Effect of Closed Kinetic Chain and Weight Shifting Exercises on Postural Stability in Unilateral Post Mastectomy Lymphedema
Phase: NA
Conditions: Postmastectomy Lymphedema
Sponsor: Cairo University

  
 
EFFECT OF CLOSED KINETIC CHAIN AND WEIGHT  
SHIFTING EXERCISES ON POSTURAL STABILITY  
IN UNILATERAL POST MASTECTOMY 
 LYMPHEDEMA 
 
 
 
 
 
 
BY 
AYA KAMAL MOUSA MOHAMED  
 
 
 
 
 
Submitted In A Partial Fulfillment Of The Requirements Of Doctoral Degree  
in Department of Physical Therapy For Surgery 
 Faculty Of Physical Therapy  
Cairo University  
2025 

  
 
SUPERVISORS 
 
 
Prof. Dr. Amal Mohamed Abd-Elbaky 
Professor of Physical Therapy for Surgery 
Faculty of Physical Therapy 
 Cairo University. 
 
 
 
Dr. Islam Elsayed Ramadan  
MD, Clinical oncology consultant. Head of Clinical Oncology 
Department, Elqabbary Hospital,  
Alexandria. 
  
 
Assist. Prof. Dr. Shaimaa Mohamed Ahmed Elsayeh 
Assistant Professor of Physical Therapy for Surgery Department 
Faculty of Physical Therapy 
Cairo University. 
 

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CHAPTER Ι 
INTRODUCTION 
        Mastectomy often results in a decline in physical fitness, balance impairments, 
and upper limb lymphedema, all of which significantly impact stability in women 
post-surgery. This procedure can drastically affect body posture and overall physical 
performance. The adverse changes caused by breast removal frequently disrupt spinal 
and shoulder girdle alignment, shift the body’s center of gravity, and impair stability 
(Zabojszcz et al., 2022). 
One of the most common complications following mastectomy is unilateral 
post-mastectomy lymphedema, a pathological condition characterized by chronic 
tissue swelling due to impaired lymphatic drainage. This condition commonly occurs 
because surgical procedures often involve lymph node removal in one or both upper 
extremities. The primary cause of lymphedema is the reduced ability to process 
lymph fluid in the axillary region of the affected side (Ha et al., 2017). Post-
mastectomy lymphedema significantly impacts the quality of life, as it involves the 
accumulation of protein-rich fluid due to lymphatic vessel damage or obstruction, 
typically caused by lymph node dissection or surgery (Saafan et al., 2018). Breast 
cancer-related lymphedema (BCRL) results from the surgical disruption of lymphatic 
pathways. This condition can be further exacerbated by soft tissue fibrosis resulting 
from inflammation, infection, radiation, or chemotherapy, leading to additional 
damage to the lymphatic system. These impairments in upper body function can 
contribute to postural instability and balance challenges (Crosbie et al., 2010). 
Maintaining balance, whether static or dynamic, is vital for performing daily and 
physical activities (Elsayeh et al., 2018). 

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Postural stability, a critical component of balance, is the ability to control the 
body’s center of gravity (COG). Postural sway, defined as any deviation of the COG 
on a supporting surface, is an indicator of stability and can be measured using a force 
platform. Various factors, including sensory-motor system impairments and weight 
asymmetry caused by conditions such as amputation or unilateral upper-body volume 
changes, can increase postural sway and compromise stability. Postural instability 
associated with unilateral post-mastectomy lymphedema has profound implications, 
including workplace challenges, difficulty in performing daily activities, and barriers 
to employment (Saafan et al., 2018). Patients experiencing reduced balance or 
postural instability after injury may exhibit diminished proprioceptive and kinesthetic 
feedback and/or muscular weakness. These deficits hinder their ability to execute 
effective corrective responses when equilibrium is disrupted (Prentice et al., 2024). 
In addressing postural instability, closed kinetic chain (CKC) exercises are 
particularly effective. These exercises involve movements where the distal limb, such 
as the foot or hand, is fixed to a stationary object while the proximal segments move 
freely (DESAI et al., 2021). CKC exercises incorporate simultaneous isometric, 
concentric, and eccentric contractions across various muscle groups within the kinetic 
chain, promoting functional strength and stability (Prentice et al., 2024). 
Also, dynamic postural control often requires lateral weight-shifting ability, a 
crucial component of daily activities. Lateral weight shifting, commonly performed 
in standing tasks, can be encouraged by having individuals practice on an inclined 
surface. Research has shown that healthy individuals experience a leaning aftereffect 
when transitioning from standing on an inclined surface to a horizontal one, 
indicating adaptability in postural control mechanisms (Inoue et al., 2021). 

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So, Integrating CKC exercises with weight-shifting activities can enhance 
balance and stability, offering a comprehensive approach to improving postural 
control in individuals affected by post-mastectomy lymphedema and related 
conditions. 
Statement of the problem: 
Are closed kinetic chain and weight shifting exercises effective on postural 
stability in unilateral post mastectomy lymphedema? 
 
Purpose of the study: 
The purpose of the study is to investigate the therapeutic effects of closed 
kinetic chain and weight shifting exercises on postural stability for unilateral post 
mastectomy lymphedema. 
Significance of the study: 
Post-mastectomy lymphedema is one of the most common chronic 
complications that significantly impacts patients’ quality of life following breast 
cancer surgery. When untreated, it can lead to chronic inflammation, cellulitis, pain, 
stiffness, and a restricted range of motion due to swelling and structural changes in 
the affected limb. Additionally, biomechanical alterations in the thoracic and 
shoulder regions often exacerbate upper body impairments, resulting in postural 
instability and balance challenges (Saafan et al., 2018). 
Hence, postural stability is maintained through the intricate integration of 
muscular forces, sensory input from mechanoreceptors, and biomechanical feedback. 
This stability is essential for achieving balance and for acquiring or reacquiring 
complex motor skills critical for daily activities and functional movement (Prentice 
et al., 2024). 

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Furthermore, closed kinetic chain (CKC) exercises play a crucial role in 
enhancing musculoskeletal stability by countering gravitational forces during both 
rest and movement. These exercises are particularly effective in promoting postural 
stability by facilitating coordinated muscle activation and joint stabilization (Selvaraj 
et al., 2019). 
In addition, weight shifting and balance are fundamental components of 
functional movement. Proprioceptive training, which focuses on improving body 
awareness and balance, is essential for developing trunk control. Activities performed 
on unstable surfaces have been shown to enhance proprioception and body position 
awareness, leading to improved stability and balance during dynamic activities (Jung 
et al., 2014). 
Therefore, integrating CKC exercises with weight-shifting and proprioceptive 
training offers a comprehensive approach to improving postural stability and 
functional outcomes in individuals with post-mastectomy lymphedema by addressing 
the interplay among these factors. 
Thus, the significance of the study lies in its investigation of the combined 
therapeutic effects of CKC and weight-shifting exercises as a potential strategy for 
enhancing postural stability and overall functional outcomes in patients with 
unilateral post-mastectomy lymphedema. By addressing the challenges of postural 
instability and balance deficits, this study aims to contribute to the development of 
more effective rehabilitation interventions, ultimately improving the quality of life 
for affected individuals. 
 
 
 
 
 

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Delimitations: 
         This study will be delimited in the following aspects: 
 
1. Subjects: 
       Sixty female patients with unilateral post mastectomy lymphedema will be 
randomly divided into four equal groups in number, each one has 15 patients.  
 
2. Equipment and tools:  
   2.1. Measurement equipment: 
2.1.a. Kinesis Balance™ fall prevention app: smartphone-based machine 
learning algorithm for assessing standing balance (Greene et al., 2021).  
2.1.b. Time up and go (TUG) test: for assessing dynamic balance and gait 
efficiency (Tomar et al., 2024). 
2.1.c. Functional reach test: for assessing Functional reach and dynamic 
balance (Alahmari et al., 2021). 
 
 2.2. Therapeutic equipment and tools: 
  2.2.a. Closed kinetic chain exercises. 
  2.2.b. Weight shifting exercises. 
 
Hypothesis:  
     It will be hypothesized that: 
Closed kinetic chain and Weight shifting exercises have no significant effect on 
postural stability in unilateral post mastectomy lymphedema.  
 
 
 

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Basic Assumptions: 
 
It will be assumed that: 
• All patients will continue in the study. 
• All patients will follow the instructions during the treatment. 
• All patients will be informed about and understood the details of the research 
procedure. 
• All patients enrolled in the study will have their informed consent. 
• The clinical methods of measurement will be reliable and valid. 
 
 

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Definitions of terms: 
     The following terms are defined for the clear understanding of the terminology 
that will be used in the present study:         
1. Closed kinetic chain exercises (CKC): 
Closed kinetic chain exercise is a movement where the distal part is fixed, as when 
the sole of the foot makes contact with the ground or the exercise equipment. With 
the distal part fixed, movement at any one joint in the kinetic chain requires motion 
as well at the other joints in the kinetic chain. Thus, both proximal and distal parts 
receive resistance training at the same time. In the case of the lower limb, CKC 
exercises are more functional, as weight bearing is, by definition, a closed kinetic 
chain activity of the lower limb. CKC exercise has been cited as producing superior 
eccentric contraction and co-contraction of muscles, as well as reducing shear forces 
while adding compressive forces to the joints, thereby enhancing joint stability 
(Kwon et al., 2013). 
 
2. Lymphedema: 
It is the accumulation of protein rich fluid due to damage and obstruction in 
lymphatic vessels that can cause tightness, fullness, heaviness, paresthesia in the 
affected side and disturb the posture (Babasaheb et al., 2021). 
 
3. Mastectomy: 
Mastectomy is an operation to remove the breast tissue and related lymph node 
tissue invaded by cancer cells. It is an appropriate oncologic surgery for women with 
established breast cancers (Ji et al., 2023). 
 
 
 

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4. Postural stability: 
Postural stability is a complex process that depends on both visual and 
proprioceptive input to maintain equilibrium (balance) and keeps the body upright. 
Accordingly, the terms balance and postural stability may be used interchangeably. 
Balance requires tension produced by muscle activity and involves the 
communication of automatic postural and voluntary motor commands of both the 
trunk and limbs (Ryan et al., 2010).  
 
5. Weight shifting exercises: 
It is the ability to transfer body weight from one leg to the other, it is a basic 
aspect of human locomotion and everyday activities (de Rond et al., 2023).  
Weight-shifting constitutes an important component of dynamic postural control 
which refers to the ability to keep one’s bodyweight within the base of support 
(Tsaklis et al., 2012). 
 
 

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CHAPTER ΙΙ 
REVIEW OF RELATED LITERATURES 
 
The review of the related studies and literatures of the main concept of this study will 
be presented under the following headings: 
1. Mastectomy  
 1.1-Definition:  
       Mastectomy is a surgical removal of the breast glandular tissue (BGT) with the 
aim of removing all in-breast neoplasia and/or glandular tissue. Surgical resection 
plays a fundamental role in breast cancer treatment to remove the tumor with some 
axillary lymph nodes and prevent recurrence of the disease (Surmeli and Cinar 
Ozdemir., 2022). 
 1.2-Types: (Kaidar-Person et al., 2021) 
    1.2.a- Simple (or total) mastectomy: 
Consists of removal of all the breast tissue, the skin of the breast the nipple and 
the areola (the dark area around the nipple). 
    1.2.b- Modified radical mastectomy:  
 Includes complete removal of the breast, breast skin-envelop, and underlying 
fascia of the major pectoral muscle, along with the removal of the level I and II 
axillary lymph nodes.   
    1.2.c- radical mastectomy:  
Removal of the breast tissue, the overlying skin, the pectoral muscles (major, 
minor and fascia), and regional lymphatics (axillary level I, II, and III nodes).  
    1.2.d- Nipple-sparing mastectomy: 
All of the breast tissue is removed, but the nipple, areola, and the skin of the 
breast is left intact.  

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    1.2.e- Prophylactic (risk-reducing) mastectomy: 
Is done to reduce the risk of developing breast cancer in someone who is at 
high risk. A prophylactic mastectomy is usually done as a bilateral simple (or total) 
mastectomy, nipple-sparing mastectomy, or skin-sparing mastectomy. Most often, 
your lymph nodes will not be removed.  
1.3-Complications: 
Postural changes are a major complication following unilateral mastectomy, 
leading to various physical, social, psychological, and functional issues such as 
shoulder pain, axillary web syndrome, muscle contracture, restricted range of motion, 
lymphedema, depression, anxiety, and a decreased quality of life. The extensive 
tissue damage in the thorax, particularly from large incisions involving the axilla and 
chest, creates significant scarring, which negatively impacts the mechanical 
properties of the skin. This can result in tissue shortening, loss of flexibility, and 
limited upper limb movement, all of which contribute to altered posture. 
Additionally, changes in the biomechanical properties of the scapula and related 
joints may lead to anterior tissue alterations, further affecting posture. The presence 
of lymphedema exacerbates these changes, as increased limb volume and weight add 
to the postural shifts. Furthermore, weight asymmetry in the upper trunk, resulting 
from mastectomy, radiation fibrosis, and muscle contraction in the cervical and 
scapular regions—often triggered by emotional stress, also plays a significant role in 
underlying posture disorders (Surmeli and Cinar Ozdemir., 2022).        
2. Lymphedema: 
    2.1-Definition: 
Breast cancer related lymphedema (BCRL) results from disruption of the 
lymphatic system. This prevents adequate drainage that allows lymph fluid to 
accumulate in the interstitial space. BCRL has been defined as a 2- cm increase in 

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limb circumference, a 200- mm increase in limb volume, or a 5% to 10% change in 
limb volume as compared to the unaffected arm (McEvoy et al., 2022). 
Lymphedema arises from congenital malformations or damage of the 
lymphatic system. It is an indicator of damaged lymphatic transport that causes 
accumulation of tissue fluid in the interstitium, and results in an increase in the 
volume and the weight of the limb (Surmeli and Cinar Ozdemir, 2022). 
   2.2-Classification: 
It is classified in two main groups: primary and secondary lymphedema. 
However, secondary lymphedema is more common and is often related to trauma, 
infection, cancer, radiation, or surgical interventions regarding the lymphatic 
structure (Surmeli and Cinar Ozdemir, 2022). 
   2.3- Stage and severity of lymphedema:  
The four stages of lymphedema based on the International Society of 
Lymphology are described as follows: Stage 0 is subclinical with no visible changes. 
Stage 1 is mild and soft edema pits, has no dermal fibrosis, and subsides with limb 
elevation. Stage 2 is moderate with loss of elasticity and evolution of dermal fibrosis 
and no decrease in swelling with arm elevation. Stage 3 is chronic and irreversible 
(McEvoy et al., 2022). 
The severity of lymphedema is categorized as mild (<20% increase in 
extremity volume), moderate (20-40%), or severe (>40%). Limb volume 
measurements can be made using a tape measure, perometer, or by water 
displacement. (Greene and Goss., 2018). 
 3.4. Symptoms of lymphedema 
According to (Rivere and Klimberg, 2018), symptoms of lymphedema 
include:  
• Changes in skin texture or appearance, such as tightness, itching, rash, 
redness, or hardening.  

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• Tingling, discomfort, or increased warmth in the arm, hand, breast, chest, or 
underarm.  
• Sensation of fullness or heaviness in the arm, hand, breast, chest, or 
underarm tightness. 
• Decreased flexibility in nearby joints, such as the shoulder, hand, or wrist.  
• Veins or tendons in the hand that are harder to see, knuckles that look less 
pronounced, or once-wrinkled skin that looks smoother. 
 2.5. Management of lymphedema: 
The basic principles of lymphedema treatment are patient education, reduction 
or protection of lymphedema volume, and control of diseases that may increase 
lymphedema. In the current literature, complex decongestive therapy (CDT) is 
accepted as an international standard conservative treatment method for the treatment 
of lymphedema. CDT includes skin care, manual lymphatic drainage, compression 
bandages, compression garments and exercises (Bilek et al., 2023). 
3. Postural stability and Postural changes in unilateral post mastectomy 
lymphedema: 
  3.1-Definition of postural stability:  
Postural stability, also referred to as balance, is the ability to control the center 
of mass (CoM) in relationship to the base of support. The nervous system generates 
forces to control the motion of the CoM. The center of pressure (CoP) is the center of 
distribution of the total force applied to the base of the support. Postural control 
involves controlling the body's position in space for the dual purposes of stability and 
vertical orientation of the posture, due to use of multiple sensory references – 
vestibular, somatosensory, and visual system (Sipko et al., 2021). 

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Postural stability is one of the most important components for normal function, 
and it is necessary in daily activities such as walking or climbing stairs. The 
maintenance of postural stability reflects the contribution of many different joints and 
muscles manifests as postural sway. While lymphedema is a common health problem 
of women who suffer from breast cancer that affects their functional status negatively 
(Angin et al., 2014). 
 3.2-Postural changes in unilateral post mastectomy lymphedema: 
Surmeli and Cinar Ozdemir (2022) highlight the interconnected nature of the 
human skeleton, where abnormalities in one area led to compensatory adjustments in 
others to maintain body balance. These postural alterations primarily occur in the 
transverse, sagittal, and frontal planes. Common changes include shoulder 
protraction, upper back flexion, anterior translation of the head, and anterior trunk 
inclination, especially following mastectomy-related surgeries. These alterations 
result from an imbalance between muscle groups, leading to anterior trunk inclination 
and thoracic kyphosis. 
On the spine, the spinous processes of vertebrae tend to shift in the vertical 
direction, with this change being more prominent in the T1-T6 vertebrae in younger 
individuals, and from the T7-T12 vertebrae in the elderly. Additionally, trunk rotation 
and shoulder protraction occur on the dominant side, particularly after mastectomy. 
This alteration leads to a greater trunk rotation angle, more noticeable changes in 
spinal alignment, increased scapula and shoulder asymmetry, and a larger pelvic tilt 
angle (Liu et al., 2024). Unilateral lymphedema also causes greater asymmetry 
between the acromion and the major trochanter, contributing to further trunk rotation 
(Bilek et al., 2023). 
Patients with lymphedema exhibit increased postural sway, indicating poor 
postural stability. Notably, there is a significant increase in the range of postural sway 
during unilateral stance with eyes closed on the contralateral side, compared to the 

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ipsilateral side. This is due to the increased volume and weight of the affected upper 
extremity, leading to a significant displacement of the center of gravity (CoG) 
towards the ipsilateral side during bilateral stance tests (Angin et al., 2014). 
 
4.Closed kinetic chain exercises (CKC): 
   4.1-Definetion:  
The term “kinetic chain” is used to describe how the body moves, with the 
limbs functioning either in an open kinetic chain (OKC) or a closed kinetic chain 
(CKC) condition. The difference between these two conditions is determined by 
whether the terminal ending of the limb is free or fixed (Kim et al., 2017). CKC 
exercises are those exercises that emphasize a weight-bearing component to the 
movement. Closed chain exercises allow the distal segment of the extremity to be 
fixed. Motion results from movement of the proximal segment over the fixed distal 
segment (Nadeem et al., 2022). 
 
  4.2- Kinetic Chain Concept: 
The human body is a multisegmented system consisting of many skeletal 
levers that are linked together by a series of joints, interactive through muscle action, 
and coordinated through central nervous system (CNS) mechanisms. Together these 
systems make up the human kinetic chain. The CNS has the ability to control all 
active, skilled, purposeful movement patterns. Thus, the CNS is considered the first 
link in the kinetic chain (Nadeem et al., 2022). 
 
  4.3- Principles of CKC exercises: 
Closed-chain exercises involve movements where the body moves on a distal 
segment that is fixed or stabilized on a support surface. Movement at one joint leads 
to simultaneous motion at both distal and proximal joints in a predictable manner. 

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These exercises stimulate joint and muscle mechanoreceptors, facilitate co-activation 
of agonist and antagonist muscles (co-contraction), and ultimately enhance dynamic 
stability. Additionally, closed-chain exercises provide greater proprioceptive and 
kinesthetic feedback since multiple muscle groups crossing various joints are 
activated. This activation generates more stress on bones, which promotes 
osteogenesis, and stimulates more sensory receptors in muscles and both intra-
articular and extra-articular structures, thereby improving balance and postural 
control (Thabet et al., 2017). 
CKC exercises lead to muscular co-contraction, resulting in improved stability. They 
require coordination and co-contraction of anti-gravity muscles, which enhances 
muscle power, particularly in the lower extremities (Suryawanshi et al., 2022). 
However, CKC exercises activate antagonistic muscle groups across multiple joints, 
which means they cannot be used to isolate or target a single muscle group (Kim et 
al., 2017). These exercises are designed to replicate the forces and motions involved 
in walking, running, stair climbing, and other activities of daily living. A common 
example is the squat, where an individual simultaneously flexes the hips and knees 
while standing to lower their body weight over their feet. This movement mimics the 
actions of sitting down and rising from a chair. During this exercise, co-contraction 
of muscles such as the quadriceps, gastroc-soleus, and gluteals helps coordinate 
movement across multiple joints, including the ankle and knee joints (Nadeem et al., 
2022). 
 4.4-Types of CKC exercises: 
Closed kinetic chain exercises included leg press in horizontal position, 
bicycling, Stairmaster climbing, Wall sits exercise, Squatting lunges exercise. 
Examples of CKC exercises include push-ups, pullups, squats, and lungs.  All types 
of CKC exercises can be performed with or without weights. (Thabet et al., 2017). 
 

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5. Weight shifting exercises:    
   5.1- Definition:  
Weight-shifting is a critical element of dynamic postural control, which 
involves maintaining one’s body weight within the base of support. As individuals 
age, their ability to perform weight-shifting becomes slower and less accurate (de 
Rond et al., 2023). 
Maintaining posture under dynamic conditions requires the capacity for lateral 
weight-shifting, which is frequently involved in many activities of daily living. One 
technique to encourage weight shifting in a specific direction is by having an 
individual stand on an inclined surface. Research shows that healthy individuals 
exhibit a leaning aftereffect when transitioning from an inclined surface to a 
horizontal one (Inoue et al., 2021). 
  5.2- Weight-shifting concept: 
Weight-shifting training-induced neural activation changes would be apparent 
mostly in the hemodynamics of the frontal and motor areas of the brain, in line with 
previous studies. Brain activation pattern during a mediolateral weight-shifting task 
in older and young adults, showing increased brain activity with age, particularly in 
the prefrontal cortex (PFC), supplementary motor area (SMA) and somatosensory 
cortex (SSC). More specifically, as we previously found the PFC to be highly 
involved in weight-shifting task, we expected a rise in cortical HbO2 levels directly 
after training and a lowering at retention indicating an increase of neural efficiency 
(de Rond et al., 2023). 
 
 

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CHAPTER III 
SUBJECTS, MATERIALS AND METHODS 
In this part of the study, the materials and methods will be presented under the 
following headings: subjects, equipment, procedures of the study and statistical 
procedures. 
1- Subjects: 
Sample size calculation 
Sample size calculation was done using Anteroposterior stability index, as 
reported in (Elsayeh et al, 2018), with 95% power at α = 0.05 level, number of 
measurements 2, for 4 groups and effect size = 0.6 using F-test MANOVA repeated 
measures within and between interaction. The minimum proper sample size is 52 
subjects, adding 8 subjects (15%) as drop out, so total sample size is 60 subjects, 15 
subjects in each group. The sample size was calculated using G*Power software 
(version 3.0.10) (figure 1). 
 
Figure (1): sample size calculation 

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Sixty patients who have unilateral post mastectomy lymphedema will 
participate in this study. Their ages will range from 40 to 60 years. The patients will 
be subdivided randomly into four equal groups by using simple randomization 
technique 1:1 ratio to four equal groups according to sample size calculation (15 
patients for each group). The allocation will be performed with a blinded investigator 
using sealed opaque envelopes including a code for each group to avoid allocation 
bias. They will be selected from the Outpatient Clinic of Faculty of Physical Therapy, 
Cairo University and Alexandria oncology center. 
All participants were informed about nature and the effect of measurement and 
treatment methods and have signed the informed consent which includes their 
agreement to participate in the study (Appendix I). They were instructed to report 
any side effects during management. 
1.1- Design of the study: 
The study will be four-armed, single-blind (assessor), parallel-group, 
randomized control trial.    
   1.1.a- Group A (n= 15)  (CKC group): 
This group will include 15 patients who will receive closed kinetic chain 
exercises, in addition to complex decongestive therapy (CDT) for the treatment of 
lymphedema. CDT includes (skin care, manual lymphatic drainage, compression 
bandages, compression garments and exercises). The total exercise time will be 30 
minutes, three times per week for eight weeks.  
 
1.1.b- Group B (n= 15)  (WS group): 
This group will include 15 patients who will receive weight shifting exercises, 
in addition to complex decongestive therapy (CDT) for the treatment of lymphedema. 
The total exercise time will be 30 minutes, three times per week for eight weeks.  
 
1.1.c- Group C (n= 15) (Combined group): 
This group will include 15 patients who will receive closed kinetic chain and Weight 
shifting exercises, in addition to complex decongestive therapy (CDT) for the 
treatment of lymphedema. The total exercise time will be 60 minutes; 30 minutes of 

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CKC and 30 minutes of WS exercise three times per week for eight weeks. 
 
1.1.d- Group D (n= 15)  (control group): 
This group will include 15 patients who will receive complex decongestive 
therapy (CDT) for the treatment of lymphedema. CDT includes (skin care, manual 
lymphatic drainage, compression bandages, compression garments and exercises). 
1.2 Criteria for the patient selection:  
    1.2. a. Inclusion Criteria: 
• Women who had a history of BCRS with upper limb lymphedema.  
• Age range of 40-60 years. 
• The body mass index (BMI) is less than 30 Kg/m2. 
• Consciousness and ability to communicate orally or in writing. 
• Treatment by unilateral mastectomy with lymph node dissection. 
• No obvious abnormal spine morphology or postural abnormalities visible to 
the naked eye.  
• All participants had moderate lymphedema according to the lymphedema 
severity assessment. 
 1.2.b. Exclusion Criteria: 
The potential patients will be excluded if they meet one of the following criteria:  
• Patients with metastases. 
• Differences between lower limb length. 
• Having acute or chronic vestibular, neurological, and orthopedic diseases. 
•  Surgery related to spine causing limitation of motion. 
• Women with psychiatric disorders, reconstructive surgery. 
• Bilateral mastectomy. 

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• Diagnosis with a neurological, skeletal, or rheumatic disorder or other disease 
that seriously affects body posture. 
• History of bodily injury such as a spinal, shoulder, or neck injury, resulting in 
permanent alteration of the normal body posture prior to the unilateral 
mastectomy.  
• Failure to complete follow-up for any reason over the course of the study. 
• Peripheral polyneuropathy, cognitive dysfunction. 
• Patients taking medication that affects body balance. 
•  Severe arthritis or orthopedic conditions in their lower extremity 
•  Poor conditioning, acute pain in any reason,  
• Neurological disorders including visual problems. 
2-Equipment:  
  2.1- Measurement equipment:  
     2.1.a. Kinesis Balance™ fall prevention app: 
Smartphone-based machine learning algorithms for assessing standing balance. 
The app uses a questionnaire on clinical falls risk factors, combined with a standing 
balance test and machine learning algorithms to assess balance and fall risk. A 
reference data set is embedded within the app and was used to compare against the 
smartphone inertial sensor data. The algorithm includes data quality checks to ensure 
tests are performed correctly including checking phone is oriented correctly during 
the test, removing signal artefact resulting from movements due to changes in initial 
positioning of the phone as well as detection and removal of unusual behavior or 
phone movement during the test (Greene et al., 2021). 
Smartphone data were sampled at the maximum rate allowed by the operating 
system. To ensure data were sampled evenly, data were interpolated to a 100 Hz 

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sampling rate using linear interpolation. Accelerometer and gyroscope data from the 
inertial sensor were band-pass filtered between 0.1–5 Hz and calibrated to produce 
acceleration and angular velocity vectors (Cerca., 2018).  
Built-in sensors in every smartphone, including accelerometers and 
gyroscopes, are key to making smartphones capable of detecting balance. Therefore, 
by combining mobility and built-in IMUs, smartphones offer the potential to provide 
an objective and convenient balance assessment method. Furthermore, smartphones 
have been applied to individuals who have experienced stroke and have been proven 
feasible in assessing balance (Hou et al., 2019).  
Test-retest reliability and effect sizes for stability measures obtained with a 
force plate and smartphone as well as correlations between force plate and 
smartphone measures based on a large sample of older adults. The test-retest 
reliability of the smartphone outcome parameters was moderate (0.5− 0.75) to good 
(0.75− 0.9). smartphone application is a valid and reliable way to measure balance 
(De Groote et al., 2021). 
The results of this study show some of the highest correlation between a 
mobile device application and that of the results measured from long-accepted force 
plate. A similar study had a correlation of 0.63 with regards to positional sway. 
Therefore, the approach to the smartphone application presented here allows for an 
accurate way to capture the positional balance and sway without need of the 
stationary force plate (Cimera and Voloshin., 2021). 
 
 
 

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  2.1.b. Time up and go test (TUG):  
The Timed Up and Go (TUG) test is a simple and efficient functional mobility 
assessment that measures the time taken for a subject to rise from a chair with 
armrests, walk three meters, turn, walk back, and sit down. The time to complete the 
task is recorded in seconds using a stopwatch (Tomar et al., 2024). 
This test evaluates gait, functional fitness, agility, and balance. It involves a 
series of functional tasks: transitioning from a sitting to a standing position, walking 
3 meters, performing a 180° turn, and returning to a seated position. The TUG test 
provides valuable insights into an individual’s mobility and balance performance 
(Zabojszcz et al., 2022). 
 
    2.1.c. Functional reach test (FRT): 
The Functional Reach Test (FRT) is a simple and cost-effective clinical tool 
used to assess dynamic balance ability (Alahmari et al., 2021). It measures the 
maximum distance a person can reach forward beyond the length of one arm while 
maintaining a fixed base of support in a standing position. This test is particularly 
useful in institutionalized settings, as it is well established that balance is crucial for 
reducing the risk of falls and enhancing the performance of activities of daily living 
(ADLs) in older adults (Ferreira et al., 2021). 
2.2. Therapeutic equipment and tools: 
     2.2.a- Closed kinetic chain exercises (CKC): 
Closed kinetic chain (CKC) exercises emphasize weight-bearing movements 
where the distal segment of the extremity is fixed, and motion occurs as the proximal 
segment moves over the stabilized distal segment (Nadeem et al., 2022). These 

23 
 
exercises stimulate joint and muscle mechanoreceptors, promoting co-activation of 
agonist and antagonist muscles (co-contraction), which enhances dynamic stability 
(Thabet et al., 2017). CKC exercises are particularly effective in generating 
muscular co-contraction, leading to improved stability and coordination. They also 
engage anti-gravity muscles, boosting muscle power in the lower extremities 
(Suryawanshi et al., 2022). 
 
   2.2.b- Weight-shifting exercises: 
Weight-shifting is a crucial aspect of dynamic postural control, which refers to 
the ability to maintain one's bodyweight within the base of support. As individuals 
age, the ability to perform weight-shifting becomes slower and less accurate (de 
Rond et al., 2023).  
Lateral weight-shifting, in particular, is essential for maintaining posture under 
dynamic conditions and is commonly performed in various activities of daily living 
(Inoue et al., 2021). 
 
3-Procedures of the study: 
    3.1-Measurement procedures: 
    All patients will be evaluated before and after eight weeks of using closed kinetic 
chain and weight shifting exercises. 
 
         3.1.a. Kinesis Balance™ fall prevention app: 
Patients will be instructed to hold the phone firmly against their sternum and 
stand with their eyes open, in a semi-tandem stance, for 30 s. The app contains audio 
and visual instructions on how to prepare for and complete the test as well as an 
audio cue to indicate test start and stop. 

24 
 
 
Figure (2): Shows Smartphone app for assessment of balance and falls risk using 
questionnaire and standing balance test (in semi-tandem stance adapted from 
(Greene et al., 2021). 
 
 3.1.b. Time Up and Go Test (TUG): 
       
Patients will be asked to stand up from a chair with armrests, walk three 
meters, turn, walk back, and sit down, figure (3). The time taken to complete this task 
will be measured in seconds using a stopwatch (Tomar et al., 2024). 
 
Figure (3): Shows Principle of the timed-up-and-go (TUG) test adapted from 
(Nierat et al., 2016). 
 

25 
 
 3.1.c- Functional Reach Test (FRT): 
The patient will enter a standing position on a line marked on the floor. An 
inch tape will be attached to a wall at approximately shoulder height of the subject. 
The therapist will stand 5–10 feet away from the patient and instruct them to stand 
close to the wall without touching it, while facing the inch tape, with the shoulder 
flexed at 90° and the hand in a fist, figure (4). The therapist will record the starting 
position at the knuckle of the third metacarpal head on the ruler. The patient will then 
be instructed to reach as far forward as possible along the length of the tape without 
moving their feet. The therapist will once again record the location of the knuckle of 
the third metacarpal. Patients will be required not to lean against the wall during the 
test. If they lose balance, the therapist will stop the test. The scores will be 
determined by assessing the difference between the starting and ending positions. 
Three trials will be conducted with one minute of rest between each trial, and the 
average distance will be recorded in centimeters (Alahmari et al., 2021). 
 
Figure (4): Shows Measurement of dynamic balance by functional reach 
test. a Starting position. b Final position adapted from (Alahmari et al., 2021) 
 
 

26 
 
3.2-Therapeutic procedures:  
     3.2.a- Closed kinetic chain exercises (CKC):  
Three sets of ten repetitions will be performed in each exercise session and a 
duration of 30 minutes will be conducted three times a week for eight weeks. There 
will be two-minute breaks between sets to avoid fatigue (Sajjad et al., 2024).  
  All types of CKC exercises can be performed with or without weights. 
(Thabet et al., 2017). 
The following closed kinetic chain exercises will be carried out by the patients 
in the treatment group figure (5) (Gbiri et al., 2013; Adegoke et al., 2019): 
 
• Quadriceps Setting Exercise 
Patients will sit on a chair with their back supported, knee extended and 
heel on the floor. They pressed their heels against the floor and thighs against 
the seat of the chair. The position was held for a count of 10 after which the 
participant relaxed. 
• Toe Raises  
Patients will be standing with feet approximately shoulder width apart 
and extend arms out slightly forward and lower than the shoulder. Lift both 
heels of the floor and try to hold the position for 10 seconds. 
• Standing with feet side by side, hold arms in the same position as described 
in the previous exercise. Place one foot on the inside of the opposing ankle and 
try to hold the position for 10 seconds. 
• Standing on one extremity for 30 seconds (repeated in both extremities), 
leaning forward, backward, and to the sides on one extremity (eyes open), 
leaning forward, backward, and to the sides on one extremity (eyes closed), 
and sitting down and standing up from a highchair slowly. 
 

27 
 
• Wall Squat  
With feet shoulder-width apart, knees aligned over ankles and back to wall, 
tighten buttocks and quads, attempting to tighten VMO first, then slide down wall 
until knees are bent, Hold. 
• Double Leg Squat  
Stand with feet shoulder-width apart, using hand support as necessary. Align 
knees over ankles, tighten buttocks, tighten quads, attempting to tighten VMO first. 
Bend knees. Do not allow knees to go forward past toes. Keep your back straight, 
bending forward at the hips. Hold for 5 to 10 seconds. Return to standing. 
• Lunge  
From standing position (hand support as needed), keep the forward knee over 
the ankle while allowing the “back” knee to bend, lunge forward. Return. Alternate 
legs.  
• Step-up and step-down 
Patients will perform forward, backward and lateral step-ups and step-
downs using a 5cm – high sturdy wooden box. They will be instructed to keep 
their trunk upright. Patients will perform 10 repetitions of each component of 
the exercise.  
 

28 
 
 
Figure (5): Shows closed kinetic exercises adapted from (Ng et al., 2022). 
 
 
3.2.b- Weight shifting exercises (WS):  
The training will be conducted on both a stable surface and an unstable surface 
(balance board) and will consist of the following five tasks, figure (6): 
1. In a standing position, shift the weight left and right maximally. 
2. In a standing position, shift the weight forward and backward maximally. 
3. In a standing position, perform bending and stretching of both knees. 
4. In a standing position, raise and lower both feet’s heels. 
5. While sitting on a chair, perform sit-to-stand exercises on the balance board. 
Each session will last for 30 minutes, occurring three days a week for a duration of 8 
weeks (Lee et al., 2015). 

29 
 
 
Figure (6): Shows Weight Shifting adapted from (Diebal et al., 2011) 
 
 3.3. Complex decongestive therapy: 
Complex decongestive therapy (CDT) for the treatment of lymphedema for 
both groups. CDT includes (skin care, manual lymphatic drainage, compression 
bandage and exercises). 
 
4-Statistical procedures: 
The collected data will be statistically analyzed using: 
• Descriptive statistics (mean and standard deviations). 
• Inferential statistics; ANOVA will be used to compare between subjects 
characteristics of the three groups.  
• Shapiro-Wilk test will be used for testing normality of data distribution. 
•  Mixed MANOVA will be used to compare parametric measured variables 
between and within groups. 
• Statistical analysis will be conducted using SPSS for Windows, version 20 
(SPSS, Inc., Chicago, IL). Statistical significance will be set at the (p< 0.05). 
 

 
 
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