Schmitz, K.H., Ahmed, R.L., Troxel, A.B., Cheville, A., Lewis-Grant, L., Smith, R., . . . Chittams, J. (2010). Weight lifting for women at risk for breast cancer-related lymphedema: A randomized trial. JAMA: The Journal of the American Medical Association, 304(24), 2699–2705.

To evaluate the onset of lymphedema after a one-year weight-lifting intervention versus no exercise among breast cancer survivors at risk for lymphedema

Patients were randomized to the weight-lifting intervention group or control group, who were to have no change in level of exercise. The weight-lifting intervention included a gym membership and 13 weeks supervised instruction with a remaining 9 months unsupervised. Specific equipment varied but provided upper-body exercises (i.e., seated row, supine dumbbell press, lateral or front raises, bicep curls, triceps pushdowns) and lower-body exercises (i.e., leg press, back extension, leg extension, and leg curl), 3 sets of 10 repetitions. Weights were increased for each exercise by the smallest possible increment after two sessions of completing 3 sets of 10 reps with no change in arm symptoms. Trainers called patients who missed more than one session per week. Those who missed two consecutive sessions were asked to reduce resistance and rebuild per protocol. All participants in the intervention or control group who developed lymphedema were given a custom compression garment and were required to wear garments during weight-lifting sessions. Certified fitness professionals employed by the centers received a three-day training course regarding exercise protocol and overview of lymphedema prevention, symptoms, and treatment.

• The study sample (N = 134) was comprised of female patients who had a diagnosis of unilateral nonmetastatic breast cancer one to five years prior.
• Mean age of participants was 54–56 years.
• Patients were included in the study if they
  • Had a body mass index of less than or equal to 50
  • No medical conditions limiting exercise
  • No weight lifting in year prior to study
  • No plans for surgery or absence for a month during the study
  • A stable weight
  • Were not trying to lose weight
  • No prior lymphedema diagnosis
  • No evidence of current lymphedema.

The study took place across multiple community fitness centers in Philadelphia, PA.

The study has clinical applicability for late effects and survivorship.

The study used a randomized controlled equivalence trial design.

• Patients self-reported demographics and treatment history.
• Surgical pathology reports were used to study removed lymph nodes.
• Weight and height (baseline only) were recorded.
• Whole-body dual-energy x-ray absorptiometry scan measured bone mineral density to avoid misrepresenting changes in relative fat mass because of changes in bone density.
• Physical activity outside of weight lifting was assessed using the International Physical Activity Questionnaire.
• Diet was assessed using the Diet History Questionnaire
• Water volume displacement measured lymphedema.
• Clinical laboratory technicians at Penn Therapy used standardized clinical evaluation based on Common Toxicity Criteria version 3.0.
• Participants were sent for evaluation of change for symptoms lasting one week or longer by fitness trainers or if three-month interval measurements by measurement staff indicated a change in treatment-arm volume of at least 5% inter-limb difference.
• Strength was measured at baseline and 12 months based on the maximum amount of weight patients could lift at once.
• Intervention adherence was evaluated by attendance logs kept by fitness trainers.
• Statistical analysis was performed using the Statistical Analysis System (SAS) version 9.2.
   

Women in the weight-lifting group became stronger with lower percentage body fat compared with the no exercise group. Lymphedema onset (5% or more increase in inter-limb volume difference during the 12 months) was 17% (n = 13) in the control group and 11% (n = 8) in the weight-lifting group.

The findings demonstrates that slowly progressive weight lifting will not increase the risk of lymphedema in breast cancer survivors, the primary objective of testing the safety of the weight-lifting intervention. 

• Key sample group differences could influence results.
• Replication to other fitness settings was limited by availability of instructors.
• Patients had limited access to clinical laboratory technicians for immediate evaluation and treatment.
• Garments to be provided to patients was not covered by insurance.

Additional research is needed to determine if weight lifting prevents lymphedema. Nurses should use caution in stating that exercise does not increase onset of lymphedema based on just this study, as it was conducted in a controlled environment, with careful instruction and observation of correct use of equipment and evaluation of arm symptoms and volume changes.