# Exercise as it relates to Disease/Physical Activity Limitations for Breast Cancer Survivors to Protect Against Arm Lymphedema

Article: Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up

## What is the background to this research?

Lymphedema is a potentially detrimental consequence of breast cancer treatments that places breast cancer survivors at life-long risk of developing this condition. It affects around 20% of this population and involves the abnormal swelling of the breast, shoulder, arm or thoracic region when lymph draining requirements exceeds the lymphatic circulation ability. In conjunction, lymphedema ramifications can include physical and emotional discomfort as well as impaired function.
The common breast cancer treatments increase the individuals risk of lymphedema as a result of damage to or removal of the axillary lymphatic nodes. Axillary treatments, lymph node dissection, the amount of lymph nodes which have been removed, radiation therapy, mastectomy, increased body mass index and infections are risk factors faced by this population.
Despite the benefits associated with physical activity, those at risk are directed to prevent the overuse of the associated arm to protect it from developing this chronic condition. This notion brings about much debate regarding the effects of physical activity and the onset of lymphedema. Given the uncertainty of the influence of exercise Sagen, Karesen & Risberg conducted a research study to determine the affects of physical activity on the development of lymphedema in the affected limb.

## Where is the research from?

This study was undertaken by researchers from the Department of Breast and Endocrine Surgery and NAR Orthopedic Center at the Oslo University Hospital in Ullevaal, Norway. Sagen and Karesen, who have previously published breast cancer research, collaborated with Risberg utilising her knowledge of rehabilitation across a variety of populations. In 2009, their article was published in Acta Oncologica and is available online through the following link: http://dx.doi.org/10.3109/02841860903061683

## What kind of research was this?

Sagen, et al. conducted a randomised controlled trial to determine the impact of physical activity on arm lymphedema postoperative breast cancer treatments. The study involved the random allocation of participants into two intervention groups; no activity restrictions (NAR) and activity restrictions (AR). By implementing a detailed exclusion criteria the researchers limited the bias presented outside of their control. The use of randomised controlled trials are an effective method of ascertaining data to evaluate potential relationships between the intervention and the identified consequence, particularly in clinical research. Data was collected using quantitative measures of physical activity, volume of affected and no affected arm and pain/sensation of the affected limb.

## What did the research involve?

A total of 204 women, aged 32-75 (x̅ = 55yrs), who met the selection criteria were included in the trial. The participants were allocated to an intervention group from a randomised computer generated program. Subjects within the NAR group (n = 104) had no limitations to physical activity and underwent supervised physical therapy that focused on moderate resistance training over a period of six months. The individuals engaged in 45 minute sessions, two to three times per week completing 15 repetitions for each set of prescribed exercises. Initially these tasks had a low resistance which progressed throughout the study dependent on individual responsiveness. The control group (n = 100) had restricted use of the affected arm and underwent typical breast cancer rehabilitation therapy for 45 minutes once a week during the same six month period. Monitoring and data collection of each participant occurred prior to treatment and then at three months, six months and two year follow-up and was analysed with SPSS 11.0 software.
The methodology was designed to address the researchers' hypothesis, whilst considering the needs of the participants. The adherence rate of the rehabilitation programs was set at 70% as it was recognised that individuals who have undergone radiation and chemotherapies are unable to maintain a greater compliance.
Limitations:
* The sample size of participants decreasing over the duration of the study, especially at the 2 year follow-up
* The physical activity questionnaire utilised in the study had not been validated

## What were the basic results?

The most significant finding of the study is that both unrestrained physical activity and moderate intensity resistance training did not affect the development of arm lymphedema.
Other findings:
* Occurrence of arm lymphedema increased across both trial groups
* Pain/sensation of heaviness in the affected arm was substantially higher in the non-restricted group, however this decreased across the duration of the study
* Physical activity score was higher in the group without activity restrictions when compared with the control AR group
From the results, the researchers established that women that have axillary node dissection are not required to restrict affected limb activity or physical activity to avoid the onset of lymphedema. The NAR group displayed the most beneficial outcomes, which highlights that engagement in physical activity is effective in reducing negative impacts of breast cancer treatments. It was noted that from a clinical perspective, pain/sensation of heaviness did not correlate with the development of lymphedema, however, a preoperative body mass index (BMI) measure > 25 placed the patient at more than three times the risk when compared to patients with a lower BMI. It was concluded that the occurrence of lymphedema is not influenced by physical activity.

## What conclusions can we take from this research?

Considering the in-depth and comprehensive nature of the longitudinal study, and the findings being supported by other research it has established that although increased activity may initially cause pain and discomfort it has no significant effects on the development of lymphedema. Therefore, it is essential to promote the continuation of daily activities and no limitations on physical activities. Given the known benefits of an active lifestyle and no impact of physical activity in developing lymphedema, breast cancer survivors should be supported in participating in exercise.
Findings from Sagen et al. are supported by a multitude of other studies. Although it was the first randomised control trial assessing physical activity's influence on lymphedema in the breast cancer population, previous research undertaken prior to this study had similar results regarding the incidence of lymphedema and exercise. Studies conducted in recent times have also found that progressive resistance training did not increase the incidence of lymphedema. To further understand the role of physical activity studies have focused on discovering other benefits of resistance exercises.

## Practical Advice

This research coincides with the current guide set out by the Breast Cancer Network Australia which emphasises the importance of physical activity during and post breast cancer treatment.
Despite the substantial research and resources available, many breast cancer patients are still advised to restrict affected limb activity to avoid the development of lymphedema. This highlights the need to increase the awareness of this type of research to disprove the common misconception about exercise within this demographic.
It is recommended that breast cancer patients and survivors communicate with a specialist lymphedema therapist before initiating an exercise program. Whichever mode of exercise is prescribed, it is important to begin at low intensities with the goal of gradually increasing intensity.

## Further reading/external links

Further information regarding physical activity of the affected limb and arm lymphedema after breast cancer surgery can be located at:
Exercise and Breast Cancer: https://www.bcna.org.au/media/2129/bcna_exercise_and_breast_cancer_booklet_0.pdf
Dragons Abreast - spreads awareness, empowers individuals and educating on the benefits of an active lifestyle:
https://www.dragonsabreast.com.au

## References

* 1 2 3 Schmitz HK, Troxel AB, Cheville A, Grant LL, Bryan CJ, Gross CR, Lytle LA, Ahmed RL. Physical activity and lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemporary Clinical Trials [Internet]. 2009 January 8 [cited 2017 August 30]; 30(3):233-245. Available from database: http://www.sciencedirect.com/science/article/pii/S1551714409000020 DOI:10.1016/j.cct.2009.01.001
* 1 2 3 Fu MR, Ridner SH, Armer J. Post-breast cancer lymphedema: part 1. American Journal of Nursing [Internet]. 2009 July [cited 2017 August 30]; 109(7):48-55. Available from database: http://www.jstor.org/stable/40385135
* 1 2 3 Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomised controlled trial of weight training and lymphedema in breast cancer survivors. Journal of Clinical Oncology [Internet]. 2006 August 20 [cited 2017 August 30]; 24(18):2765-2772. Available from database: http://ascopubs.org/doi/full/10.1200/JCO.2005.03.6749 DOI:10.1200/JCO.2005.03.6749
* ↑ Australian Government. Lymphedema [Internet]. Australia: Cancer Australia; 2017 [cited 2017 August 30]. Available from: https://canceraustralia.gov.au/clinical-best-practice/lymphoedema
* 1 2 3 Sagen A, Karesen R, Risber MA. Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up. Acta Oncologica [Internet]. 2009 October 28 [cited 2017 September 2]; 48(8):1102-1110. Available from database: http://www.tandfonline.com/doi/pdf/10.3109/02841860903061683?needAccess=true DOI:10.3109/02841860903061683
* ↑ Kabisch M, Ruckes C, Seibert-Grafe M, Blettner M. Randomized controlled trials. Deutsches Arzteblatt International [Internet]. 2011 September 30 [cited 2017 September 10]; 108(39):663-668. Available from database: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3196997/
* ↑ Schmitz KH, Ahmed RL, Troxel AB. Weight lifting for women at risk for breast cancer-related lymphedema. JAMA [Internet]. 2010 December 22 [cited 2017 September 10]; 304(24):2699-2705. Available from database: http://jamanetwork.com.ezproxy.canberra.edu.au/journals/jama/fullarticle/187112 DOI:10.1001/jama.2010.1837
* ↑ Brown JC, Schmitz KH. Weight lifting and physical function among survivors of breast cancer: a post hoc analysis of a randomized controlled trial. Journal of Clinical Oncology [Internet]. 2015 July 1 [cited 2017 September 10]; 33(19):2184-2189. Available from database: http://web.b.ebscohost.com.ezproxy1.acu.edu.au/ehost/detail/detail?vid=0&sid=05a44e20-8962-4eee-af41-8ad0c8b0c5ab%40sessionmgr120&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=25964257&db=mdc DOI:10.1200/JCO.2014.57.7395
* ↑ Breast Cancer Network Australia. Exercise and breast cancer [Internet]. Australia: BCNA; 2014 September [cited 2017 August 30]. Available from: https://www.bcna.org.au/media/2129/bcna_exercise_and_breast_cancer_booklet_0.pdf