Immediate versus delayed shoulder exercises after axillary lymph node dissection. A Randomized Controlled Trial on the Prevention of Seroma after Partial or Total Mastectomy and Axillary Lymph Node Dissection. Timing of shoulder exercise after modified radical mastectomy: a prospective study. Two exercise schemes in postoperative breast cancer: comparison of effects on shoulder movement and lymphatic disturbance. Effects of supervised exercise therapy in patients receiving radiotherapy for breast cancer. The effectiveness of early rehabilitation in patients with modified radical mastectomy. Wound drainage following radical mastectomy: the effect of restriction of shoulder movement. Axillary lymphadenectomy. A prospective, randomized trial of 13 factors influencing drainage, including early or delayed arm mobilization. Shoulder function following early mobilization of the shoulder after mastectomy and axillary dissection. Effectiveness of a self-administered, home-based exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection: a preliminary study. A pilot study to assess the influence of tai chi chuan on functional capacity among breast cancer survivors. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. Efficacy of comprehensive group rehabilitation for women with early breast cancer in South Korea. Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy. Rehabilitation of the mastectomy patient: a randomized, blind, prospective study. Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: a prospective randomized study. Evaluation of immediate versus delayed shoulder exercises after breast cancer surgery including lymph node dissection--a randomised controlled trial. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. Dance and movement program improves quality-of-life measures in breast cancer survivors. Pectoral stretching program for women undergoing radiotherapy for breast cancer. Physiotherapy treatment of late symptoms following surgical treatment of breast cancer. [Efficacy of massage and mobilization of the upper limb after surgical treatment of breast cancer].
A total of 144 evaluable patients with breast cancer were enrolled in a multicenter, randomized, prospective study to establish the role of delayed shoulder exercises on wound drainage and shoulder function after axillary lymph node dissection. Patients in group 1 (n = 78) started active shoulder exercises 1 day postoperatively. Patients in group 2 (n = 66) started on the eight postoperative day, following 1 week of immobilization of the arm. Patients in group 2 had 14% less wound drainage volume than those in group 1 (600 +/- 436 mL versus 701 +/- 398 mL); this difference, however, was not significant. Also, no differences could be established between the two groups when duration and volume of wound drainage, number and volume of seroma aspirations, wound complication rates, and shoulder function were compared 6 months after surgery. BACKGROUND: Wound seroma is one of the most frequent complications of mastectomy, but an effective strategy for its prevention has not yet been established. The purpose of this study was to determine the effectiveness of delayed shoulder exercise on the prevention of wound seroma after partial or total mastectomy with axillary dissection for the treatment of cancer. METHODS: This study prospectively randomized two exercise schemes after mastectomy with axillary lymph node dissection. The immediate exercise group (n =58) started shoulder exercise on the first postoperative day. In the delayed exercise group (n =58) the movement of the upper limb was limited to usual daily activities during the first postoperative week. RESULTS: Preoperative levels of shoulder function were regained within one month when shoulder exercise was delayed for one week after operation. Significant decrease of drainage volume and lower incidence of seroma formation were seen in the delayed exercise group. CONCLUSION: These observations suggest that seven days of unrestricted moverment and avoiding active exercise of the shoulder joint, is the optimal routine reduce seroma formation after mastectomy. There are several factors those contribute to the amount of axillary drainage after modified radical mastectomy. The drains should be removed as early as possible. Whether the active shoulder movement of the lesion side increases the amount of axillary drainage needs to be studied prospectively.
                From 1994 through 1995, 344 consecutive patients were randomly divided into three groups. One hundred sixteen patients in the early group performed upper arm exercises including pendulum, wall climbing and pulley exercises beginning the third post-operative day. One hundred fifteen patients in the later group patients did the same exercises beginning the sixth post-operative day and 113 patients in the delayed group did the same exercises after all the drains were removed.
                There were no significant differences in patient characteristics, including age, body weight, operation methods and the pathology in the three groups. The amount of axilla fossa drainage was significantly less in the patients in the delayed group than in the early and later group (485 ml, 568 ml, 559 ml, respectively, p = 0.032). However, there were no differences in the amount of chest wall site drainage or the number of aspiration of seroma among the three groups. The drains were removed on the average of seventh and ninth post-operative day in the delayed and early group patients, respectively (p = 0.124). Although the range of motion (ROM) of the shoulders in the delayed group patients was slightly limited during the first month after operation, ROM returned at 3 months and no difference was found 6 months after operation.
                Upper arm exercise can start after the drains in the axilla are removed. The delay does not limit the shoulder function at 6 months after modified radical mastectomy. We attempted to determine the best method of performing the exercises in rehabilitation after breast cancer surgery and their influence on postoperative complications. Currently, there are no guidelines for these exercises. The scope of this study was to evaluate the effect of two schemes of physiotherapy exercises (directed or free) on shoulder function and lymphatic disturbance in postoperative rehabilitation.
                Sixty women who underwent a modified radical mastectomy or quadrantectomy with axillary dissection were randomized into two groups.
                The physiotherapy technique used was kinesiotherapy. The directed group performed physiotherapy following a regimen of 19 exercises. The free group performed the exercises following the biomechanical physiological movements of the shoulder without a previously defined sequence or number of repetitions.
                The averages of the flexion, abduction and external rotational movements of the shoulder showed better recovery with statistical significance in the directed group compared to the free group. There was no significant difference between the groups in lymphatic disturbance.
                At the end of 42 days of follow-up, the movements of flexion, extension, abduction and external rotation of the shoulder were better rehabilitated in the directed group. The two schemes of exercises were not different with regard to lymphatic disturbance. Postoperative radiotherapy for breast cancer has a number of associated complications. This study examined whether supervised moderate-intensity exercise could mitigate the complications that occur during radiotherapy.
                Forty women were randomized before radiotherapy after various operations for breast cancer. Seventeen patients who were assigned to the exercise group performed supervised moderate-intensity exercise therapy for 50 min 3 times per week for 5 weeks. Twenty-three patients in the control group were asked to perform self-shoulder stretching exercise. The World Health Organization Quality of Life-BREF (WHOQOL-BREF), brief fatigue inventory (BFI), range of motion (ROM) of the shoulder, and pain score were assessed before and after radiotherapy.
                There were no significant differences noted at baseline between groups. In the exercise group, there was an increase in the WHOQOL-BREF and shoulder ROM and decrease in BFI and pain score after radiotherapy. On the other hand, patients in the control group showed decrease in the WHOQOL-BREF and shoulder ROM and increase in BFI and pain score after radiotherapy. There were statistically significant differences in the changes in the WHOQOL, BFI, shoulder ROM, and pain score between the groups.
                Patients receiving radiotherapy for breast cancer may benefit in physical and psychological aspects from supervised moderate-intensity exercise therapy. The aim of this prospective study was to investigate the effects of early onset rehabilitation program on shoulder mobility, functional status, lymphedema, and the incidence of postoperative complications in patients who had modified radical mastectomy. Fifty-seven women were randomly assigned to either treatment group or home exercise program groups, which were consisted of 27 and 30 patients, respectively. After removal of the drains, the patients were instructed to 15 sessions of individual rehabilitation program and continued with home-based physical activity program. The home exercise program groups only received a form including the exercises, which could be performed by themselves after removal of the drains. Range of motion of the shoulder joint and upper extremity circumferential difference were measured. Functional status was assessed by functional index score. Each patient was assessed preoperatively and then postoperatively at fifth day and first, third, and sixth months. The improvement in measurements of flexion, abduction, and adduction movements of the shoulder joint and the functional questionnaire scores were significantly better in treatment group. There was no statistically significant difference in the development of lymphedema and postoperative complications in both groups. Early onset rehabilitation program after modified radical mastectomy provides improvement in shoulder mobility and functional capacity without causing adverse effect in postoperative period. A randomized prospective clinical trial has been performed to determine the effect of temporary immobilization of the shoulder on wound drainage following radical mastectomy. In 64 patients admitted to the trial the mean volume of drainage was reduced by 40 per cent in those who had shoulder movement restricted for the first 7 days after operation when compared with the group in whom early arm exercises were encouraged. The mean drainage time was reduced by 29 per cent. Shoulder immobilization did not result in increased shoulder stiffness, although there was an increased incidence of mild lymphoedema of the arm. Greater amount and duration of postoperative wound drainage after lymphadenectomy impede healing. We evaluated the influence of early vs delayed initiation of shoulder mobilization on postoperative drainage. Fifty-seven women with clinical stage I or II breast cancer were randomized to either early (postoperative day 2) or delayed (postoperative day 5) shoulder motion. Early vs delayed time of exercise initiation had no effect on total amount or duration of drainage, either as an inpatient or outpatient. The two groups were determined to be homogeneous as to age, breast size, weight, height, obesity, previous biopsy, excision of pectoralis minor, excision of thoracodorsal complex, level of axillary dissection, total number of lymph nodes, number of positive lymph nodes, lymphatic vessel invasion (with negative lymph nodes), and whether the dominant hand was on the side operated on. The two factors predicting greater drainage were large numbers of positive lymph nodes and no previous surgical biopsy (as in one-step procedure). A prospective clinical trial was conducted to determine the effect of axillary node dissection for breast carcinoma on shoulder function and seroma production. 59 Operations were carried out in 57 patients. The patients were divided into two groups. In group A, shoulder exercises were started, under the guidance of a physiotherapist, immediately following surgery, and in group B the exercises were begun on the seventh postoperative day. A full range of motion within six months was achieved in 25 patients of group A (81%) and in 22 of group B (79%). There was no significant difference in wound drainage between the two groups. Restricted shoulder movement was often seen after local wound complications following axillary radiotherapy or after seriously disturbed wound healing. This pilot study examined the effects of a self-administered, home-based exercise (HBE) rehabilitation programme designed to help women regain shoulder mobility immediately following surgery for a modified radical mastectomy and axillary node dissection.
                Twenty-seven women who were scheduled for surgery were randomly assigned to either a post-surgical experimental HBE rehabilitation group (n = 16) or a usual care group (UC; n = 11). Women assigned to the HBE group followed an 11 day (days 3-14 post-surgery), home-based rehabilitation programme consisting of shoulder flexibility and stretching exercises that were described on videotape. The videotape programme was modelled after the exercises and guidelines described in a brochure produced by the Canadian Cancer Society.
                As a result of the exercise programme intervention, there was a time x group interaction indicating that the HBE group demonstrated a significantly greater increase in shoulder flexion range of motion (ROM) (p = 0.003) and abduction ROM (p = 0.036) when compared to the UC. There were no statistical differences in shoulder strength between groups over time. External rotation (p = 0.036) and grip strength (p = 0.001) significantly increased in both groups during the intervention period but there were no interaction effects. With respect to the forearm circumferences, there was a significant decrease over time (p < 0.001) but no interaction between groups.
                This HBE rehabilitation programme is an effective way to improve shoulder mobility and ROM during the immediate 2-week recovery period following surgery. Treatment of breast cancer can significantly diminish functional capacity in patients months and even years after the completion of treatments. Tai chi chuan (TCC) is a moderate form of exercise that may be an effective therapy for improving functional capacity among breast cancer survivors. We sought to provide pilot data comparing the efficacy of TCC and psychosocial therapy (PST; physical activity control) for improving functional capacity among breast cancer survivors post treatment. Twenty-one women who had completed treatment of breast cancer were randomized to receive TCC or PST 3 times/wk for 12 weeks. Functional capacity was assessed at baseline and at 12 weeks. The TCC group demonstrated significant improvement in functional capacity (specifically aerobic capacity, muscular strength, and flexibility) whereas the PST group showed significant improvement in flexibility only. These data suggest that TCC may be an efficacious intervention for enhancing functional capacity among breast cancer survivors and may support the need for larger randomized, controlled clinical trials to further elucidate these relationships. Breast cancer chemotherapy may cause unfavorable changes in physical functioning, body composition, psychosocial functioning, and quality of life (QOL). We evaluated the relative merits of aerobic and resistance exercise in blunting these effects.
                We conducted a multicenter randomized controlled trial in Canada between 2003 and 2005 that randomly assigned 242 breast cancer patients initiating adjuvant chemotherapy to usual care (n = 82), supervised resistance exercise (n = 82), or supervised aerobic exercise (n = 78) for the duration of their chemotherapy (median, 17 weeks; 95% CI, 9 to 24 weeks). Our primary end point was cancer-specific QOL assessed by the Functional Assessment of Cancer Therapy-Anemia scale. Secondary end points were fatigue, psychosocial functioning, physical fitness, body composition, chemotherapy completion rate, and lymphedema.
                The follow-up assessment rate for our primary end point was 92.1%, and adherence to the supervised exercise was 70.2%. Unadjusted and adjusted mixed-model analyses indicated that aerobic exercise was superior to usual care for improving self-esteem (P = .015), aerobic fitness (P = .006), and percent body fat (adjusted P = .076). Resistance exercise was superior to usual care for improving self-esteem (P = .018), muscular strength (P < .001), lean body mass (P = .015), and chemotherapy completion rate (P = .033). Changes in cancer-specific QOL, fatigue, depression, and anxiety favored the exercise groups but did not reach statistical significance. Exercise did not cause lymphedema or adverse events.
                Neither aerobic nor resistance exercise significantly improved cancer-specific QOL in breast cancer patients receiving chemotherapy, but they did improve self-esteem, physical fitness, body composition, and chemotherapy completion rate without causing lymphedema or significant adverse events. The purpose of this study was to evaluate the effects of a comprehensive group rehabilitation program on the range of motion of the shoulder joint, psychosocial adjustment, and the quality of life for early breast cancer patients. Fifty-five women with early breast cancer were assigned to an intervention group or a control group. Intervention was provided three times per week for 10 weeks. The results showed an increased range of motion of the shoulder joint, and psychosocial adjustment and quality of life were shown to be significantly higher in the intervention group than in the control group. The rehabilitation program comprised psychology-based education, exercise, and peer support group activity to promote recovery of the affected shoulder joint range of motion, alleviate physical symptoms, and improve psychosocial adjustment and quality of life for early breast cancer patients in South Korea. Breast screening programmes have facilitated more conservative approaches to the surgical and radiotherapy management of women diagnosed with breast cancer. This study investigated changes in shoulder movement after surgery for primary, operable breast cancer to determine the effect of elective physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were completed preoperatively, at day 5 and at 1 month, 3, 6, 12 and 24 months postoperatively. The CG only received an exercise instruction booklet in comparison to the TG who received the Physiotherapy Management Care Plan (PMCP). Analyses of variance revealed that abduction returned to preoperative levels more quickly in the TG than in the CG. The TG women had 14 degrees more abduction at 3 months and 7 degrees at 24 months. Functional recovery at 1 month was greater in those randomised to the TG, with a dominant operated arm (OA) or receiving breast-conserving surgery. However, it was not possible to predict recovery over the 2 years postoperatively on the basis of an individual woman's recovery at 1 month postoperatively. The eventual recovery of abduction or flexion range of movement was not related to the dominance of the OA nor to the surgical procedure performed. The PMCP provided in the early postoperative period is effective in facilitating and maintaining the recovery of shoulder movement over the first 2 years after breast cancer surgery. After biopsy confirmation of breast carcinoma, women who were scheduled to undergo a modified radical mastectomy had demographic data collected, goniometric measurements of shoulder flexion and abduction, and functional evaluation of the ipsilateral shoulder performed, and upper extremity circumferential measurements at five levels determined. Patients were then randomly assigned either to a group that received immediate postoperative physical therapy or to one that did not. Results represent the combination of data from a pilot study and this subsequent study following appropriate statistical analysis. Sixty-four women in the treatment group showed a statistically significant increase in shoulder range of motion in both abduction and flexion as compared to 51 women who received no physical therapy. The treated group also had fewer problems with five of the six upper extremity functional tasks that were assessed. There were no significant differences between the groups for length of hospital stay, postoperative complications, or upper extremity edema. The authors conclude that early physical therapy intervention makes a significant contribution to return to normal function without increasing the incidence of postoperative complications or prolonging hospital stay. Seromas and impaired shoulder function are well-known complications after modified radical mastectomy for breast cancer. Early postoperative physiotherapy is a common treatment to avoid shoulder dysfunction. The aim of this study was to evaluate if the frequency of postoperative seromas could be reduced, without increasing shoulder dysfunction, by delayed postoperative shoulder exercises.
                In a prospective study 163 patients with breast cancer undergoing modified radical mastectomy were randomized to physiotherapy starting on postoperative day 1 or day 7. Patients were seen by the surgeons and the physiotherapists during hospital stay and in the outpatient department. Seromas and other complications were registered by the surgeons. The physiotherapists instructed the patients pre- and postoperatively and assessed shoulder function.
                There was a significantly higher incidence of postoperative seromas in the group of patients that started physiotherapy postoperative day 1 (38%) compared to the group that started physiotherapy postoperative day 7 (22%) (p < 0.05). There was no significant difference between the groups in the late outcome of shoulder function.
                The incidence of seromas after modified radical mastectomy for breast cancer is reduced by delaying shoulder exercises one week postoperatively. Earlier postoperative physiotherapy is not necessary to avoid impaired shoulder function. Two hundred and thirty women who had undergone surgery for breast cancer were randomised to a prospective study, comparing early (group A) and delayed (group B) shoulder exercise. Preoperatively, group A received instructions and an exercise programme supervised by a physiotherapist, whereas group B received written instructions to use the arm normally but to avoid heavy work. Two weeks after surgery both groups were given identical exercise programmes. Shoulder mobility, hand strength and arm volume were measured preoperatively, 1 month, 6 months and 2 years postoperatively. After 2 years 13.8% of the women had lymphoedema, but there were no significant differences between the groups. Grip strength was slightly decreased during the postoperative period in both groups (n.s.). Postoperatively, all movements in both groups were decreased after 2 weeks and 1 month and shoulder elevation and abduction remained decreased at 2 years. Mobility in group A recovered significantly earlier than in group B. Lymphedema is a common condition that breast cancer survivors face. Despite a lack of supporting evidence from prospective observational studies, occupational and leisure time physical activity are feared to be possible risk factors for lymphedema onset or exacerbation. We examined effects of supervised upper- and lower-body weight training on the incidence and symptoms of lymphedema in 45 breast cancer survivors who participated in the Weight Training for Breast Cancer Survivors study.
                Participants were on average 52 years old, 4 to 36 months post-treatment, and had axillary dissection as part of their treatment. Thirteen women had prevalent lymphedema at baseline. The intervention was twice-a-week weight training over a period of 6 months. Lymphedema was monitored at baseline and 6 months by measuring the circumference of each arm, and by self-report of symptoms and clinical diagnosis.
                None of the intervention-group participants experienced a change in arm circumferences > or = 2.0 cm after a 6-month exercise intervention. Self-reported incidence of a clinical diagnosis of lymphedema or symptom changes over 6 months did not vary by intervention status (P = .40 and P = .22, respectively).
                This is the largest randomized controlled trial to examine associations between exercise and lymphedema in breast cancer survivors. The results of this study support the hypotheses that a 6-month intervention of resistance exercise did not increase the risk for or exacerbate symptoms of lymphedema. These results herald the need to start reevaluating common clinical guidelines that breast cancer survivors avoid upper body resistance activity for fear of increasing risk of lymphedema. A pilot research study was conducted at 2 cancer centers in Connecticut to determine the effect of a dance and movement program on quality of life and shoulder function in breast cancer survivors treated within the prior 5 years. Thirty-five women completed the trial that included a 12-week intervention, using The Lebed Method, Focus on Healing Through Movement and Dance. The study design was a randomized control trial with a wait list control group crossover to active treatment in weeks 13 to 25, with the treatment group receiving the program in weeks 1 to 12, and no program in weeks 13 to 25. Outcome measures were the Breast Cancer Quality of Life (FACT-B), Shoulder range of motion (ROM), and Body Image Scale. FACT-B significantly improved in the intervention group at 13 weeks from 102.0 +/- 15.8 to 116.7 +/- 16.9, compared to the wait list group 108.1 +/- 16.4 to 107.1 +/- 21.3 (time x group effect, P = .008). During the crossover phase, the FACT-B score increased in the wait list group and was stable in the treatment group. The overall effect of the training at 26 weeks was significant (time effect, P = .03), and the order of training was also significant (P = .015). Shoulder ROM increased in both groups at 13 weeks--15 degrees and 8 degrees in the intervention and wait list groups (Time effect, P = .03; time x group, P = .58). Body Image improved similarly in both groups at 13 weeks (time effect, P = .001; time x group, P = .25), and at 26 weeks. There was no significant effect of the order of training for these outcome measures. A dance movement program that addressed the physical and emotional needs of women following treatment for breast cancer substantially improved a breast cancer-specific quality-of-life measure. Larger studies are justified to determine the acceptability of this therapy as part of the continuum of care for breast cancer survivors. Surgery and radiotherapy commonly cause adverse musculoskeletal problems, particularly loss of strength and range of motion, in the upper quadrant of breast cancer patients. Few well-designed studies have investigated whether these impairments can be prevented. Stretching is an effective technique for increasing range of motion, hence the aim of this study was to investigate whether a stretching program reduced acute musculoskeletal impairments in patients undergoing radiotherapy for breast cancer. Sixty-four women were recruited prior to commencement of radiotherapy following breast cancer surgery. Participants were randomised to either a control or stretch group. Participants in both groups were reviewed by the physical therapist on a weekly basis for approximately 6 weeks, and were given general information about skin care and lymphedema. The control group received no advice about exercise. The stretch group received instruction on low-load, prolonged pectoral stretches, which were to be performed daily and were checked at weekly visits. Shoulder range of motion, strength, arm circumference, and quality of life measurements were taken prior to, and at completion of radiotherapy, and at 7 months after radiotherapy. There was no difference in any outcome between groups. Breast symptoms increased for both groups during radiotherapy, without loss of strength or range of movement. The incidence of lymphedema during the study was low for both groups and did not differ between groups. The pectoral stretching program did not influence the outcomes measured because the symptoms reported by patients were not a consequence of contracture. Women who have been subjected to surgical treatment for breast cancer may develop late sequelae in the area of operation on the chest wall and/or in the ipsilateral arm or shoulder after the immediate surgical discomfort has passed. As many patients seek treatment of their own accord by physiotherapists, we considered it relevant to evaluate the effect of two different physiotherapy regimes. We also wished to determine whether there was a possible relationship between occurrence of late sequelae and physical findings, carried out by means of a simple clinical examination based on physiotherapeutic methods of examination. Fifty-nine patients, 1-4 years postoperatively, were randomized to two different physiotherapy regimens. Patients were examined by a physician before and after the treatment, and they answered a questionnaire four times in all within the course of the investigation. The questionnaire covered six main late sequelae, as well as the degree of discomfort. Our investigation shows that many women experience late symptoms after surgical treatment of breast cancer, and that is possible in these patients, to demonstrate a reduction in strength in the ipsilateral extremity, reduced movement and increased muscle tone. Physiotherapy can improve the strength, movement and muscle tone in the operated extremity and also reduce the presence and severity of the late symptoms. We have compared different modes of rehabilitation after breast cancer surgery on a population of 257 patients treated at the Institute Gustave-Roussy in 1990 and 1991. The mode of rehabilitation was randomized according to a 2 X 2 design, between physiotherapy alone, shoulder movement alone, both or neither. Treatment began the day after breast surgery and continued for 7 days. Afterwards, all patients had physiotherapy and shoulder movements until the end of hospitalisation. Treatment efficacy was evaluated at day 7 by the volume of lymph drained, and by degree of shoulder movement. The volume of lymph collected by day 7 was reduced in the physiotherapy groups, but was not modified in the groups with shoulder movement. The degree of motion was larger in the group who had had both physiotherapy and shoulder movement. The frequencies of complications at day 7 and later were similar in the four treatment groups, but locoregional pain was less frequent in the two groups with shoulder movement than in the two other groups. An early treatment including both physiotherapy and shoulder movement seems advisable.
Exercise can result in a significant and clinically meaningful improvement in shoulder ROM in women with breast cancer. In the post-operative period, consideration should be given to early implementation of exercises, although this approach may need to be carefully weighed against the potential for increases in wound drainage volume and duration. High quality research studies that closely monitor exercise prescription factors (e.g. intensity), and address persistent upper-limb dysfunction are needed.