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Exercise Shortly After Breast Cancer Surgery Improves Arm and Shoulder Mobility

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Women at high risk of arm and shoulder problems who started a physical therapist–led exercise program about a week after breast cancer surgery with no reconstruction had better upper arm mobility than women who received standard care, according to a study.

The research was published online on Nov. 11, 2021, by the journal BMJ. Read “Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation.”

Breast cancer surgery risks
About the study
What this means for you

Breast cancer surgery risks

Besides infection and healing problems, the most common risks of surgery to remove breast cancer are shoulder and arm stiffness and lymphedema.

Lymphedema is abnormal swelling that can develop in the arm, hand, breast, or torso as a side effect of breast cancer surgery or radiation therapy. It’s caused by a buildup of lymph fluid.

Breast cancer surgery, lymph node removal surgery, and radiation therapy for breast cancer can remove or damage the lymph nodes and lymph channels under the arm and around the breast. This can cause lymph fluid to build up in the soft tissues, which causes swelling, achiness, fullness or heaviness, and tightness in the affected area. Experts estimate that about 20% to 30% of people who have breast cancer surgery develop lymphedema.

The researchers who did this study reported that up to 33% of women have limited shoulder mobility, chronic pain, and lymphedema after breast cancer surgery.

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About the study

Called UK Prevention of Shoulder Problems Trial (PROSPER), the study was done at 17 cancer centers in the United Kingdom.

In the U.K., guidelines for breast cancer surgery with no reconstruction say that women should gradually start to use their arm and shoulder on the affected side after surgery. If problems develop, a woman is referred to a physical therapist.

These guidelines are different from U.S. guidelines, which recommend you start gentle stretching and range-of-motion exercises the morning after surgery or as soon as your doctor gives you the OK.

The final analysis included information on 274 women who were scheduled to have surgery to remove breast cancer with no immediate reconstruction between January 2016 and July 2017. The women’s ages ranged from 28 to 88 years. All the women had a higher-than-average risk of developing upper arm problems after surgery:

  • 86% were scheduled for axillary lymph node surgery; in this procedure, surgeons remove many lymph nodes, rather than just the one or two they remove during sentinel lymph node surgery
  • 83% were scheduled to have radiation to the lymph nodes
  • 73% had a body mass index (BMI) of 30 or greater
  • 21% had existing shoulder problems

The researchers randomly assigned the women to one of two groups after surgery:

  • 139 women were in the standard care group and received printed information recommending exercises they could do after surgery
  • 135 women were in the exercise group; besides the printed information, these women also got referrals to a physical therapist for a supervised, structured exercise program aimed at restoring arm and shoulder range of motion and improving strength

The exercise program included three in-person sessions with a physical therapist that took place:

  • seven to 10 days after surgery
  • one month after surgery
  • three months after surgery

The women were allowed up to six sessions in the year after surgery, and the last three sessions could be in person or over the phone.

The first exercise session was a one-hour assessment by the physical therapist who then created a tailored set of range-of-motion exercises that women were to do daily. The women also were taught how to keep an exercise diary and how to overcome barriers to exercise.

The rest of the sessions were 30 minutes long. At each one, the physical therapist assessed the women’s shoulder strength and then prescribed strengthening exercises targeting areas that needed improvement. The women were given resistance bands to use at home and were asked to do strength exercises at least twice a week. The physical therapist asked the women to gradually increase the amount of time they exercised per week, aiming to reach 150 minutes of moderate-intensity exercise per week, which is what the American Cancer Society recommends.

About 75% of the women attended three or more sessions with the physical therapist.

To assess arm and shoulder problems, the researchers had the women fill out the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, a tool commonly used for this purpose. The DASH questionnaire asks about 30 functions and symptoms, including opening and closing jars, writing, dressing, and lifting shopping bags. The women were asked to rate how difficult something was or how severe a symptom felt based on scale of 0 (no issue at all) to 100 (the most severe issue).

The women filled out the DASH questionnaire three times:

  • just after surgery, but before they were assigned to either the standard care or exercise groups
  • six months after surgery
  • 12 months after surgery

The higher the DASH score, the more problems a woman had.

At 12 months after surgery, the average DASH score was:

  • 16.3 for the women in the exercise group
  • 23.7 for women in the standard care group

This difference was statistically significant, which means that it was likely due to the exercise program and not just because of chance.

Specifically, women in the exercise group reported:

  • less pain after surgery
  • fewer arm problems
  • better physical health–related quality of life
  • more confidence in returning to their usual activities

“We found robust evidence that early, structured, progressive exercise is safe and clinically effective for women at higher risk of developing shoulder and upper limb problems after non-reconstructive breast surgery,” the researchers wrote.

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What this means for you

This study supports earlier research, which shows that doing specially tailored exercises after breast cancer surgery can ease its side effects and help you get back to your usual activities.

If you are scheduled to have radiation therapy after surgery, these exercises are important to help keep your arm and shoulder flexible.

It makes sense to ask your doctor about a post-surgery exercise program that’s right for you as you’re planning your surgery. Your doctor may recommend you see a physical therapist, an occupational therapist, or a lymphedema specialist.

It’s important to know that you shouldn’t do certain exercises until your doctor removes all the drains and stitches. But there are several range-of-motion exercises you can start doing right after surgery.

The American Cancer Society — in collaboration with the Oncology Section of the American Physical Therapy Association — has developed a set of exercises people can do after breast cancer surgery.

Read more about Surgery for information about the different types of breast cancer surgery, including lymph node surgery.

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Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, MD, medical adviser


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