January 18, 2009
Breast Cancer, Physical Therapy & Lymphedema
Robert A. Wascher, MD, FACS
Exercise Improves Lymphedema Symptoms In Breast Cancer Survivors
Arm lymphedema, or chronic swelling of the arm, occurs in 10 to 30 percent of women following treatment for breast cancer. When the lymphatic drainage network in the arm has been disrupted by the surgical removal of armpit lymph nodes by the surgeon, or by radiation therapy to the armpit area (or, sometimes, following both types of treatment), the delicate network of lymphatic vessels that return excess tissue fluid back to the heart can become obstructed. This lymphatic obstruction can result in chronic swelling of the hand and arm. Patients with significant lymphedema of the arm following breast cancer treatment may experience considerable swelling (edema), heaviness, stiffness and discomfort of the affected hand and arm.
Physicians caring for breast cancer patients have traditionally advised against heavy lifting following breast cancer surgery, for fear that doing so might increase arm lymphedema. However, a new prospective randomized clinical research study calls into question the traditional advice against vigorous exercise involving the upper extremities, including lifting weights as a strengthening exercise.
This new study, which appears in the New England Journal of Medicine, included 141 breast cancer survivors with chronic lymphedema. These women were divided into two groups, with a treatment group randomized to twice-weekly progressive weight training and a control group of women who were randomized to no weight training. All of the women participating in this study were followed for one year, at the end of which the degree of arm lymphedema was reassessed. Of note, all of the women who were randomized to the weight training group were required to wear custom-fitted compression garments when they were lifting weights.1
Not surprisingly, the women who participated in regular weight training reported significant improvement in upper and lower body strength during the course of this research study. Moreover, at the end of one year, both the patients and a certified lymphedema specialist reported a significant decrease in the severity and frequency of lymphedema symptoms among the patients who were randomized to the weight-lifting group. At the same time, twice weekly weightlifting sessions had no significant effect on the extent of arm and hand swelling among these women with chronic lymphedema.
The results of this clinical study are good news for breast cancer survivors with chronic lymphedema. Physicians who care for such patients should all be made aware of the results of this research study, and they should begin encouraging their lymphedema patients to engage in regular weight training (provided, of course, that there are no health issues that preclude lifting weights). Not only does regular weight training appear to decrease the severity and frequency of lymphedema symptoms (based upon the findings of this study), but the added health advantages of such training also include increased strength and a decreased risk of osteoporosis as well.
Breast Cancer, Physical Therapy & Lymphedema
Arm lymphedema, or chronic swelling of the arm, occurs in 10 to 30 percent of women following treatment for breast cancer. When the lymphatic drainage network in the arm and hand has been disrupted by the surgical removal of axillary (armpit) lymph nodes, or by radiation therapy to the axilla (or, sometimes, following both types of treatment), the delicate network of lymphatic vessels that return excess tissue fluid back to the heart can become obstructed. This lymphatic obstruction can then result in chronic swelling of the hand and arm. Patients with significant lymphedema of the arm following breast cancer treatment may experience considerable swelling (edema), heaviness, stiffness and discomfort of the affected hand and arm.
Unfortunately, there are no known effective methods available to prevent lymphedema, and once significant lymphedema does develop, compression sleeves and soft tissue massage are the primary treatment modalities currently available. Unfortunately, currently available lymphedema treatments are often not highly effective for many patients, and there is no known cure for lymphedema once it develops.
Now, a newly published research study, in the British Medical Journal, suggests that physical therapy, when initiated early after breast cancer surgery, can significantly decrease the risk of arm and hand lymphedema. In this prospective randomized clinical research study, 120 women who underwent removal of their axillary lymph nodes for breast cancer were randomized to one of two groups. Women assigned to the experimental group underwent physical therapy 3 times per week, for a total of 3 weeks. Physical therapy techniques used in this group included manual lymph drainage and soft tissue massage techniques, as well as progressive shoulder exercises. Both groups of women also underwent the same lymphedema management educational course, but the control group of women did not receive any physical therapy interventions. 2
Among the 116 women who completed at least one year of follow-up, 18 women (16 percent) went on to develop lymphedema. Fourteen of the women who developed lymphedema were in the control group, while the remaining 4 women were in the experimental group. Thus, in this clinical study, early physical therapy following axillary lymph node dissection (ALND) was associated with a very significant 72 percent reduction in the risk of developing lymphedema, at least within the first year following breast cancer surgery.
Whether or not the use of early postoperative physical therapy can reduce the incidence of arm lymphedema over periods longer than one year is unknown at this time, and additional follow-up of the patients who participated in this clinical research study will be required to answer this very important question. However, this is one of the very few studies available that suggests a role for physical therapy in the actual prevention of arm and hand lymphedema following ALND for breast cancer. If additional, mature follow-up of these patients confirms a long-term benefit from early postoperative physical therapy in preventing arm lymphedema, then a strong case could be made for the routine use of early physical therapy in women who undergo ALND, and perhaps, as well, women who undergo sentinel lymph node biopsy with subsequent radiation therapy to the breast and armpit (axilla) area.
- Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP. Weight Lifting in Women with Breast-Cancer--Related Lymphedema N Engl J Med. 2009 Aug 13;361(7):664-73
- Lacomba, MT, Sanchez, MJY, Goni, AZ, Merino, DP, del Moral, OM, Tellez, EC, Elena Minayo Mogollon,EM. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial BMJ 2010;340:b5396
- For additional information and resources related to cancer-associated lymphedema, please click on the links below:
- Reprinted by permission
- Of Interest:
- Exercise If At Lymphedema Risk
Yoga for HIV/Aids, Cancer and other Life Challenges
Three Keys to Manage Breast Cancer-Related Lymphedema