Sagen, A., Karesen, R., & Risberg, M.A. (2009). 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 (Stockholm, Sweden), 48(8), 1102–1110.

To study the development of arm lymphedema, pain, and sensation of heaviness in the affected limb after different postoperative rehab programs that involve different physical activity levels of the upper limbs

Women were randomized to one of two groups after surgery: no activity restriction (NAR) and activity restrictions (AR). Patients in the NAR group had a supervised physical therapy program in an outpatient clinic, emphasizing progressive resistance training two to three times per week. Patients in the NAR group were given standard detailed information on the unrestricted program. The AR group was told to restrict use of the affected limb for six months, including avoidance of aerobic or other types of exercise involving heavy upper-limb activity, and to avoid carrying or lifting anything more than 3 kg. Patients in the AR group also participated in the usual care physical therapy, which included six different passive techniques emphasizing flexibility and light massage. Usual care was provided for six months. Arm volumes were measured as three months, six months and two years.

• The study sample was comprised of 204 female patients initially and 152 at two-year follow-up.
• Mean age of patients was 55 years with a range of 32–75 years.
• Patients had early-stage breast cancer, underwent mastectomy or breast conserving surgery with axillary node dissection (levels I and II), and may or may not have had radiotherapy, chemotherapy, or hormone treatment.

The study took place at a mutlisite, outpatient setting in Norway.

The study used a randomized, single-blind, controlled trial design.

• The difference in volume of affected and control arm was compared using simplified water displacement instrument.
• Visual analog scales (VAS) measured pain and heaviness in the affect limb.
• Upper-limb physical activity questionnaire developed by the investigators was completed by patients.
• Body mass index was measured for all patients.

Mean duration of the rehabilitation programs was 21 weeks for the NAR group and 22 weeks for the AR group. Arm volumes at three months, six months and two years did not differ between study groups. In both groups arm edema increased significantly over time. VAS ratings for pain and heaviness for the affect limb were significantly higher in the NAR group at three months and six months (p  < 0.05) but did not differ between groups at two years. Individuals with a body mass index greater than 25 kg/m² had in increased risk of developing arm lymphedema (OR 3.42, p < 0.005) at two years. At three and six months, the amount of home physical activity reported by the NAR group was significantly higher (p = 0.001), but there were no differences in this finding between groups at two years. Approximately 13% of patients in each group had arm lymphedema at two years.

During activity participation in rehabilitation it appears that the use of progressive resistance activity and no activity restrictions were associated with more pain and sensation of heaviness with physical activity than usual care in the short term; however, there were no differences in longer-term development of lymphedema or associated symptoms. Findings suggest that activity restriction does not result in improved outcomes.

• Body mass index, volume difference, and pain and heaviness sensations risk factors were measured at baseline only.
• Subgroup analysis based upon other disease factors or specific aspects of surgical procedures done was not done.
• Supervised rehabilitation lasted for about the first six months, and there is no information about the ongoing participation in any exercise activity between that time and the two-year final follow-up measurement.
• Scoring and results of questionnaires regarding leisure time activity involving the upper extremity are not provided.

Findings suggest that doing progressive resistance exercise may help reduce lymphedema symptoms in the short term among women after breast cancer surgery because those who had restricted activity had no difference in symptoms in longer-term outcomes in the study. Given the relation between high body mass index and lymphedema development, it would be of interest to study whether weight control and weight loss after surgery would have any impact on lymphedema development.