Exercise in patients with lymphedema: a systematic review of the contemporary literature

Abstract

Background

Controversy exists regarding the role of exercise in cancer patients with or at risk for lymphedema, particularly breast. We conducted a systematic review of the contemporary literature to distill the weight of the evidence and provide recommendations for exercise and lymphedema care in breast cancer survivors.

Methods

Publications were retrieved from 11 major medical indices for articles published from 2004 to 2010 using search terms for exercise and lymphedema; 1,303 potential articles were selected, of which 659 articles were reviewed by clinical lymphedema experts for inclusion, yielding 35 articles. After applying exclusion criteria, 19 articles were selected for final review. Information on study design/objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted. Study evidence was also rated according to the Oncology Nursing Society Putting Evidence Into Practice® Weight-of-Evidence Classification.

Results

Seven studies were identified addressing resistance exercise, seven studies on aerobic and resistance exercise, and five studies on other exercise modalities. Studies concluded that slowly progressive exercise of varying modalities is not associated with the development or exacerbation of breast cancer-related lymphedema and can be safely pursued with proper supervision. Combined aerobic and resistance exercise appear safe, but confirmation requires larger and more rigorous studies.

Conclusions

Strong evidence is now available on the safety of resistance exercise without an increase in risk of lymphedema for breast cancer patients. Comparable studies are needed for other cancer patients at risk for lymphedema.

Implications for cancer survivors

With reasonable precautions, it is safe for breast cancer survivors to exercise throughout the trajectory of their cancer experience, including during treatment.

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References

  1. 1.

    Armer JM. The problem of post-breast cancer lymphedema: impact and measurement issues. Cancer Invest. 2005;23(1):76–83.

    PubMed  Google Scholar 

  2. 2.

    Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin. 2000;50(5):292–307. quiz 308–11.

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    McWayne J, Heiney SP. Psychologic and social sequelae of secondary lymphedema. Cancer. 2005;104(3):457–66.

    PubMed  Article  Google Scholar 

  4. 4.

    Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Holzel D. Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients. Breast Cancer Res Treat. 2003;79(1):47–57.

    PubMed  Article  Google Scholar 

  5. 5.

    Kwan W, Jackson J, Weir LM, Dingee C, McGregor G, Olivotto IA. Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. J Clin Oncol. 2002;20(20):4242–8.

    PubMed  Article  Google Scholar 

  6. 6.

    Kornblith AB, Herndon 2nd JE, Weiss RB, Zhang C, Zuckerman EL, Rosenberg S, et al. Long-term adjustment of survivors of early-stage breast carcinoma, 20 years after adjuvant chemotherapy. Cancer. 2003;98(4):679–89.

    PubMed  Article  Google Scholar 

  7. 7.

    Ahmed RL, Prizment A, Lazovich D, Schmitz KH, Folsom AR. Lymphedema and quality of life in breast cancer survivors: the iowa women's health study. J Clin Oncol. 2008;26(35):5689–96.

    PubMed  Article  Google Scholar 

  8. 8.

    Maunsell E, Brisson J, Deschenes L. Arm problems and psychological distress after surgery for breast cancer. Can J Surg. 1993;36(4):315–20.

    PubMed  CAS  Google Scholar 

  9. 9.

    Passik S, Newman M, Brennan M, Holland J. Psychiatric consultation for women undergoing rehabilitation for upper-extremity lymphedema following breast cancer treatment. J Pain Symptom Manage. 1993;8(4):226–33.

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Segerstrom K, Bjerle P, Nystrom A. Importance of time in assessing arm and hand function after treatment of breast cancer. Scand J Plast Reconstr Surg Hand Surg. 1991;25(3):241–4.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Tobin MB, Lacey HJ, Meyer L, Mortimer PS. The psychological morbidity of breast cancer-related arm swelling. Psychological morbidity of lymphoedema. Cancer. 1993;72(11):3248–52.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Velanovich V, Szymanski W. Quality of life of breast cancer patients with lymphedema. Am J Surg. 1999;177(3):184–7. discussion 188.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Jensen MR, Simonsen L, Karlsmark T, Bulow J. Lymphoedema of the lower extremities—background, pathophysiology and diagnostic considerations. Clin Physiol Funct Imaging. 2010;30(6):389–98.

    PubMed  Article  Google Scholar 

  14. 14.

    Lawenda BD, Mondry TE, Johnstone PA. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009;59(1):8–24.

    PubMed  Article  Google Scholar 

  15. 15.

    Harwood CA, Mortimer PS. Causes and clinical manifestations of lymphatic failure. Clin Dermatol. 1995;13(5):459–71.

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Mortimer PS. The pathophysiology of lymphedema. Cancer. 1998;83(12 Suppl American):2798–802.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. J Natl Cancer Inst. 2001;93(2):96–111.

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer. 2010;116(22):5138–49.

    PubMed  Article  Google Scholar 

  19. 19.

    SEER Cancer Statistics Review, 1975–2007, National Cancer Institute, S. Altekruse, et al., Editors. 2009: Bethesda, MD.

  20. 20.

    American Cancer Society. Breast Cancer Facts & Figures 2009–2010, Atlanta: American Cancer Society, Inc..

  21. 21.

    Doyle C, Kushi LH, Byers T, Courneya KS, Demark-Wahnefried W, Grant B, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323–53.

    PubMed  Article  Google Scholar 

  22. 22.

    Kushi LH, Byers T, Doyle C, Bandera EV, McCullough M, McTiernan A, et al. American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2006;56(5):254–81. quiz 313–4.

    PubMed  Article  Google Scholar 

  23. 23.

    World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington, DC: AICR; 2007.

    Google Scholar 

  24. 24.

    Physical Activities Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report. U.S. Department of Health and Human Services: Washington, DC; 2008

  25. 25.

    Cheema B, Gaul CA, Lane K, Fiatarone Singh MA. Progressive resistance training in breast cancer: a systematic review of clinical trials. Breast Cancer Res Treat. 2008;109(1):9–26.

    PubMed  Article  Google Scholar 

  26. 26.

    Ganz PA. The quality of life after breast cancer—solving the problem of lymphedema. N Engl J Med. 1999;340(5):383–5.

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Rockson SG. Precipitating factors in lymphedema: myths and realities. Cancer. 1998;83(12 Suppl American):2814–6.

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    McKenzie DC. Abreast in a boat—a race against breast cancer. CMAJ. 1998;159(4):376–8.

    PubMed  CAS  Google Scholar 

  29. 29.

    Unruh AM, Elvin N. In the eye of the dragon: women's experience of breast cancer and the occupation of dragon boat racing. Can J Occup Ther. 2004;71(3):138–49.

    PubMed  Google Scholar 

  30. 30.

    Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409–26.

    PubMed  Article  Google Scholar 

  31. 31.

    Young-McCaughan S, Arzola SM. Exercise intervention research for patients with cancer on treatment. Semin Oncol Nurs. 2007;23(4):264–74.

    PubMed  Article  Google Scholar 

  32. 32.

    Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database Syst Rev. 2006(4):CD005001.

  33. 33.

    Fappiano M, Gangaway J. Aquatic physical therapy improves joint mobility, strength, and edema in lower extremity orthopedic injuries. Journal of Aquatic Physical Therapy. 2008;16(1):10–5.

    Google Scholar 

  34. 34.

    Katz E, Dugan NL, Cohn JC, Chu C, Smith RG, Schmitz KH. Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study. Arch Phys Med Rehabil. 2010;91(7):1070–6.

    PubMed  Article  Google Scholar 

  35. 35.

    Lymphoedema Framework. Best Practice for the Management of Lymphoedema. International consensus. London: MEP Ltd; 2006.

    Google Scholar 

  36. 36.

    Mitchell SA,Friese CR. ONS PEP (Putting Evidence into Practice) Weight of Evidence Classification Schema: Decision Rules for Summative Evaluation of a Body of Evidence. http://www.ons.org/Research/media/ons/docs/research/outcomes/weight-of-evidence-table.pdf.

  37. 37.

    Steelman VM, Pape T, King CA, Graling P, Gaberson KB. Selection of a method to rate the strength of scientific evidence for AORN recommendations. AORN J. 2011;93(4):433–44.

    PubMed  Article  Google Scholar 

  38. 38.

    Schmitz KH, Troxel AB, Cheville A, Grant LL, Bryan CJ, Gross CR, et al. Physical Activity and Lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials. 2009;30(3):233–45.

    PubMed  Article  Google Scholar 

  39. 39.

    Speck RM, Gross CR, Hormes JM, Ahmed RL, Lytle LA, Hwang WT, et al. Changes in the Body Image and Relationship Scale following a one-year strength training trial for breast cancer survivors with or at risk for lymphedema. Breast Cancer Res Treat. 2010;121(2):421–30.

    PubMed  Article  Google Scholar 

  40. 40.

    Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009;361(7):664–73.

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Schmitz KH, Ahmed RL, Troxel AB, Cheville A, Lewis-Grant L, Smith R, et al. Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA. 2010;304(24):2699–705.

    PubMed  Article  CAS  Google Scholar 

  42. 42.

    Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol. 2006;24(18):2765–72.

    PubMed  Article  Google Scholar 

  43. 43.

    Sagen A, Karesen R, Risberg 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 Oncol. 2009;48(8):1102–10.

    PubMed  Article  Google Scholar 

  44. 44.

    Kilbreath SL, Refshauge KM, Beith JM, Ward LC, Simpson JM, Hansen RD. Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial. BMC Cancer. 2006;6:273.

    PubMed  Article  Google Scholar 

  45. 45.

    Irdesel J, Kahraman Celiktas S. Effectiveness of exercise and compression garments in the treatment of breast cancer related lymphedema. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi. 2007;53(1):16–21.

    Google Scholar 

  46. 46.

    Sander AP. A safe and effective upper extremity resistive exercise program for woman post breast cancer treatment. Rehabilitation Oncology. 2008;26(3):3–10.

    Google Scholar 

  47. 47.

    Courneya KS, Segal RJ, Mackey JR, Gelmon K, Reid RD, Friedenreich CM, et al. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol. 2007;25(28):4396–404.

    PubMed  Article  Google Scholar 

  48. 48.

    Bicego D, Brown K, Ruddick M, Storey D, Wong C, Harris SR. Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther. 2006;86(10):1398–405.

    PubMed  Article  Google Scholar 

  49. 49.

    De Backer IC, Schep G, Backx FJ, Vreugdenhil G, Kuipers H. Resistance training in cancer survivors: a systematic review. Int J Sports Med. 2009;30(10):703–12.

    PubMed  Article  Google Scholar 

  50. 50.

    Poage E, Singer M, Armer J, Poundall M, Shellabarger MJ. Demystifying lymphedema: development of the lymphedema putting evidence into practice card. Clin J Oncol Nurs. 2008;12(6):951–64.

    PubMed  Article  Google Scholar 

  51. 51.

    Hayes SC, Reul-Hirche H, Turner J. Exercise and secondary lymphedema: safety, potential benefits, and research issues. Med Sci Sports Exerc. 2009;41(3):483–9.

    PubMed  Article  Google Scholar 

  52. 52.

    Portela AL, Santaella CL, Gomez CC, Burch A. Feasibility of an exercise program for puerto rican women who are breast cancer survivors. Rehabil Oncol. 2008;26(2):20–31.

    PubMed  Google Scholar 

  53. 53.

    Kilgour RD, Jones DH, Keyserlingk JR. 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 Res Treat. 2008;109(2):285–95.

    PubMed  Article  Google Scholar 

  54. 54.

    Moseley AL, Piller NB, Carati CJ. The effect of gentle arm exercise and deep breathing on secondary arm lymphedema. Lymphology. 2005;38(3):136–45.

    PubMed  CAS  Google Scholar 

  55. 55.

    Beurskens CH, van Uden CJ, Strobbe LJ, Oostendorp RA, Wobbes T. The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a randomized controlled study. BMC Cancer. 2007;7:166.

    PubMed  Article  Google Scholar 

  56. 56.

    de Rezende LF, Franco RL, de Rezende MF, Beletti PO, Morais SS, Gurgel MS. Two exercise schemes in postoperative breast cancer: comparison of effects on shoulder movement and lymphatic disturbance. Tumori. 2006;92(1):55–61.

    PubMed  Google Scholar 

  57. 57.

    Torres Lacomba M, Yuste Sanchez MJ, Zapico Goni A, Prieto Merino D, del Moral OMayoral, Cerezo Tellez E, et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ. 2010;340:b5396.

    PubMed  Article  Google Scholar 

  58. 58.

    National Lymphedema Network. http://www.lymphnet.org/lymphedemaFAQs/positionPapers.htm. 2011.

  59. 59.

    Johansson K, Piller N. Weight-bearing exercise and its impact on arm lymphoedema. J Lymphoedema. 2007;2(1):15–22.

    Google Scholar 

  60. 60.

    Johansson K, Tibe K, Weibull A, Newton RC. Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology. 2005;38(4):167–80.

    PubMed  CAS  Google Scholar 

  61. 61.

    Jonsson C, Johansson K. Pole walking for patients with breast cancer-related arm lymphedema. Physiother Theory Pract. 2009;25(3):165–73.

    PubMed  Article  Google Scholar 

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Acknowledgments

This systematic review of contemporary peer-reviewed exercise and lymphedema literature was jointly commissioned by the ALFP and the International Lymphoedema Framework to evaluate the level of evidence in support of exercise in the management of lymphedema. A summary of these findings will be used to support the revisions of the second edition of the Best Practices document [35]. The objectives of the ALFP are to provide evidence of the best practice of lymphedema care, to assist in establishing guidelines for the management of lymphedema, and to increase awareness of this condition in the USA and worldwide. We acknowledge the reference librarian at the University of Missouri and the staff of the ALFP for their contribution to this systematic review.

Source of support

ALFP staff and reference librarian time were supported by industry donations to the ALFP. All authors donated their time in preparation of this manuscript.

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Correspondence to Marilyn L. Kwan.

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Kwan, M.L., Cohn, J.C., Armer, J.M. et al. Exercise in patients with lymphedema: a systematic review of the contemporary literature. J Cancer Surviv 5, 320–336 (2011). https://doi.org/10.1007/s11764-011-0203-9

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Keywords

  • Lymphedema
  • Breast cancer
  • Exercise
  • Physical activity
  • Systematic review
  • Literature review