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

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

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

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

The study took place across multiple settings in Pennsylvania.

The study has clinical applicability for late effects and survivorship.

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

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

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

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

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

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