Transcript Ashley 2pt

Exercise for Women With or at Risk for Breast Cancer-Related Lymphedema
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Bicego D, Brown K, Ruddick M, et al. Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther. 2006 Oct; 86 (10): 1398405
Abstract
Introduction
Aim
The purpose of this update is to review and critique recent studies investigating the
effects of aerobic exercise and UE resistance training for women with or at risk for
breast cancer–related lymphedema. The questions we will address are: (1) Does
aerobic or resistance exercise lead to lymphedema in women who are at risk for the
condition? and (2) Does aerobic or resistance exercise reduce or exacerbate preexisting lymphedema? We begin by reviewing the prevalence, etiology and
pathophysiology, and diagnosis of lymphedema and then review recent exercise
studies.
Background
Management of lymphedema in women with breast cancer has been a subject of
debate for many years. Treatment options include elevation, massage, compression
garments, pneumatic compression pumps, and complex physical therapy. Traditionally,
women who had been treated for breast cancer and those with pre-existing
lymphedema were advised to avoid strenuous or repetitive activities that required effort
with the affected UE because these activities were assumed to initiate or exacerbate
lymphedema.
Methods
Studies were systematically retrieved from published articles from 2001-2005 included
in CINAHL, EMBASE, MEDLINE, PEDro, and PubMed databases using the keywords
“breast cancer”, “exercise”, and “lymphedema”. The articles were appraised by five
individuals and then placed into hierarchical levels based off of Sackett’s rules of
evidence rank studies.
Results
Eight studies were included in the review that directly related to breast cancer-related
lymphedema and exercise. Exercise was found to neither initiate nor exacerbate
lymphedema.
Conclusions
Additional research with larger samples, more rigorous designs (eg, randomized
controlled trials), and more sophisticated outcome tools to measure lymphatic flow (eg,
lymphoscintigraphy) is needed to address the safety and effectiveness of exercises for
women with breast cancer–related lymphedema, one of the most concerning and
prevalent secondary complications of breast cancer treatments.
•Breast cancer is commonly treated by surgery (axillary dissection), chemotherapy, or
radiation.
•Axillary dissection or radiation can result in lymphedema due to obstruction, trauma,
and inflammation of the lymphatic system.
•“25% of patients develop lymphedema after breast cancer surgery, with an increase to
38% for those who also undergo radiation therapy”
• Lymphedema has been defined as an abnormal accumulation of protein-rich fluid,
edema, and chronic inflammation and can elicit pain, tightness, and heaviness in the
upper extremity (UE), as well as lead to recurrent skin infections.
•Management of lymphedema in women with breast cancer has been a subject of
debate for many years. Treatment options include elevation, massage, compression
garments, pneumatic compression pumps, and complex physical therapy.
•Traditionally, women who had been treated for breast cancer and those with preexisting lymphedema were advised to avoid strenuous or repetitive activities that
required effort with the affected UE because these activities were assumed to initiate
or exacerbate lymphedema.
Purpose
•To review and critique recent studies investigating the effects of aerobic exercise and
UE resistance training for women with or at risk for breast cancer–related lymphedema.
•(1) Does aerobic or resistance exercise lead to lymphedema in women who are at risk
for the condition? and (2) Does aerobic or resistance exercise reduce or exacerbate
pre-existing lymphedema
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Methods and Materials
•The authors searched the following databases: CINAHL, EMBASE, MEDLINE, PEDro,
and PubMed.
•Keywords used: “breast cancer”, “exercise”, and lymphedema
•The search was limited to human, female and English-language studies
•Five reviewers were used to critique the articles.
•Exclusion criteria: review articles, clinical practice guidelines, studies in which exercise
was not an independent variable, and studies in which the type of exercise therapy was
not defined.
•The authors found eight articles that directly related to breast cancer-related
lymphedema and exercise. The years of publication ranged from 2001-2005.
•The two categories of articles the authors researched included: effects of exercise for
women with pre-existing lymphedema and the effects of exercise for those with
lymphedema due to breast cancer.
•The authors used Sackett’s rules of evidence rank studies in order to place the articles
in a hierarchical level. The levels are ranked I to V:
•I: large randomized controlled trail with low false positive or false negative errors
•II: small randomized controlled trial with high false positive or false negative
errors
•III: nonrandomized, concurrent cohort comparisons
•IV: nonrandomized, historical cohort comparisons
•V: case series without controls
•The majority (5 out of the 8 articles) of the research included in the article was level V
(case series without control). The highest level of research included in this article was
level II (small, randomized controlled trials), which only included three studies.
Results
•This article helped to confirm the notion that physical activity for patients with breast
cancer-related lymphedema is safe and should not increase their symptoms.
•According to the authors, “Additional research with larger samples, more rigorous
designs (eg, randomized controlled trials), and more sophisticated outcome tools to
measure lymphatic flow (eg, lymphoscintigraphy) is needed to address the safety and
effectiveness of exercises for women with breast cancer–related lymphedema”
Article #1 and Evidence
Schmitz K, Ahmed R, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan C,
Williams-Smith C, Greene Q. Weight Lifting in Women with Breast-Cancer-Related
Lymphedema. N Engl J Med. 2009; 361: 664-673.
•This randomized control trial supports the original articles conclusion that it is safe
for patients with lymphedema to perform exercises even with the involved
extremities.
•The researchers not only found that it was safe to exercise, but it may actually be
beneficial for patients.
•The results of this article included “a decreased incidence of exacerbations of
lymphedema, reduced symptoms and increased strength”, all of which are benefits
for this patient population.
Article #2 and Evidence
Clinical Significance
•Considering the large number of women affected by lymphedema, physical therapists
are highly likely to see a large number of breast cancer survivors who may be suffering
from lymphedema complications so as healthcare providers we need to be aware of
treatment techniques that are not contraindicated
•This article refuted the notion that physical activity is unsafe for patients with
lymphedema and would increase exacerbations.
•As a PT it is important for us to stay up to date with the most current evidence and be
aware of what interventions are no longer contraindicated with certain patient
populations. This article makes us aware that we can incorporate exercise into our
interventions and not be concerned about an increase in the patient’s symptoms.
Chan D, Lui L, So W. Effectiveness of exercise programmes on shoulder mobility and
lymphedema after axillary lymph node dissection for breast cancer: systemic review.
Journal of Advanced Nursing. 2010 May; 66 (9): 1902-1914.
•This systemic literature review supports the findings of the original article.
•Among the six studies that measured the effect of exercise on lymphedema found no
significant difference between the treatment group, which consisted of an exercise
regimen, and the control group.
•The authors found that exercise did not increase exacerbations of lymphedema and
they also found that early implementation of exercise post-operatively prevents a
decrease in shoulder ROM.
•According to the review, “physical exercise may improve shoulder mobility, and it does
not alter the severity of lymphedema.”
Summary
Conclusion
•The authors concluded that it is safe for individuals with breast cancer-lymphedema to
perform PRE and the aerobic activity will.
•However, the lack of high quality evidence led the authors to also conclude to more
research needs to be performed in this area with higher research quality and larger
patient populations.
•The most recent publications are refuting old beliefs that exercise is not indicated and
may increase exacerbations in patients with lymphedema.
•This new research is proving that not only is exercise safe and will not increase
symptoms, but now this patient population (i.e. breast cancer survivors) can receive all
the benefits from a weight lifting program, such as a reduction in body fat and
improvement in their body mass index (BMI).
•These results now give healthcare providers the confidence to prescribe an exercise
program to this population and not be concerned with adverse effects.
Ashley Walker, DPT Student