Furthermore, there is empirical evidence that upper-body exercise does NOT result in increased onset of lymphedema among breast cancer survivors.[27,28];[23,29,30] The largest of these studies (N = 204) [Level of evidence: I] measured the arms of women before breast surgery with axillary node dissection and randomly assigned participants to one of two rehabilitation programs:
- No activity restrictions (NAR). The women in this group (N = 104) had no restrictions on physical activities that used the affected limb for 6 months postsurgery. The NAR patients followed a supervised program of moderate, progressive resistance exercise training 2 to 3 times per week. The resistance exercises (total exercise time = 45 minutes) included a minimum of 15 repetitions for each exercise, using low resistance (0.5 kg) during the first 2 weeks. The resistance was increased individually for each patient (no upper limit), with the aim of enhancing muscular strength and endurance but always using 15 repetitions per set for each exercise.
- Activity restrictions (AR). The women in this group (N = 100) were instructed to restrict the activity of the affected limb for 6 months postsurgery. The patients were told to avoid heavy or strenuous physical activities such as aerobic or other types of exercise classes that included heavy upper-limb physical activity or work, and to avoid carrying or lifting groceries or other items weighing more than 3 kg.
At the end of 2 years of postsurgical follow-up, the incidence of new lymphedema was 13% in both groups. Of note, the single most important predictor of lymphedema onset in this large study was obesity.
Another large (N = 134 completers) randomized study compared a 1-year weight-lifting intervention with a no-exercise control group for breast cancer survivors who had unilateral disease and at least two lymph nodes removed. No patients had evidence of lymphedema at baseline. A progressive weight-lifting program did not result in an increased incidence of lymphedema. The study was designed as an equivalence trial but noted a lower incidence of lymphedema in the weight-training group (11% vs. 17%, with a significant difference of 7% vs. 22%, for those with five or more lymph nodes removed).
Patients with and at risk for lymphedema should be evaluated by a certified lymphedema therapist to ensure it is safe to proceed with exercise of the affected body part. (See the Lymphology Association of North America Web site for referrals to certified lymphedema therapists in locations across the United States.)
Patients who have lymphedema should wear a well-fitting compression garment during all exercise that uses the affected limb or body part. If there are questions regarding whether lymphedema is present, there is no evidence as to whether use of a garment will be helpful or harmful. Garments must be well fitted to be useful, are costly, may not be covered by insurance without a clear diagnosis, and must be replaced every 6 months. Among women with an unclear diagnosis, it is likely that the risk of avoiding upper-body activity outweighs the risk of engaging in slowly progressive upper-body activity without a garment. Patients without lymphedema do NOT need to wear a garment while doing exercise with the at-risk limb.