 0%, FEMALES: 100%
KEY DISEASE CHARACTERISTICS: Patients with breast cancer who all had lymph node dissection for early breast cancer surgery

Setting:

SITE:  Single site  

SETTING TYPE:  Inpatient  

LOCATION: Rome, Italy

Phase of Care and Clinical Applications:

PHASE OF CARE: Transition phase after active treatment

Study Design:

Two-group cohort comparison

Measurement Instruments/Methods:

  • Shoulder-arm mobility, upper limb function, presence of lymphedema, prescription of outpatient physiotherapy
  • Constant and Murley Score for mobility
  • Arm circumference measures

Results:

Although no differences were identified between two groups in the outcome assessment, statistically significant differences (p <  0.05), in favor of Group B, were encountered at the 180-day follow-up visit, including shoulder-arm mobility, upper limb function (p < 0.001), and presence of lymphedema (p = 0.036).

Conclusions:

The early assisted mobilization (beginning on the first postoperative day) and home rehabilitation, in conjunction with written information on precautionary hygienic measures to observe, play a crucial role in reducing the occurrence of postoperative side-effects of the upper limb.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Risk of bias(sample characteristics)
  • Other limitations/explanation: limited follow-up duration, retrospective first follow-up visit in Group A

Nursing Implications:

The study findings suggest that nurses should be aware of early rehabilitation (e.g., early assisted mobilization right after the surgery) and home exercises rehabilitation as well as written/educational information may play a critical role to prevent postoperative side-effects in patients with breast cancer. Studies with rigorous design are warranted to further evaluate the study intervention.

Sisman, H., Sahin, B., Duman, B.B., & Tanriverdi, G. (2012). Nurse-assisted education and exercise decrease the prevalence and morbidity of lymphedema following breast cancer surgery. Journal of B.U.O.N.: Official Journal of the Balkan Union of Oncology, 17(3), 565–569.

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Study Purpose:

To investigate the effect of education and exercises on development and progression of lymphedema

Intervention Characteristics/Basic Study Process:

Patients were informed about measures to prevent lymphedema and about exercises. They were given written material prepared by the investigators. No further specifics about the education or exercises is provided.

Sample Characteristics:

  • The sample (N = 55) was comprised of 1.8% male and 98.2% female patients.
  • All patients had breast cancer.
  • Ninety-six percent of patients had modified radical mastectomy and 45% had adjuvant radiotherapy.

Setting:

The study took place in an outpatient setting in Turkey.

Study Design:

The study used a prospective observational design.

Measurement Instruments/Methods:

Arm circumference was measured.

Results:

Authors compared the percent of patients with minimal to severe lymphedema between those who exercised and those who did not over a six-month period; however, only 10 patients were noted to not exercise and sample sizes used in analysis were extremely small per severity group. Some patients who had lymphedema at study entry were stated to have no lymphedema at week 6.

Conclusions:

 Results are inconclusive given multiple limitations of the study.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • The study had risk of bias due to no blinding, no random assignment, and no control group.
  • Measurement and methods are not well described, making the measurment validity and realiablity questionable.
  • The study does not provide clear information about node dissection and radiotherapy in relation to lymphedema development, does not fully describe the intervention or any other standard care interventions (e.g., bandanging), and does not describe how severity of lymphedema was determined.
  • There was only a single point at which arm circumference was measured, which is a questionable measurement method. 
  • Time since surgery was highly varied with a range of 1–105 months.

Nursing Implications:

Study findings are inconclusive regarding the effect of patient education and information to prevent or manage lymphedema in patients with breast cancer.  Findings provide minimal support for use of exercise because of study report limitations.

Torres Lacomba, M., Yuste Sanchez, M.J., Zapico Goni, A., Prieto Merino, D., Mayoral del Moral, O., Cerezo Tellez, E., & Minayo Mogollon, E. (2010). Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: Randomised, single blinded, clinical trial. BMJ (Clinical Research Ed.), 340, b5396.

doi:10.1136/bmj.b5396
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Study Purpose:

To determine effectiveness of an early physiotherapy program in reducing the risk of secondary lymphedema in women after surgery for breast cancer

Intervention Characteristics/Basic Study Process:

Early therapy included manual lymph drainage, stretching exercises for key muscle groups, progressive active and assisted shoulder exercises, proprioceptive facilitation exercises without resistance along with education consisting of instruction with printed materials. All patients were followed up 4 weeks after surgery and at 3, 6 and 12 months. Follow-up time points were somewhat flexible by design; however, actual differences in follow-up are not described. If secondary lymphedema occurred, complex decongestive therapy was carried out.

Sample Characteristics:

  • The study sample (N = 116)  was comprised of female patients with breast cancer postoperatively.
  • Mean age was 52.9 years.
  • Patients were excluded if they were receiving adjuvant therapies.

Setting:

The study took place in an outpatient setting in Spain.

Study Design:

The study used a randomized, single-blinded, controlled trial design.

Measurement Instruments/Methods:

  • Arm circumference was measured at 5 cm intervals on both arms.
  • Demographic data was collected.
  • Computed volume ratio was compared between arms.

Results:

Incidence of secondary lymphedema was 25% in the control group compared to 7% in the intervention group (p = 0.01). In both groups the volume of the affected arm increased over time. In the control group, the volume was an average of 5.1% greater in the affected arm compared to 1.6% greater in the intervention group (p = 0.0065). Survival analysis showed that secondary lymphedema developed more rapidly in the control group and the protective effect of early physiotherapy remained for a longer time.

Conclusions:

Early physiotherapy can be an effective intervention for prevention or mitigation of secondary lymphedema after surgery for breast cancer within one year after surgery.

Limitations:

  • Actual exercise done by the control group is not known.
  • Adherence of any patients to educational guidance is not discussed.
  • Methods state that complex decongestion would be done in any case of lymphedema; however, these findings or differences between groups are not mentioned.
  • One-year follow-up does not make it clear if early physiotherapy remains effective over the longer term.

Nursing Implications:

Early physiotherapy and related exercises are helpful in preventing or mitigating lymphedema in the short term for patients who have had surgery for breast cancer involving axillary lymph node dissection. Ongoing research in this area is needed to determine effective strategies in the longer term for this chronic problem.

Systematic Review/Meta-Analysis

Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., & Harris, S.R. (2006). Exercise for women with or at risk for breast cancer-related lymphedema. Physical Therapy, 86(10), 1398–1405.

doi: 10.2522/ptj.20050328
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Purpose:

To question: (a) Does aerobic or resistance exercise lead to lymphedema in women who are at risk? and (b) Does aerobic or resistance exercise reduce or exacerbate preexisting lymphedema?

Search Strategy:

Databases searched were in CINAHL, EMBASE ,MEDLINE PEDro, and PubMed.

Literature Evaluated:

Eight studies were reviewed; five were Sackett level V and three studies were level ll.

Conclusions:

It has long been believed that aerobic exercise and UE resistance should be avoided for women at risk of or who have lymphedema; however, recent studies suggest that it may be safe.

Nursing Implications:

Additional research with larger randomized controls is needed to determine the safety and effectiveness of exercise for women with breast cancer-related lymphedema.

Chan, D.N., Lui, L.Y., & So, W.K. (2010). Effectiveness of exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: Systematic review. Journal of Advanced Nursing, 66(9), 1902–1914.

doi: 10.1111/j.1365-2648.2010.05374.x
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Purpose:

To review the effectiveness of exercise programs on shoulder mobility and lymphoedema in patients with breast cancer after having axillary lymph node dissection as revealed by randomized controlled trials

Search Strategy:

Databases searched were CINAHL, Ovid Medline, the BritishNursing Index, Proquest, Science Direct, PubMed, Scopus, and the Cochrane Library. Search keywords were breast; cancer, malignancy, neoplasm, or tumour; modified radical mastectomy, radical mastectomy, breast conservation surgery, wide local excision, axillary lymph node dissection, or adjuvant therapy; exercise, training, weight training, stretching exercise, physical activity, rehabilitation or resistance training, aerobic training, strength training, or lifestyle or range of motion exercises; lymphoedema, arm circumference, arm swelling, oedema, range of motion or shoulder mobility, joint movement, or shoulder function. Studies were included in the study if they

  • Were published in English
  • Were randomized controlled trials
  • Included women undergoing breast cancer treatment with axillary lymph node dissection
  • Had treatment strategies defined as various types of exercise programs: weight training, aerobic and strengthening exercises, stretching and range of motion exercises.

Studies were excluded if they

  • Targeted male participants
  • Reported only decongestive therapy involving manual lymphatic drainage, compression garments, or skin care as interventions
  • Dealt with patients undergoing sentinel lymph node biopsy.
     

Literature Evaluated:

The total number of studies initially reviewed was 325. A quantitative effectiveness review was used with levels of evidence defined by the Joanna Briggs Institute.

Sample Characteristics:

  • Six studies were included in the report.
  • The total sample size across studies was 429 female patients with a range of 27–205.
  • Mean age of the sample was less than 60 years.
  • Patients were from the United States, Sweden, the Netherlands, Turkey, Canada, and Australia.

Conclusions:

Early rather than delayed onset of training did not affect the incidence of postoperative lymphoedema, but early introduction of exercises was valuable in avoiding deterioration in range of shoulder motion.

Nursing Implications:

Nurses have an important role in educating and encouraging patients to practice these exercises to speed up recovery.

Chang, C.J., & Cormier, J.N. (2013). Lymphedema interventions: Exercise, surgery, and compression devices. Seminars in Oncology Nursing, 29, 28–40.  

doi: 10.1016/j.soncn.2012.11.005
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Purpose:

STUDY PURPOSE: To review the current literature regarding the treatment of lymphedema, providing applications of the evidence to the care of patients with cancer, with or at risk for, lymphedema

TYPE OF STUDY:  General review and semisystematic

Search Strategy:

DATABASES USED: 11 major medical indices from 2004–2010
 
KEYWORDS:  Lymphedema, exercise, surgical treatment, excisional procedures, lymphatic reconstruction, tissue transfer, lymphedema management, intermittent pneumatic compression
 
EXCLUSION CRITERIA:  Predefined, not listed in this article

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: N = 1,303
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: 659 reviewed by clinical lymphedema experts for inclusion in categories of lymphedema, with exercise and/or surgery

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED =  19 exercise; 20 surgery; 13 IPC
 
TOTAL PATIENTS INCLUDED IN REVIEW:   Approximately 2,554; > 295 exercise, 2,016 surgery, 243 IPC

Phase of Care and Clinical Applications:

PHASE OF CARE:  Mutliple phases of care

Results:

The PAL trial provides the strongest evidence to date that progressive resistive exercises may reduce the risk of, and not exacerbate pre-existing,  BCRL. However, no clear evidence-based recommendation regarding compression garment use during exercise can be made. Surgical treatment is associated with risk, and should not be considered a first line treatment.  IPC devices may play a role in a multi-modality approach.  There are no clear evidence-based guidelines for pressure setting use in lymphedema management.

Conclusions:

CDT remains the standard in LE therapy, but there is some limited evidence supporting consideration of adjunctive therapies, such as exercise, surgery, and IPC. More RCTs looking at exercise and LE in populations other than those with breast cancer are needed, especially studies with LE of other areas of body, and role of compression garments during exercise. Surgical treatments are promising in LE not responsive to standard therapy. IPC in low to moderate pressure ranges appear to be a safe adjunctive treatment option for appropriate, selective patients, in conjunction with CDT.

Limitations:

  • Exercise studies were limited to BCRL. 
  • Surgical studies need larger cohorts. 
  • Longer follow-up was needed. 
  • IPC studies are needed evaluating cost benefit, as well as specific recommendations, for pressure settings and length of treatments.

Nursing Implications:

Patients with LE need education regarding the benefits of exercise in general health and cancer prevention, tailored to their individual needs and comorbidities. Surgery for LE should not be considered a first-line treatment. Microvascular procedures should be treated by experienced surgeons offering ongoing care with support from certified lymphedema providers. IPC is potentially a valuable adjunctive therapy, and should be prescribed only by practitioners trained at a specialist level. With no clear guidelines for use, the authors recommend the current NLN recommendations for pump pressures from 30-60 mmHG. Additional research is essential in these categories to provide evidence based guidelines and safe, effective patient care for patients with lymphedema.

Cheema, B., Gaul, C.A., Lane, K., & Fiatarone Singh, M.A. (2008). Progressive resistance training in breast cancer: A systematic review of clinical trials. Breast Cancer Research and Treatment, 109(1), 9–26.

doi: 10.1007/s10549-007-9638-0
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Purpose:

To systematically review studies that have prescribed progressive resistance training (PRT) in breast cancer

Search Strategy:

Databases searched were PubMed, Medline, CINAHL, SportDiscus, Embase, and Web of Science. Search keywords were breast cancer, oncology, malignancy, neoplasm, tumor, mastectomy, lumpectomy, radiotherapy, chemotherapy, and exercise training, training, physical activity, rehabilitation, resistance training, aerobic training, strength training, lifestyle, muscle, endurance, and strength. Studies were included if they

  • Had a patient population of adults aged 18 years or older diagnosed and surgically treated for malignancy of the breast
  • Prescribed PRT in isolation or in combination with other exercise modalities (e.g., aerobic training) after breast cancer surgery, adjuvant therapies (i.e., radiotherapy or chemotherapy), or any other time after breast cancer treatment
  • Evaluated outcomes potentially responsive to chronic PRT, including a broad spectrum of physiological, functional, and psychological outcome measures.

Studies were excluded if they investigated the effects of single, acute bouts of PRT, prescribed movement exercises without loading against a resistance, or prescribed PRT before breast cancer treatment.
 

Literature Evaluated:

The total number of studies initially reviewed was 12. The Delphi List was used as the method of study evaluation.
 

Sample Characteristics:

  • The number of studies included in the report was 10.
  • The total sample size across studies was 538, with a range of less than 20 to 242.
  • Patients were female and being treated for breast cancer stages 0–III.
  • Some patients had lymphedema.
  • Patient age ranged from 25–78 years.
  • Most patients were post-menopausal.
  • The majority of patients received intervention after chemotherapy or radiation.

Results:

The study included a broad spectrum of physiological (body compositions, including reduced sum of five skinfolds, reduced waist and hip circumferences, reduced percent body fat, and increased muscle mass) , functional (improved upper-body strength, increased upper-body muscular endurance, increased flexibility of the ipsilateral (surgical) and contralateral shoulder joint, and improvements of lower-body strength) and psychological (improved aspects of quality of life, depression, and mood) outcome measures. Lymphedema incidence secondary to exercise programs was tracked as an adverse event in six studies. There was no incidence or exacerbation of lymphedema or improvements in lymphedema attributed to the exercise regimens.

Conclusions:

Women surgically treated for breast cancer can derive health-related and clinical benefits by performing PRT after breast cancer surgery. No exacerbation or improvement of objectively measured or subjectively reported lymphedema symptoms were reported.

Nursing Implications:

PRT should be advocated among oncologists and in community care settings.

Kwan, M.L., Cohn, J.C., Armer, J.M., Stewart, B.R., & Cormier, J.N. (2011). Exercise in patients with lymphedema: A systematic review of the contemporary literature. Journal of Cancer Survivorship: Research and Practice, 5(4), 320–336.

doi: 10.1007/s11764-011-0203-9
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Purpose:

To examine the evidence and produce recommendations for exercise and lymphedema management in female breast cancer survivors

Search Strategy:

  • Databases searched were MEDLINE, CINAHL, Cochrane Library, PapersFirst, ProceedingsFirst, WorldCat, PEDro, National Guidelines Clearing House, DARE, and ACP Journal Club.
  • Search keywords were lymphedema, swelling, edema and keywords for exercise, such as physical activity, physical therapy, exercise, strength training.
  • Studies were included if they were randomized controlled, cohort, or case-control studies or meta-analyses or systematic reviews.
  • Exclusion criteria were not specified. 

Literature Evaluated:

A total of 659 references were retrieved. Two authors used the Oncology Nursing Society Putting Evidence Into Practice (PEP) categories of evidence to evaluate the references.

Sample Characteristics:

  • The final number of studies included was 19.
  • The sample size across studies was 912 patients with breast cancer, with a range of 14–242.

Phase of Care and Clinical Applications:

Patients were undergoing multiple phases of care.

Results:

Resistance exercises were determined to be "Likely to be effective." Aerobic and resistance exercise were rated as "Benefits balanced with harms," though no clear harms were obvious in the review of the studies. Other exercise approaches studied were deemed "Effectiveness not established."

Conclusions:

Benefits of exercise have been reported, and this review suggests that current evidence supports the use of resistance exercising.

Limitations:

  • The method of evaluating aerobic exercise was not clear.
  • Not all studies included use of compression garments during exercise.

Nursing Implications:

Findings support the use of resistance exercise in women with breast cancer for the management of arm lymphedema.

McNeely, M.L., Campbell, K., Ospina, M., Rowe, B.H., Dabbs, K., Klassen, T. P., . . . Courneya, K. (2010). Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database of Systematic Reviews (Online), 6, CD005211.

doi:10.1002/14651858.CD005211.pub2
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Purpose:

To examine the evidence of effectiveness from randomized controlled trials involving exercise interventions for preventing, minimizing, and improving upper-limb dysfunction because of breast cancer treatment

Search Strategy:

Databases searched were Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, EMBASE, CINAHL, and LILACS (to August 2008). Experts, hand-searched reference lists, conference proceedings, clinical practice guidelines and other unpublished literature sources were also considered. Search keywords were neoplasm, tumor, tumour, mastectomy, axillary dissection, sentinel node dissection, adhesive capsulitis, cording, axillary web syndrome, physical therapy, physiotherapy, rehabilitation, exercise, stretching, mobilization, physical activity, exertion, range of motion, strength, lymphedema, pain, and quality of life. Studies were included if they were randomized controlled trials evaluating the effectiveness and safety of exercise for upper-limb dysfunction. Studies were excluded if they included cancers other than breast cancer (e.g., melanoma) unless separate data were available for a breast cancer subgroup.
 

Literature Evaluated:

The total number of studies reviewed initially was 82. Two authors independently performed the data abstraction. One author performed the initial pre-screen of all the databases to identify potential trials and screened the results to exclude articles that were clearly irrelevant. Two independent authors screened the reduced search results. If either or both authors felt that the article potentially met the inclusion criteria, or if there was inadequate information to make a decision, full-text copies of the article were retrieved. Using the defined eligibility criteria, the two authors independently decided on trial inclusion. A priori, authors made the decision to exclude any data that were available only in abstract form. Review authors were not blinded to study authors, journal, or study results. Agreement was measured and assessed using kappa statistics. Three investigators independently assessed quality of the trials and extracted data independently using a standardized form. Investigators were contacted for missing data.
 

Sample Characteristics:

  • The total number of studies included was 24.
  • The sample size across studies was 2,132, with a range of 21–344.
  • Patients were women with lymphedema after breast caner treatment.
  • Mean age of patients ranged from 46.3–62.1 years.

Conclusions:

Exercise can result in a significant and clinically meaningful improvement in shoulder ROM in women with breast cancer. There is evidence that patients benefit from exercise interventions that include more structured instruction and supervision when compared to exercise instruction through a pamphlet or no exercise instruction. Of note, larger benefits were found for shoulder range of motion and shoulder function outcomes from physical therapy treatment that was introduced in the early weeks following surgery. There was no evidence of a negative effect from upper-extremity exercise on the incidence of upper-limb lymphedema at any time point following surgery.

Nursing Implications:

In the postoperative period, consideration should be given to early implementation of exercises, although this approach may need to be carefully weighed against the potential for increases in wound drainage volume and duration. High-quality research studies that closely monitor exercise prescription factors (e.g., intensity) and address persistent upper-limb dysfunction are needed.

Preston, N.J., Seers, K., & Mortimer, P.S. (2008). Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database of Systematic Reviews (Online), Issue 4, CD003141.

doi: 10.1002/14651858.CD003141.pub2
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Purpose:

To assess the effect of physical treatment programs on the volume, shape, condition, and long-term (six months) control of oedema in lymphoedematous limbs and to assess the psycho-social benefits of physical treatment

Search Strategy:

Databases included in the review were the Cochrane Breast Cancer Group Trials Register, The Cochrane Central Register of Controlled Trials, MEDLINE©, EMBASE, CINAHL©, the National Research Register and UnCover, PASCAL, SIGLE, reference lists produced by The British Lymphology Society, and The International Society of Lymphology Congress Proceedings. Keywords were lymphoedema, lymphedema, lymphodema, or elephantiasis; exercise; physical therapy; bandage; hosiery or hose; compression; bandages and dressings; compression garments; physical therapy modalities; intermittent pneumatic compression devices; physiotherapy; kinesiotherapy; compression stocking; pneumatic compression; limb volume; limb size; excess (limb) volume; oedema or edema volume; and quality of life measure or tool. Studies were included in the review if they were randomized controlled trials that tested physical therapies with a follow-up period of at least six months. Studies were excluded if they had a follow-up  less than six months or the trial did not use limb volume as the method of assessing change in size.

Literature Evaluated:

The total number of studies reviewed initially was 185. Two blinded reviewers independently assessed trial quality and extracted data. Meta-analysis was not performed because of the poor quality of the trials.

Sample Characteristics:

  • Three studies were included in the report.
  • The total sample size was 150.
  • The sample range across studies was 25–33.
  • All types of lymphedema were included, non cancer-related and cancer- related.
  • Patients with cancer had to have completed their cancer treatment at least six months before entering the trial and could not have evidence of recurrent malignant disease when going into the trial.

Conclusions:

Wearing a compression sleeve is beneficial. The bandage plus hosiery results in a greater reduction in excess limb volume than hosiery alone and this difference in reduction was maintained long term.

Limitations:

All three trials have their limitations and have yet to be replicated, so their results must be viewed with caution.

Nursing Implications:

There is a clear need for well-designed, randomised trials of the whole range of physical therapies if the best approach to managing lymphedema is to be determined.

Young-McCaughan, S., & Arzola, S.M. (2007). Exercise intervention research for patients with cancer on treatment. Seminars in Oncology Nursing, 23, 264–274.

doi: 10.1016/j.soncn.2007.08.004
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Purpose:

To review research and guidelines regarding the use and potential benefits of exercise for patients with cancer undergoing treatment

Search Strategy:

Databases searched were Ovid, MEDLINE, and CINAHL (1980–2007).

Sample Characteristics:

  • Studies involved male and female patients with cancer undergoing treatments. The majority of studies involved women with breast cancer. Other cancers included prostate, colon, lung, stomach, endometrial, head and neck, lymphoma, multiple myeloma, and melanoma. Patients undergoing bone marrow or stem cell transplant also were represented.
  • Most studies involved patients with stage I or II disease, and some studies involved patients with metastatic disease. In patients with metastatic disease, as high as two-thirds were able to complete a 12-week program.
  • Most exercise intervention studies with patients with cancer followed the American College of Sports Medicine recommendations.  

Results:

Stage of Disease:

  • Evidence suggests that, although most studies recruited from patient populations with early stage I or II disease, even patients with metastatic disease have been able to exercise successfully.
  • Stage of disease may influence exercise program completion rates.  In one study, however, almost two-thirds of the participants with stage III or IV disease were able to complete the 12-week intervention study. Patients appear to be able to safely and successfully exercise.

Types of exercise programs:

Most studies involved aerobic exercise, 11 studies included strength training, and 8 studies examined a combination of aerobic with strength training. None evaluated flexibility exclusively. 

Outcomes:

Compared to controls, the exercise groups improved cardiovascular and muscular fitness, experienced less fatigue, and slept longer. Exercise has been shown to improve almost all aspects of physiologic and psychologic functioning, including immune status. Of all the measures affected, cancer fatigue was the most improved. Although cancer fatigue has been thought to prevent patients with cancer from exercising, evidence has demonstrated that those who exercise experience less fatigue.

Frequency, intensity and adherence to exercise programs:

Participants exercised anywhere from 3–7 days a week for 2–52 weeks, for 10–45 minutes per session at 50%–85% of heart rate reserve. Adherence to the exercise prescription of frequency, intensity, time, and type ranged from 66%–78%. Typically, subjects in control groups started their own exercise programs (39%), such that diffusion of treatment effects can be an issue.

Interest:

In 2005, 63% of 187 participants agreed to join an exercise study, whereas in 2003, only 19% agreed to participate. Many hospital, clinics, and health clubs now offer programs specifically for cancer survivors. 

Concerns:

Concerns about exercise when undergoing cancer treatment have included bone metastasis, cardiac toxicities of therapies, and lymphedema. However, studies have shown that

  • Patients with bone metastasis in nonweight-bearing bones safely can exercise.
  • Exercise programs have been successfully tested to increase exercise tolerance in childhood cancer survivors who have received therapies with cardiac toxicities (e.g., anthracyclines, high-dose chemotherapy). In view of the paucity of information, one recommendation might be no exercise. However, based on the benefits of exercises in other patients with congestive heart failure symptoms, another recommendation would be to exercise as tolerated, reducing exercise intensity for symptoms, such as unusual fatigue, muscular weakness, shortness of breath, dizziness, faintness, or other unusual symptoms. 
  • Exercise has been blamed for exacerbating or triggering lymphedema, theoretically because of increased blood flow and increased metabolic waste that could trigger an increase lymphatic flow and load on an already compromised system.  However, at least three clinical trials of women with breast cancer have shown no increased risk for or exacerbation of LE from either aerobic or resistance exercise.  The recommendation is to start lymphedema patients with exercise slowly, gradually increasing the time and intensity of the exercise sessions.

Conclusions:

Because of lack of research, the best mode of exercise for patients with cancer has not been determined. At the same time, no mode in any of the studies reviewed here have been determined to be harmful. Of all the nonpharmacologic interventions for cancer-related fatigue recommended by the National Comprehensive Cancer Network (NCCN), exercise has the strongest evidence.  Any exercise prescription should include the components of frequency, intensity, time, type, and progression.  Issues regarding exercise prescription in patients with cancer relate more to the treatment side effects than to the cancer itself.  Since recovery from cancer treatment is unpredictable and side effects are individual in nature, collaboration between experts in cancer care and experts in exercise physiology is essential. In general, however, frequency and duration goals should be met before intensity goals and progression should be slower and more gradual for the deconditioned patient or those who are experiencing severe side effects of treatment.

Nursing Implications:

Nurses can encourage exercise as part of a patient’s therapy and guide the patient to a safe program.

Guideline/Expert Opinion

International Society of Lymphology. (2009). The diagnosis and treatment of peripheral lymphedema. 2009 Concensus Document of the International Society of Lymphology. Lymphology, 42(2), 51–60. Retrieved from http://www.u.arizona.edu/~witte/contents/2009.42.2.concensus.pdf

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Purpose & Patient Population:

To review the evidence regarding evaluation and management of patients with peripheral lymphedema

Type of Resource/Evidence-Based Process:

This International Society of Lymphology (ISL) Consensus Document is the current revision of the 1995 Document for the evaluation and management of peripheral lymphedema. It is based on modifications that were

  • Suggested and published following the 1997 XVI International Congress of Lymphology (ICL) in Madrid, Spain, which were discussed at the 1999 XVII ICL in Chennai, India, and considered and confirmed at the 2000 (ISL) Executive Committee meeting in Hinterzarten, Germany.
  • Derived from integration of discussions and written comments obtained during and following the 2001 XVIII ICL in Genoa, Italy, as modified at the 2003 ISL Executive Committee meeting in Cordoba, Argentina.
  • From suggestions, comments, criticisms, and rebuttals as published in the December 2004 issue of Lymphology.
  • Suggested from discussions from both the 2005 XX ICL in Salvador, Brazil, and the 2007 XXI ICL in Shanghai, China, as modified at the 2008 Executive Committee Meeting in Naples, Italy.

Search strategy was not provided.

Results Provided in the Reference:

The consensus included the following components.

  • General considerations: Because lymphedema is a chronic, generally incurable ailment, it generally requires, as do other chronic disorders, lifelong care and attention along with psychosocial support. The compliance and commitment of the patient also is essential to an improved outcome.
  • Staging of lymphedema: The current lymphedema stages (Stage O, Stage I, Stage II, and Stage III) only refer to the physical condition of the extremities. A more detailed and inclusive classification needs to be formulated in accordance with improved understanding of the pathogenetic mechanisms of lymphedema (e.g., nature and degree of lymphangiodysplasia, lymph flow perturbations and nodal dysfunction as defined by anatomic features and physiologic imaging and testing) and underlying genetic disturbances. Recent publications incorporating both physical (phenotypic) findings with functional imaging into a combined staging may be forecasting the future changes in staging.
  • Diagnosis: The diagnosis of lymphedema can be readily determined from the clinical history and physical examination. A thorough medical evaluation is indispensable before embarking on lymphedema treatment.
    • Imaging: If the diagnosis of lymphedema is unclear or in need of better definition for prognostic considerations, consultation with a clinical lymphologist or referral to a lymphologic center if accessible is recommended. The diagnostic tool of isotope lymphography (also termed lymphoscintigraphy or lymphangioscintigraphy) has proved extremely useful for depicting the specific lymphatic abnormality.
    • Genetic testing is almost becoming practical to define a limited number of specific hereditary syndromes with discrete gene mutations such as lymphedemadistichiasis (FOXC2), some forms of Milroy disease (VEGFR-3), and hypotrichosislymphedema-telangiectasis (SOX18).
    • Biopsy: Caution should be exercised before removing enlarged regional lymph nodes in the setting of longstanding peripheral lymphedema as the histologic information is seldom helpful and such excision may aggravate distal swelling.
  • Treatment: Therapy of peripheral lymphedema is divided into conservative (nonoperative) and operative methods.
    • Meticulous skin hygiene and care (e.g., cleansing, low pH lotions, emollients) is of importance to the success of virtually all treatment approaches.
    • Basic range of motion exercise of the extremities combined with external limb compression and limb elevation are also helpful to virtually all patients undergoing treatment. As previously stated, even widely used methods have yet to undergo sufficient meta-analysis of multiple studies, which have been rigorous, well-controlled, and with sufficient follow-up.

Guidelines & Recommendations:

The following Research Agenda has been proposed.

  • Ongoing epidemiologic studies on the incidence and prevalence of lymphedema regionally and worldwide need to be conducted.
  • Assessment of lymphedema risk and steps for lymphedema prevention in different groups of at-risk patients need to be determined. Studies might include research on minimizing or preventing secondary lymphedema through altered operative or sampling techniques (e.g., sentinel node biopsy, precise anatomical knowledge of derivative pathways), vector control (as demonstrated in China) and prophylactic drugs for filariasis, identification of patients with heritable genetic defects for lymphangiodysplasia (lymphedema), and use of massage or compression where lymphatic drainage is subclinically impaired as documented by imaging techniques.  
  • Research in molecular lymphology, including lymphatic system genomics and proteomics, should be encouraged. With the cellular and molecular basis of lymphedema-associated syndromes better defined, an array of specificbiologically based treatments, including modulators of lymphatic growth and function, should become available.  
  • Improved imaging techniques and physiological testing need to be devised to allow more precise noninvasive methods to measure lymph flow dynamics and lymphangion activity. Continuous improvement is needed in imaging techniques as well as in the development of new technologies (e.g., near infrared) to visualize the superficial and deep lymphatic system.  
  • As knowledge accrues, the current crude classification of lymphedema should be revisited and modified to include a more encompassing clinical description based on genetic, anatomic, and functional disability.
  • Accordingly, treatment, whether by designer drugs, gene or stem cell therapy, tissue engineering, physical methods, or new operative approaches, should be directed at preventing, reversing, or ameliorating the specific lymphatic defect and restoring function and quality of life.

Nursing Implications:

Lymphedema may be simple or complex but should not be neglected. Accurate diagnosis and effective therapy is now available, and lymphology itself is now recognized as an important specialty in which clinicians are carefully trained in the intricacies of the lymphatic system, lymph circulation, and related disorders. The emerging era of molecular lymphology should result in improved understanding, evaluation, and treatment in clinical lymphology. Limited evidence exists regarding treatment. Basic recommendations are meticulous skin hygiene and care and range of motion exercise with compression. This document provides extensive information on the state of knowledge and areas for future research in lymphedema prevention and management.

Lymphoedema Framework. (2006). International consensus: Best practice for the management of lymphoedema. London, UK: Medical Education Partnership. Retrieved from http://www.woundsinternational.com/pdf/content_175.pdf

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Purpose & Patient Population:

TYPES OF PATIENTS ADDRESSED: Sample not described

Type of Resource/Evidence-Based Process:

PROCESS OF DEVELOPMENT: Study utilized previous Cochrane Systematic reviews along with current references to a United Kingdom national consensus on standards of practice for people at-risk for, or who have, lymphedema (LE)

Evidence weighed using the following classification:
  • A = Clear research evidence
  • B = Limited supporting research evidence
  • C = Experienced common sense judgment.

Guidelines & Recommendations:

Recommended for Practice
 
Complete decongestive therapy
  • Patients with LE should receive a coordinated package of care appropriate to their needs (B).
Compression bandaging
  • Multilayer inelastic lymphedema bandaging (B)
  • Compression garments (C)
Management of infection: Cellulitis/erysipelas
  • Criteria for hospitalization
    • Signs of septicemia (e.g., high fever, hypotension, tachycardia, confusion, vomiting).
    • Continuing or deteriorating systemic signs with or without deteriorating local signs after 48 hours of antibiotic therapy.
    • Unresolved or deteriorating local signs with or without systemic signs after first- and second-line oral antibiotics.
    • Close medical follow-up
Exclude other causes of systemic infection, DVT, or dermatologic conditions such as eczema and contact dermatitis.
  • Before starting antibiotics
    • Swab any exudates, if present
    • Mark extent of rash and date edge
    • Note any painful or swollen regional lymph nodes
    • Obtain labs for ESR, CRP, WBC, and blood cultures.
Begin antibiotics as soon as possible (recommended for practice).
 
During bed rest, elevate limb, administer appropriate analgesia, and increase fluid intake.
 
Avoid simple lymphatic drainage (SLD) and manual lymphatic drainage (MLD). If tolerated, continue compression at a reduced level or switch from compression garments to MLLB.
 
Avoid long periods without compression.
 
Likely to be Effective
 
Manual lymphatic drainage (C) 
 
Prevention of infection: skin care 
  • Good skin care regimens should be implemented by patients and caregivers in the management of LE (B).
  • Use neutral pH soaps to avoid drying.
  • Apply emollients. 
  • Keep skin folds clean and dry.
  • Inspect skin for cuts, scrapes, abrasions, and insect bites.
  • Avoid scented products.
Benefits Balanced With Harm                                      

Exercise

  • Exercise/movement/elevation (C)
  • Breathing exercises (C) 

Prophylactic antibiotics: prevention of infection 

  • Patients are advised to travel with a two-week supply of antibiotics if they have a history of lymphedema. 
Effectiveness not Established

Intermittent pneumatic compression (C)

Simple lymphatic drainage (SLD)

Surgery (limited evidence, carefully selected patients may benefit, more research needed)

  • Surgical reduction
  • Bypass of lymphatic obstruction
  • Liposuction/lipectomy
Expert Opinion

Patient education 

  • People at risk of lymphedema should be identified early during routine assessment, monitored, and taught self-care (C). 
  • Patients and caregivers should be offered information about LE and its management.
  • Take good care of skin and nails.
  • Maintain optimal body weight (B).
  • Eat a balanced diet.
  • Avoid tight clothing, watches, and jewelry.
  • Avoid extremes in temperature.
  • Use sunscreen and insect repellent.
  • Wear compression garments if prescribed.
  • Undertake exercise and diaphragmatic breathing exercises.
  • Wear comfortable, supportive shoes.
  • Risk factors for upper extremity lymphedema 
  • Surgery of breast with axillary node dissection
  • Scar formation, radiodermatitis from postoperative radiotherapy
  • Radiotherapy to breast
  • Drainage or wound complications
  • Cording or seroma formation
  • Obesity
  • Congenital predisposition
  • Trauma to affected extremity (venipuncture, injection, BP)
  • Taxane chemotherapy
  • Insertion of a pacemaker
  • AV fistula for dialysis
  • Living in or visiting a lymphatic filariasis endemic area
  • Risk factors for lower extremity lymphedema
  • Inguinal node dissection
  • Postoperative pelvic radiotherapy
  • Recurrent soft-tissue infection
  • Obesity
  • Vein stripping or vein harvesting
  • Genetic predisposition
  • Intrapelvic or intra-abdominal tumor
  • Thrombophlebitis
  • Poor nutritional status
  • Chronic skin disorders or inflammation
  • Any unresolved asymmetric edema
  • Concurrent illness
  • Immobilization or prolonged limb dependency
  • Living in or visiting a lymphatic filariasis endemic area
Measurement 
  • Accurate assessment including staging (C)
    • Measurement  of LE
    • Assessment of skin
    • Assessment of vascular integrity
  • Patients with LE should receive psychological screening to identify those who require help to cope with the condition and those who require specialist intervention (C).
 

 

Schmitz, K. H., Courneya, K. S., Matthews, C., Demark-Wahnefried, W., Galvão, D. A., Pinto, B. M., . . . American College of Sports Medicine. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise, 42, 1409–1426.

doi: 10.1249/MSS.0b013e3181e0c112
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Purpose & Patient Population:

To synthesize the literature on the safety and efficacy of exercise training during and after cancer treatment and provide guidelines for exercise for patients with and survivors of cancer. Adults with cancer during and after adjuvant cancer treatment were addressed. The guidelines state that the focus is on sites where the most evidence exists:  breast, prostate, colon, hematologic, and gynecologic cancers.

Type of Resource/Evidence-Based Process:

Evaluation of evidence was based on categories from the National Heart, Lung and Blood Institute (A–D levels). Panel member reviews were presented and discussed at the roundtable, and guidelines were developed by consensus. Specific strategy and terms were not described. Guidelines were developed by an expert roundtable in which members were asked to review relevant literature. The guidelines were limited to an adult population and provided an overview of a volume of evidence in multiple outcome areas related to exercise.

Results Provided in the Reference:

A comprehensive and detailed set of guidelines for exercise approaches applicable for survivors of  breast, prostate, colon, hematologic, and gynecologic cancers was provided in the guidelines, as well as some of the issues of exercise training timing related to phases of care. The guidelines also provided a summary of evidence used per cancer site and identified gaps in research because of the small number of studies in some cases and small sample sizes in many of the studies.

Guidelines & Recommendations:

Recommendations for exercise testing were as follows:

  • Evaluate for peripheral neuropathies, musculoskeletal morbidities, and fracture risk in those who have received hormonal therapies.
  • Assess for risks associated with bone metastases and cardiac risks.
  • In patients with breast cancer, evaluate arm and shoulder morbidity prior to upper-body exercise.
  • In patients with prostate cancer, evaluate muscle strength and wasting.
  • In patients with colon cancer, check for infection prevention behaviors for existing ostomy.
  • In patients with gynecologic cancers, evaluate for lower-extremity lymphedema prior to vigorous aerobics or resistance; in patients with morbid obesity assess for safety.
  • Exercise testing before walking, flexibility, or resistance training is not required.
  • In survivors with or at risk for lymphedema, one repetition maximum testing is safe.

Recommendations for exercise prescription were as follows:

  • Allow adequate healing time after surgery (may be as much as eight weeks).
  • Resolve arm or shoulder problems with patients with breast cancer before upper-body training.
  • Swelling or inflammation in gynecology cases should be resolved before exercise training. 
  • Patients with ostomies should have doctor permission before contact sports and weight training.
  • Changes in symptoms are reasons to stop an exercise program.
  • Patients with bone metastases may need to alter exercise intensity, duration, and mode because of fracture risk.
  • Specific cancer site–related recommendations are provided for injury prevention and emergencies.

General activity guidelines were as follows:

  • Avoid inactivity.
  • Aerobic exercise recommendations are the same as general age-appropriate national guidelines.
  • Resistance training should be supervised for at least 16 sessions for patients with breast cancer.
  • Patients with radical prostatectomy should also perform a pelvic floor exercise with resistance training.
  • Resistance training is more important than aerobics for patients who have received transplants.
  • Resistance training should be used with caution in patients with lower-limb lymphedema.
  • Age-appropriate flexibility training should be followed.
  • Ostomies require avoidance of excessive intra-abdominal pressure.
  • Research gaps and recommendations were outlined for yoga, sports, Pilates, and other exercises.
     

Limitations:

No participant associations were described.

Nursing Implications:

The guidelines concluded that there was consistent evidence that exercise is safe during and after cancer treatment, with consideration of specific risks that are associated with various types. Exercise training can be expected to improve aerobic fitness, muscular strength, quality of life, and fatigue. Resistance training can be performed safely in patients with and at risk for lymphedema with breast cancer. Some exercise is recommended for all types of patients. Further study is needed in the areas of dose-response effects of exercise training. The guidelines provided additional evidence-based and expert support for the incorporation of various types of exercise in the care of patients with cancer during and after adjuvant treatment. Continued research is needed in this area in terms of research in other cancer types and determination of dose-response relationships for various outcomes.
 


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