Lymphedema is swelling of the arm, hand, chest wall, back, or other body part caused by lymph fluid collecting in tissue after surgery, especially breast cancer surgery that removes underarm (axillary) lymph nodes. Edema is the medical term for swelling, so swelling caused by lymph fluid is "lymphedema."
You may have heard about the Physical Activity and Lymphedema Trial, called PAL for short. PAL was one of several studies that found that a program of gradually increasing exercise supervised by a certified lymphedema therapist -- meaning you start gently and intensify slowly over time -- is not likely to increase the risk of lymphedema. This also is the recommendation made in the National Lymphedema Network’s Position Statement on Exercise.
A study has found that the Strength After Breast Cancer program, the exercise and education program developed at the University of Pennsylvania that was studied in PAL, can be successfully implemented in a larger, real-world setting. The study also found certain factors that could make the program less successful and offered solutions.
The study was published in issue 50 of a special monograph of the Journal of the National Cancer Institute. Read “A Hybrid Effectiveness-Implementation Trial of an Evidence-Based Exercise Intervention for Breast Cancer Survivors.”
Kathryn Schmitz, Ph.D., M.P.H., professor of clinical epidemiology at the University of Pennsylvania, was the lead author of the study. Dr. Schmitz also is a member of the Breastcancer.org Professional Advisory Board.
PAL looked at 154 women at risk for breast cancer-related lymphedema, putting them in one of two groups:
- a program of slowly progressive weight training, starting out with very light weights
- no exercise
Among women who had five or more lymph nodes removed, the weight training made a difference:
- 7% of the women in the exercise group had an incident of lymphedema
- 22% of the women in the no-exercise group experienced lymphedema
Also as part of PAL, the research team randomly assigned 141 breast cancer survivors who had stable lymphedema to either a slowly progressive weight training program or no exercise. Women in the weight-training group didn’t have any increase in the risk of developing arm swelling. Women in the weight-training group also had fewer lymphedema flare-ups:
- 14% of the women in the exercise group had a flare-up
- 29% of the women in the no-exercise group had a flare-up
as assessed by a certified lymphedema therapist.
Because the gradual weight training program worked so well in a controlled, research setting, the next step for the researchers was to see how well it worked in a real-world setting, such as a physical therapy clinic.
In this new study, 84 women who had been diagnosed and treated for breast cancer -- including women who were at risk for lymphedema or had been diagnosed with lymphedema -- completed the year-long Strength After Breast Cancer exercise and education program. Based on input from cancer doctors, physical therapists, and breast cancer survivors, the researchers changed certain parts of the program to increase the likelihood that women would stick with the program, as well as lower the cost of the program without affecting the safety or effectiveness of the program.
For example, PAL had 26 trainer-supervised, small-group training sessions over 13 weeks. Many doctors and survivors were concerned that this many sessions wouldn’t be covered by insurance. So the Strength After Breast Cancer program included four small-group physical therapy sessions over 1 to 2 months with the expectation that the women would do the strength-training exercises they learned in the sessions twice a week at home for the rest of the year.
The Strength After Breast Cancer program was conducted by physical therapists who had been trained by the researchers.
Before the women started the program, the researchers measured the women’s weight, arm volume, and muscle strength, and asked them how they felt about their bodies. The researchers took these same measurements again after the year-long program was done.
As in PAL, the researchers found that the Strength After Breast Cancer program didn’t increase the risk of lymphedema and helped ease lymphedema symptoms. The women were also stronger at the end of the program and felt better about their bodies.
The researchers also found that there were some factors that hindered the program and offered solutions:
- The physical therapists conducting the program thought the group format was harder to manage because each woman had different ability levels. In the future, the program might offer individual training sessions or place women in groups by ability level.
- Both physical therapists and oncologists thought the program needed to be covered by insurance or be low-cost enough so women could participate. The researchers reported that the program was covered by almost all insurance companies.
- A physical therapy “champion” was needed to help physical therapists accept the program and modify the referral and training procedures as needed. Without this person advocating for the Strength After Breast Cancer program, the program wouldn’t have been successful.
- After referring a woman to the program, someone in the oncologist’s office needs to follow up to make sure the woman has successfully enrolled.
"The results of this study are exciting because they demonstrate that an evidence-based exercise and education program for breast cancer survivors can be translated to a new setting while still remaining effective and safe," said Rinad Beidas, assistant professor of psychiatry at the University of Pennsylvania and one of the researchers. "Importantly, we were also able to identify the types of barriers that should be addressed when taking this program to scale, which provides important information on translating research into practice, which historically has taken up to 17 years."
If you're scheduled for breast cancer surgery, be sure to ask your doctor about your risk of lymphedema and any steps you can take to lower that risk. After surgery, talk to your doctor about exercises and any activity restrictions that make the most sense for your unique situation. If you'd like to do strength training after surgery, you might want to ask your doctor about the Strength After Breast Cancer program and if it’s available in your area. You also may want to ask for the name of a physical therapist who works with women who have lymphedema or are at risk for lymphedema.