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Jaewon Park1
, Miran Jung2
, Miran Jung2
Abstract
Purpose
This systematic review and meta-analysis was performed to confirm the effects of exercise on Breast Cancer-Related Lymphedema (BCRL) in breast cancer survivors.
Methods
Totally, 1,614 articles were retrieved from databases including PubMed, Ovid MEDLINE, Embase, Cochrane CENTRAL, CINAHL, Korea Med, Kmbase, KISS, NDSL, KiSTi, and academic journals related to nursing in Korea between June 17 and 18, 2019. Fifteen Randomized Controlled Trials (RCTs) were selected for the analysis from June 19 to July 12, 2019. Cochrane's Risk of Bias assessed the quality and risk of bias of selected articles. Review Manager version 5.3 was used for the meta-analysis.
Results
Studies were published since 2006 including a total of 1,109 participants who were diagnosed with or at risk of BCRL or had undergone surgery for breast cancer treatment. Although exercises were found ineffective for reducing upper extremity edema (Z=0.37, 95% Confidence Interval [CI]=−0.06~0.04, p=.710), they significantly improved shoulder Range of Motion (ROM), especially flexion (Z=5.88, 95% CI=3.06~6.12, p<.001) and abduction (Z=3.41, 95% CI=2.71~10.06, p<.001), upper extremity function (Z=4.02, 95% CI=−12.09~−4.17, p<.001), and Quality of Life (QoL) (Z=3.00, 95% CI=0.13~0.61, p=.003). Egger's regression test assessed publication bias (Intercept=3.75, t=1.79, df=8, p=.111).
Conclusion
Results suggest that exercise is beneficial to BCRL management, especially improvement of shoulder ROM, upper extremity function, and QoL. However, exercise must be performed carefully to prevent side effects. Therefore, nurses should continuously observe signs and symptoms related to BCRL and educate breast cancer survivors on safely performing exercise.
Figures and Tables
Table 1
Characteristics of 15 Studies Included in Systematic Review and Meta-analysis
ALND=axillary lymph node dissection; BCRL=breast cancer-related lymphedema; BIS=bioimpedance spectroscopy; CDT=complete or complex decongestive therapy; CG=comparison group; CTx=chemotherapy; DLE=distal to the midpoint of the lateral epicondyle; Hormone Tx=hormone therapy; IG=intervention group; MCP joint=metacarpophalangeal joint; MRM=modified radical mastectomy; PLE=proximal to the midpoint of the lateral epicondyle; ROM=range of motion; RTx=radiotherapy; SLNB=sentinel lymph node biopsy; US=ulnar styloid; †Studies included in meta-analysis.
Table 2
Effect Measurement of Exercise from the 15 included Studies
AC=arm circumference; AV=arm volume; CDT=complete or complex decongestive therapy; DASH=diasabilities of arm, shoulder, and hand; ECF=extracellular fluid; FACT-B=functional assessment of cancer therapy for breast cancer; LYMQoL=lymphoedema quality of life questionnaire; PO=primary outcome; QLQ-BR23=Eucopean organization for research and treatment of cancer-breast cancer-specific QoL questionnaire; QLQ-C30=Eucopean organization for research and treatment of cancer QoL questionnaire C30; QoL=quality of life; ROM=range of motion; SF-36=short-form 36 health survey; SO=secondary outcome; †Studies included in meta-analysis.
Appendix
Appendix 1
Studies included in Systematic Review and Meta-analysis
A1. Kizil R, Dilek B, Şahin E, Engin O, Soylu AC, Akalin E, et al. Is continuous passive motion effective in patients with lymphedema? A randomized controlled trial. Lymphatic Research and Biology. 2018;16(3):263-9.† https://doi.org/10.1089/lrb.2017.0018
A2. Park J-H. The effects of complex exercise on shoulder range of motion and pain for women with breast cancer-related lymphedema: a single-blind, randomized controlled trial. Breast Cancer. 2017;24(4):608-14.† https://doi.org/10.1007/s12282-016-0747-7
A3. Do JH, Kim W, Cho YK, Lee J, Song EJ, Chun YM, et al. Effects of resistance exercises and complex decongestive therapy on arm function and muscular strength in breast cancer related lymphedema. Lymphology. 2015;48(4):184-96.†
A4. Cormie P, Pumpa K, Galvão DA, Turner E, Spry N, Saunders C, et al. Is it safe and efficacious for women with lymphedema secondary to breast cancer to lift heavy weights during exercise: a randomized controlled trial. Journal of Cancer Survivorship. 2013;7(3):413-24.† https://doi.org/10.1007/s11764-013-0284-8
A5. Johansson K, Hayes S, Speck RM, Schmitz KH. Water-based exercise for patients with chronic arm lymphedema: a randomized controlled pilot trial. American Journal of Physical Medicine & Rehabilitation. 2013;92(4):312-9. https://doi.org/10.1097/PHM.0b013e318278b0e8
A6. Jeffs E, Wiseman T. Randomised controlled trial to determine the benefit of daily home-based exercise in addition to selfcare in the management of breast cancer-related lymphoedema: a feasibility study. Supportive Care in Cancer. 2013;21 (4):1013-23. https://doi.org/10.1007/s00520-012-1621-6
A7. Kilbreath SL, Refshauge KM, Beith JM, Ward LC, Lee MJ, Simpson JM, et al. Upper limb progressive resistance training and stretching exercises following surgery for early breast cancer: a randomized controlled trial. Breast Cancer Research and Treatment. 2012;133(2):667-76.† https://doi.org/10.1007/s10549-012-1964-1
A8. 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. https://doi.org/10.1001/jama.2010.1837
A9. Kim DS, Sim Y-J, Jeong HJ, Kim GC. Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2010;91(12):1844-8.† https://doi.org/10.1016/j.apmr.2010.09.008
A10. Sagen Å, Kåresen 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 Oncologica. 2009;48(8):1102-10. https://doi.org/10.3109/02841860903061683
A11. 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 Research and Treatment. 2010;121(2):421-30.† https://doi.org/10.1007/s10549-009-0550-7
A12. Hayes SC, Reul-Hirche H, Turner J. Exercise and secondary lymphedema: safety, potential benefits, and research issues. Medicine & Science in Sports & Exercise. 2009;41(3):483-9.† https://doi.org/10.1249/MSS.0b013e31818b98fb
A13. Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. Journal of Clinical Oncology. 2006;24(18): 2765-72. https://doi.org/10.1200/JCO.2005.03.6749
A14. Portela ALM, Santaella CLC, Gómez CC, Burch A. Feasibility of an exercise program for Puerto Rican women who are breast cancer survivors. Rehabilitation Oncology. 2008;26(2):20-31.†
A15. Lee SG. Effects of strengthening exercise and complex decongestive therapy on edema and quality of life for patients with upper lymphedema [master's thesis]. Seoul: Korea University; 2008.†
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