ARTICLES
Effect of Acute Exercise on Upper-Limb Volume in
Breast Cancer Survivors: A Pilot Study
Margaret L. McNeely, Kristin L. Campbell, Kerry S. Courneya, John R. Mackey
ABSTRACT
Purpose: Strenuous upper-extremity activity and/or exercise have traditionally been prescribed for breast cancer survivors with or at risk of developing
lymphedema. The purpose of this study was to assess the effect of an acute bout of exercise on upper-limb volume and symptoms in breast cancer
survivors, with the intent to provide pilot data to guide a subsequent larger study.
Methods: Twenty-three women who regularly participated in dragon-boat racing took part in the study. A single exercise bout was performed at a
moderate intensity (rating of perceived exertion: 13–14) for 20 continuous minutes on an arm ergometer. The difference between affected and unaffected
limb volume was assessed pre- and post-exercise via measurements of limb circumference at five time points.
Results: Although limb volume increased following exercise in both limbs, the difference between the limbs remained stable at each measurement point.
Only one participant was found to have an increase in arm-volume difference of 4100 ml post intervention, and only four participants reported symptoms
of tension and/or heaviness in the affected limb.
Conclusion: The results suggest that limb volume in breast cancer survivors increases after an acute bout of upper-limb exercise but that, for the majority
of women, the response is not different between affected and unaffected limbs. Future research using a larger sample and more sensitive measurement
methods are recommended.
Key Words: arm, breast neoplasms, exercise, lymphedema, upper extremity
McNeely ML, Campbell KL, Courneya KS, Mackey JR. Effect of acute exercise on upper limb volume in breast cancer survivors: a
pilot study. Physiother Can. 2009;61:244-251.
RÉSUMÉ
Objectif : De l’exercice ou une activité intenses des membres supérieurs ont toujours été déconseillés pour les femmes ayant survécu à un cancer du sein
ou risquant de développer un lymphœdème. L’objectif de cette étude était d’évaluer les effet d’un épisode d’exercices intenses sur le volume du membre
supérieur ou sur les symptômes chez les survivantes à un cancer du sein, le tout dans le but de fournir des données pilotes pouvant servir de base à une
étude ultérieure à plus grande échelle.
Méthodes : En tout, 23 femmes participant régulièrement à la course des bateaux-dragons ont participé à l’étude. Un seul exercice a été effectué, à
intensité modérée, durant 20 minutes d’affilée, à l’aide d’un ergomètre pour les bras.
Résultats : Même si après les exercices, les deux membres supérieurs avaient plus de volume, la différence entre les membres supérieurs est
demeurée stable à chaque prise de mesure. On a constaté une différence post-intervention dans le volume des bras de l’ordre de 4100 ml chez
une seule participante et quatre participantes seulement ont signalé des symptômes de tension/une sensation de lourdeur aux membres supérieurs
affectés.
Conclusions : Ces résultats suggèrent que le volume des membres supérieurs chez les femmes ayant survécu à un cancer du sein augmente à la suite d’un
épisode d’exercices soutenus sollicitant les membres supérieurs, mais également que, pour une majorité de femmes, la réaction des membres touchés
n’est pas différente de celle des membres non touchés. Des recherches ultérieures à l’aide d’un échantillon plus important et de méthodes de mesure plus
nuancées ou plus sensibles sont recommandées.
Mots clés : bras, exercise, lymphœdème, membres supérieurs, néoplasme, sein, tumeur
Dr. McNeely and Dr. Campbell were supported by Full-Time Health Research
Studentships from the Alberta Heritage Foundation for Medical Research.
Dr. Courneya is supported by the Canada Research Chairs Program.
The authors would like to thank Ms. Laura Sandmeyer, BPE, for her assistance
with data collection.
Margaret L. McNeely, PhD: Physical Therapy Department, University of Alberta,
and Cross Cancer Institute, Edmonton, Alberta.
Kristin L. Campbell, PhD: Physical Therapy Department, University of British
Columbia, Vancouver, British Columbia.
244
Kerry S. Courneya, PhD: Faculty of Physical Education, University of Alberta,
Edmonton, Alberta.
John R. Mackey, MD: Medical Oncology, University of Alberta, and Cross
Cancer Institute, Edmonton, Alberta.
Address correspondence to Margaret L. McNeely, Department of Physical
Therapy, University of Alberta, 2–50 Corbett Hall, Edmonton, AB T6G 2G4
Canada. Tel.: 780-248-1531. Fax: 780-492-4429.
E-mail: mmcneely@ualberta.ca.
DOI:10.3138/physio.61.4.244
McNeely et al. Effect of Acute Exercise on Upper-Limb Volume in Breast Cancer Survivors: A Pilot Study
INTRODUCTION
Lymphedema is a chronic progressive condition that
can have profound adverse effects on a breast cancer
survivor’s quality of life and is one of the most feared
long-term complications of breast cancer treatment.1
Numerous lifestyle factors have been implicated in the
development of lymphedema, and guidelines for the prevention of lymphedema have been developed.2 Vigorous
upper-extremity activity and/or exercise have traditionally been proscribed for breast cancer patients and survivors because of the risk of developing lymphedema.3,4
Over the last decade, breast cancer survivors have
challenged this long-standing recommendation against
upper-extremity activity by participating in dragon-boat
racing and upper-extremity strength-training programmes. Early evidence suggests that the majority
of breast cancer survivors are able to engage safely in
vigorous upper-extremity exercise without developing
lymphedema.5–8 More recent lymphedema riskreduction guidelines have been tempered to reflect emerging evidence refuting upper-extremity exercise as a
potential factor in the development of lymphedema.3
In the clinical setting, breast cancer survivors often
report a transient increase in limb tension, heaviness,
and/or swelling with use of the limb for work, functional
activities, or exercise.9 These symptoms are cause for
concern, as periods of transient and/or intermittent
swelling often predate the onset of chronic lymphedema10 and may represent early warning signs of a failing
or compromised lymphatic system. For the breast cancer
survivor, these symptoms may be a deterrent to activity
and exercise. Physiotherapists responsible for educating
patients on risk-reduction strategies for lymphedema
would benefit from knowing the significance of these
symptoms.
The purpose of this study was to assess the effect of
an acute bout of exercise on upper-limb volume and
symptoms in breast cancer survivors, with the intent to
provide pilot data to guide a subsequent larger study.
METHODS
This pilot study enrolled 23 participants. Approval for
the study was received from the Research Ethics
Committee of the Alberta Cancer Board and from the
Health Research Ethics Board of the University of
Alberta. Verbal confirmation of participants’ interest in
the study was obtained at a dragon-boat racing group
meeting. Informed consent was obtained from each participant prior to testing.
Eligibility criteria consisted of a diagnosis of earlystage breast cancer, treated with surgical resection of
the tumour (lumpectomy or mastectomy) along with
sentinel and/or axillary node dissection. Survivors were
excluded if they had any known or suspected complications due to breast cancer (e.g., distant metastases, local
245
cancer recurrence). All participants had completed primary cancer treatments. This patient population was
chosen for the pilot study because the women had just
completed a 7-month progressive exercise-training
programme, including a competitive season of dragonboat racing, and thus adequate training had occurred to
allow for adaptation of the affected limb to exercise. The
sample was considered at low risk of acute stress to an
untrained or potentially weakened affected limb, which
could confound the study results and potentially lead to
excessive muscle soreness, injury, or lymphedema.
Acute Exercise Intervention
The independent variable for the study was the acute
exercise bout. Following a 2-minute warm-up, exercise
was performed for 20 continuous minutes on an arm
ergometer (Angio Single Set with programmable control
unit; Lode, Groningen, The Netherlands). The arm ergometer was mounted on a table, and the seat position
was adjusted to fit each participant. The level of
resistance was determined by rating of perceived exertion
using the Borg scale.11 Participants were asked to arm
cycle at a minimum of 50 revolutions per minute
(rpm). A rating of perceived exertion of 13 to 15 (‘‘somewhat hard’’ to ‘‘hard’’) was used as the target for the
experimental exercise bout. Participants who normally
wore a compression sleeve while exercising were asked
to wear their compression sleeve during the exercise
session.
Endpoints
The dependent variable in the study was the difference between affected and unaffected upper-limb
volume. Thus, each participant’s unaffected limb served
as a control. The changes in limb circumference
were expressed in centimetres, and lymphedema
volume was calculated and expressed in millilitres. A
priori, we planned to classify participants into one of
two groups (covariate) at baseline:
1. Lymphedema (LE) group: Signs and symptoms indicative of clinically significant lymphedema: 4200 mL
of fluid difference12 or a difference of 42 cm at any
one measurement point.4,12
2. Breast Cancer (BC) group: No signs or symptoms of
lymphedema, but have sustained damage to the lymphatic system through surgical lymph node removal
or irradiation.
Measurement Protocol
Participants were assessed at five time points:
(1) baseline measures: about 5 minutes prior to exercise;
(2) within 5 minutes of completion of the exercise bout;
(3) 15 minutes post exercise; (4) 30 minutes post exercise;
and (5) 1 hour post exercise. The affected and unaffected
limbs were measured and compared at each time point.
246
For the present study, measurement of circumference
was used to calculate limb volume. Circumferential
(girth) measurements are simple and efficient and can
be performed within the time constraints of recovery
from exercise. Measurements were taken of both limbs,
starting at the metacarpopharyngeal (MCP) joints, across
the hand, including the thumb MCP and wrist. For the
purpose of the volumetric calculation, circumference
measurements at 4 cm intervals from wrist to axilla
were taken. Limb volume was calculated based on the
formula for a truncated cone.13,14 Using the same measurement technique and formula, the reported correlation between the calculated volume from circumference
measurements and the total water displacement volume
was r ¼ 0.99, and the coefficient of determination (r2) was
0.98.13 The reliability of the circumference measurements, expressed as an intra-class correlation coefficient
(ICC), varied from 0.96 to 0.99, and the standard error of
measurement (SEM) was reported as 0.09–0.20 cm.13,15
For the present study, a non-stretch fibreglass tape measure, accurate to 0.1 cm, was used to measure both the
circumference and the length of the upper extremity. A
single assessor performed the measurements of circumference. A single measurement was taken at each point
along the limb. Intrarater reliability was established
prior to study initiation (ICC ¼ 0.98; SEM ¼ 0.2 cm).
Circumferential measurements were recorded by a
research assistant. The assessor was blinded to all prior
measurements.
The clinical symptom assessment (heaviness and
tension) was performed using a visual analogue scale
(VAS). The experiences of tension and heaviness of
each limb were scored by the participant on a 100 mm
horizontal VAS whose endpoints were described as ‘‘no
tension’’ (0 mm) and ‘‘worst imaginable tension’’
(100 mm) and as ‘‘no heaviness’’ (0 mm) and ‘‘worst
imaginable heaviness’’ (100 mm). Each participant was
asked to record subjective sensations in each limb prior
to the exercise and at each of the time points following
the exercise.
Analysis
Data were analyzed using SPSS 15.0 (SPSS Inc.,
Chicago, IL). As this was a pilot study, the purpose of
the statistical analyses was to determine point and interval estimates (parameter estimation) to guide future
research. We were interested in determining the proportion of participants experiencing an absolute increase in
limb-volume difference (affected limb – unaffected limb)
of 4100 ml16,17 or an increase that resulted in a 4200 ml
difference between the limbs (i.e., reclassification from
BC to LE group). Descriptive analysis included examining
individual differences between limbs before and after
exercise.
Physiotherapy Canada, Volume 61, Number 4
RESULTS
Participants
Twenty-three participants were enrolled and completed the study. Eighteen participants had a baseline
limb volume difference (affected limb volume—
unaffected limb volume) of < 100 ml and did not have
any limb circumference measurements that reached or
exceed 2 cm for any measurement point. None of these
participants reported current or past diagnosis of lymphedema, and they were therefore classified in the BC
(breast cancer) group. Five participants were classified
into the LE (lymphedema) group. Three LE participants
presented with a limb-volume difference of4200 ml, and
two participants presented with 42 cm circumferential
measurement difference at more than one point. In
these two participants, the calculated volume difference
between the limbs exceeded 95 ml but did not exceed
200 ml. All five LE participants had previously been
diagnosed with lymphedema. Participant characteristics
are provided in Table 1. All participants completed the
exercise regimen as prescribed (see Table 2). No adverse
events occurred during or following the exercise
intervention.
Table 1
Participant Demographic Information
Variable
Lymphedema
(LE) Group
(n ¼ 5)
Breast Cancer
(BC) Group
(n ¼ 18)
Age, mean (min, max), y
Time from diagnosis, mean (min,
max), y
BMI, mean (SD), kg/m2
Obese, n
Disease stage, n
0–I (T1N0)
II (T1N1, T2N0); (T2N1, T3N0)
III (T1N2, T2N2, T3N1–2)
Surgical protocol, n
BCS
Mastectomy
Axillary node dissection
Lymph nodes removed, median
(min, max)
Post-surgical complications, n
Seroma/drainage
Infection
Chemotherapy, n
Radiation therapy, n
Breast only
Breast and axillary region
Breast and supraclavicular region
Volume difference between limbs,
mean (SD), ml
Symptoms of tension in affected
limb, n
Symptoms of heaviness in affected
limb, n
55 (48, 62)
5.6 (1.4, 9.7)
52 (48, 56)
6.6 (4.0, 9.1)
27.6 (4.3)
1
27.1 (3.8)
4
1
2
2
7
9
2
3
2
5
8 (4, 13)
10
8
18
9 (0, 22)
3
1
3
2
3
9
2
1
1
235 (125)
7
6
0
1 (53)
1
0
1
1
BMI ¼ body mass index; BCS ¼ breast conservation surgery; T ¼ tumour, size and
extent, rated T0–T4; N ¼ node, presence or absence of lymph-node involvement,
rated N0–N3
p ¼ 0.001
247
McNeely et al. Effect of Acute Exercise on Upper-Limb Volume in Breast Cancer Survivors: A Pilot Study
Table 2
Details on Exercise Regimen Completed
Group
Overall (N ¼ 23)
LE (n ¼ 5)
BC (n ¼ 18)
Total time of continuous exercise, minutes
Watts during exercise bout, mean (min, max)
Revolutions per minute (RPM) (min, max)
Rating of perceived exertion during exercise bout (min, max)
22
43 (20, 55)
71 (50, 90)
14 (13, 16)
22
50 (40, 55)
73 (59, 81)
14.6 (13, 16)
22
41 (20, 50)
70 (50, 90)
14 (13, 15)
LE ¼ Lymphedema group; BC ¼ Breast Cancer group.
Table 3
Mean Limb Volume in Breast Cancer Survivors at Baseline, Immediately Post Exercise, and in the Recovery Period Following Exercise (N ¼ 23)
Group
Limb
Volume ml
Baseline
Mean (SD)
Post-exercise
Mean (SD)
15 Minutes
Mean (SD)
30 Minutes
Mean (SD)
60 Minutes
Mean (SD)
Total Group (N ¼ 23)
Affected limb
Unaffected limb
Limb-volume difference
2,250 (408)
2,199 (367)
58 (130)
2,312 (414)
2,264 (365)
51 (138)
2,270 (413)
2,221 (364)
57 (146)
2,250 (403)
2,205 (358)
52 (133)
2,236 (408)
2,186 (358)
54 (149)
Table 4
Mean Arm Volume by Group at Baseline, Immediately Post Exercise, and in the Recovery Period Following Exercise
Group
Limb
Volume ml
Baseline
Mean (SD)
Post-exercise
Mean (SD)
15 Minutes
Mean (SD)
30 Minutes
Mean (SD)
60 Minutes
Mean (SD)
LE Group (n ¼ 5)
Affected limb
Unaffected limb
Limb-volume difference
Affected limb
Unaffected limb
Limb-volume difference
2,425 (588)
2,190 (483)
235 (125)
2,202 (351)
2,201 (346)
1 (53)
2,488
2,270
218
2,263
2,263
2,449 (604)
2,210 (469)
239 (157)
2,219 (349)
2,223 (345)
3 (69)
2,412 (576)
2,190 (464)
222 (140)
2,206 (349)
2,209 (339)
3 (61)
2,425 (579)
2,176 (448)
249 (164)
2,183 (351)
2,190 (345)
7 (59)
BC Group (n ¼ 18)
Limb Volume
Baseline to post-intervention limb-volume measurements are provided in Table 3. Limb volume increased
immediately following exercise in both limbs and recovered to slightly below baseline levels by 60 minutes. The
difference between the limbs, however, remained stable
at each measurement point. The baseline differences
between the affected and unaffected limbs were
1 53 ml for the BC group and 235 124 ml for the LE
group (see Table 4). In the BC group, the response to
and recovery from exercise were similar in both limbs.
In the LE group, there were differences in limb volume
between the affected and unaffected limbs at each time
point; however, the difference between the limbs did not
change significantly at any time point following the exercise bout. None of the participants in the BC group
exceeded the 200 ml cut-point for the difference between
limbs post intervention (see Figure 1). Only one participant, in the BC group, had an increase of 4100 ml difference between limbs post intervention (see Figure 2). This
participant had undergone a modified radical mastectomy with axillary node dissection on her dominant
limb side and had received radiation therapy to the axillary region. Other risk factors for lymphedema in this
(575)
(477)
(130)
(363)
(345)
0 (82)
participant included a history of postoperative wound
infection and current BMI 430 kg/m2.2,18
Symptoms of Tension and Heaviness
None of the participants reported symptoms of tension and/or heaviness in the unaffected limb at any time
point. Four participants, however, reported symptoms of
tension and/or heaviness in the affected limb at one or
more of the measured time points. One participant (LE
group) reported symptoms of tension (5/10 on VAS) and
heaviness (5/10 on VAS) in her affected limb (non-dominant side) at baseline that were unchanged following
exercise. Another participant (BC group) reported symptoms of heaviness (2/10 on VAS) in her affected limb
(dominant limb) at baseline that were also unchanged
following exercise. One participant (BC group) reported
the onset of symptoms of tension (3/10 on VAS) and
heaviness (4/10 on VAS) in her affected limb (dominant
limb) following exercise; however, in this participant the
affected limb was smaller than the unaffected limb at all
time points following exercise. The fourth participant (BC
group) with symptoms reported heaviness (2/10 on VAS)
in her affected limb (dominant limb) following exercise;
248
Physiotherapy Canada, Volume 61, Number 4
Figure 1
Volume difference between affected and unaffected limbs, by participant group, before and after exercise.
Figure 2
Change in limb-volume difference post exercise by participant group.
in this participant, an increase in limb-volume difference
(affected – unaffected) of 58 ml was observed.
absolute limb volume of 51 ml was observed in the
affected limb, compared to the mean increase of 84 ml
in the unaffected limb.
Potential Moderators
Three participants wore a compression sleeve during
the exercise intervention, and all three were in the LE
group. In these participants, a smaller mean increase in
Sample-Size Estimates
The findings of the pilot study were used to
determine the sample size for a subsequent study.
McNeely et al. Effect of Acute Exercise on Upper-Limb Volume in Breast Cancer Survivors: A Pilot Study
Of the 23 participants who took part in the pilot study,
only one had an increase of 4100 ml between the limbs
post exercise. Thus, the proportion of participants with
the outcome of interest (4100 ml increase) was approximately 4% (95% CI: -4%, 12%). Assuming an expected
proportion of 0.04 and a 95% CI of 0.02–0.07, the required
sample size for the subsequent study would be approximately 369 participants. This sample size was calculated
for an exact confidence interval based on the binominal
distribution.
DISCUSSION
This pilot study is one of the first to examine the effect
of acute exercise on limb volume and symptoms of
upper-limb tension and heaviness in women with
breast cancer. Strengths of the study include the use of
a moderate-intensity continuous upper-extremity exercise regimen to assess limb-volume response; this type
of exercise was chosen specifically to induce increased
blood flow to the limb to allow for assessment of
response and recovery in terms of limb volume and
symptoms of tension and heaviness. No differences
were found in the exercise response between affected
and unaffected limbs in our overall sample. Notably, we
observed changes between the limbs in both directions
and an increase of 4100 ml in only one participant. Four
participants (one in the LE group, three in the BC group)
reported symptoms of tension and/or heaviness at one or
more time points, although most reported low levels on
the VAS. Thus, for the vast majority of women in the
study, exercise did not have a significant impact on
upper-limb volume or on symptoms.
The findings of this pilot study are consistent with
evidence from the literature that suggests that participation in an exercise programme does not precipitate or
exacerbate lymphedema.7,8 In theory, exercise should
be beneficial for lymphatic function, as skeletal muscle
contraction, which can be facilitated by exercise, is a primary force propelling lymph fluid by direct compression
of the collecting lymphatic vessels.19 Thus, exercise may
potentially enhance the ‘‘muscle pump’’ effect on the
lymphatic system. Exercise can also improve lymphatic
flow by increasing heart rate and arterial pulsations and
by inducing changes in intrathoracic pressure via deep
breathing.9 Moreover, exercise can improve soft-tissue
and joint mobility, thereby reducing any potential
impact of tissue fibrosis on venous and lymphatic
flow.20,21
Lane et al. examined the effect of an acute bout of
intermittent exercise on lymphatic function.22 The
study participants were breast cancer survivors with lymphedema (BCRL: n ¼ 10), breast cancer survivors without
lymphedema (BC: n ¼ 10), and a control group of healthy
age-matched women (Control: n ¼ 10). The authors
reported that the BCRL group had similar clearance
249
from the hand during exercise but reduced accumulation
of radiopharmaceutical colloid reaching the axillary
lymph nodes on the affected side. Moreover, the BCRL
group was found to have greater activity in the forearm
region, suggesting dermal backflow that worsened with
exercise. The authors also reported a variable response
from exercise in the BC group, suggesting that some participants may have been at risk for developing lymphedema. In our pilot study, we did not observe a significant
between-limb difference in the response to exercise for
the overall group. However, we examined limb volume as
a method to reflect a change in lymphatic function. This
method does not provide information on the components that may contribute to an increase or decrease in
limb volume and, furthermore, cannot detect subtle
(sub-clinical) changes in lymphatic function that may
be visualized through imaging techniques such as lymphoscintigraphy, used in the Lane study. Finally, our
sample was composed of women who regularly took
part in high-intensity exercise, while only two participants with BCRL in the Lane study reported regular exercise. Regular participation in an upper-body exercisetraining programme may have allowed for adaptation of
the lymphatic system, such that the acute exercise bout
did not have a large impact. Thus, regular participation in
dragon-boat racing by women in this study may have
provided a level of protection that would not otherwise
be experienced by breast cancer survivors not accustomed to upper-limb exercise.
An interesting finding of the pilot study was that only
three participants reported wearing a compression sleeve
for exercise, despite recommendations for the use of
compression garments by survivors with or at high risk
for lymphedema (e.g., patients who have undergone an
axillary node dissection and radiation therapy).3
Interestingly, the three participants who wore a compression sleeve during the acute bout of exercise were found
to have a smaller increase in affected limb volume than
in unaffected limb volume. Although an observational
finding, this is suggestive of a potential protective effect
from the garment. Johansson et al., who examined the
acute effect of low-intensity resistance exercise on lymphedema volume in 31 breast cancer survivors with or
without a compression sleeve,23 found a significant
increase in affected limb volume (p < 0.01) and a borderline significant increase in lymphedema volume
(p ¼ 0.07) (i.e., affected limb volume – unaffected limb
volume) in the affected limb immediately following exercise for both conditions (sleeve or no sleeve), which
resolved over 24 hours. In contrast to our findings,
Johansson et al. reported a non-significant increase in
limb lymphedema volume when participants wore a
compression sleeve during exercise, suggesting no benefit from use of the sleeve. One explanation for the disparity in findings is that the exercise bout in our study
resulted in a larger overall increase in limb volume
250
bilaterally relative to the Johansson study. Moreover, we
examined the effect of a moderate-intensity, continuous
bout of aerobic exercise, whereas Johansson et al. examined low-intensity resistance exercise. Thus, the benefit
of wearing a compression sleeve during exercise may be
related to the type (aerobic vs. resistance) and intensity
(moderate vs. low) of exercise; this point is worthy of
further investigation.
The main limitation of the present pilot study was that
it was underpowered to detect changes between the
groups, as it was undertaken with the intent to inform
future work. A future study with a larger sample would
allow for evaluation of within-subject factors (e.g., obesity) and treatment-related factors (e.g., radiation therapy
to the axilla) that are associated with increased risk of
lymphedema.
In this study, a minority of women (22%) presented
with lymphedema, using limb volume and limb circumference as the criteria; however, the percentage in the
sample would be consistent with the reported incidence
in the breast cancer population.18 The sample consisted
of women who regularly participated in vigorous upperlimb exercise, and thus the findings are not generalizable
to breast cancer survivors who do not regularly perform
this type of exercise.
A further limitation of the pilot study was the choice of
measurement outcome. Measurement of circumference
was used in the pilot study because it is a simple and
quick measurement method. Water-displacement volumetry, however, is considered the gold standard. Waterdisplacement volumetry was not chosen for the pilot
study because it would not allow for measurements to
be performed within the time constraints of exercise
recovery. An alternative method to reduce error associated with limb-circumference measurements would
be to use an opto-electrical volumetric system24 such as
the Perometer (Juzo, USA, Inc., Cuyahoga Falls, OH). The
Perometer allows for measurement of the limb within a
few seconds, has been shown to be highly reliable, and
has been validated by comparison with circumferential
and water-volume measurements.24 Bioimpedance spectroscopy (BIS) is an alternative method that measures the
impedance, or opposition to flow, of an electric current
through body fluids and is used to assess extracellular,
intracellular, and total-body water.25 More recent evidence has demonstrated that BIS directly measures lymphedema with greater sensitivity and specificity than the
indirect measures of limb circumference and limb
volume.25 BIS is able to quantify differences in fluid
levels between the affected and unaffected limbs prior
to detectable changes in limb volume and circumference.25 The use of the Perometer in conjunction with
BIS would allow for measurement of both limb volume
and extracellular fluid within the time constraints of
exercise recovery. Further validation of findings could
be achieved through the addition of imaging techniques,
Physiotherapy Canada, Volume 61, Number 4
such as magnetic resonance or lymphoscintigraphy, that
would allow for visualization of the effect of exercise on
the structure and function of the lymphatic system.
A final limitation of the pilot study was that the exercise intensity for the study was determined by asking
participants to select an exercise intensity based on an
RPE (13 to 15, ‘‘somewhat hard’’ to ‘‘hard’’). In a future
study, it would be important to ensure a more consistent
intensity of exercise across participants by monitoring
objective physiologic measures such as heart rate.
CONCLUSIONS
The study findings suggest that the response to acute
exercise in terms of changes in upper-limb volume
is similar between affected and unaffected limbs in
women with breast cancer who regularly engage in
upper-limb exercise. The number of individuals potentially experiencing a transient increase in limb volume
from an acute bout of moderate-intensity upper-limb
endurance exercise appears to be low. Further research
with a larger sample is needed to allow for appropriate
evaluation of the effect of exercise on the lymphatic
system and to explore the relationship between exercise
response and known factors associated with increased
risk of lymphedema.
KEY MESSAGES
What Is Already Known on This Subject
Lymphedema is a chronic progressive condition that
can have profound adverse effects on a breast cancer
survivor’s quality of life. Preliminary research evidence
suggests that participation in an exercise programme
does not precipitate or exacerbate lymphedema. In the
clinical setting, however, transient increases in arm
swelling and/or symptoms of tension and heaviness
are often reported to occur following acute upper-limb
exercise or activity. The significance of these symptoms is
unclear.
What This Study Adds
The findings of this pilot study suggest that the
response to acute upper-extremity exercise in terms of
upper-limb volume and symptoms is similar between
affected and unaffected limbs in women with breast
cancer who perform regular upper-extremity exercise.
This study provides preliminary data that can be used
to design future investigations on this topic.
REFERENCES
1. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in
breast cancer patients. J Nat Cancer Inst. 2001;93:96–111.
McNeely et al. Effect of Acute Exercise on Upper-Limb Volume in Breast Cancer Survivors: A Pilot Study
2. Ridner SH. Breast cancer lymphedema: pathophysiology and risk
reduction guidelines. Oncol Nurs Forum. 2002;29:1285–93.
3. NLN Medical Advisory Committee. Position statement of the National
Lymphedema Network: exercise [Internet]. Oakland, CA: The
Network; 2008 [cited 2008 Oct 1]. Available from: www.lymphnet.org/pdfDocs/nlnexercise.pdf.
4. Harris SR, Hugi MR, Olivotto IA, Levine M, Steering Committee for
Clinical Practice Guidelines for the Care and Treatment of
Breast Cancer. Clinical practice guidelines for the care and
treatment of breast cancer: 11. Lymphedema. Can Med Assoc J.
2001;164:191–9.
5. Harris SR, Niesen-Vertommen SL. Challenging the myth of exerciseinduced lymphedema following breast cancer: a series of case reports.
J Surg Oncol. 2000;74:95–8; discussion 98–9.
6. McKenzie DC, Kalda AL. Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study. J Clin
Oncol. 2003;21:463–6.
7. Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled
trial of weight training and lymphedema in breast cancer survivors.
J Clin Oncol. 2006;24:2765–72.
8. Courneya KS, Segal R, Mackey JR, Gelmon K, Reid RD,
Friedenreich CM, et al. Effects of aerobic and resistance exercise in
breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol. 2007;25:1–9.
9. Miller L. Lymphedema: unlocking the doors to successful treatment.
Innov Oncol Nurs. 1994;10:58–62.
10. Mortimer P, Badger C. Lymphoedema. In: Doyle D, editor. Oxford
textbook of palliative medicine. 3rd edn. New York: Oxford
University Press; 1998. p. 657–65.
11. Borg GAV. Borg’s Perceived Exertion and Pain Scales. London:
Human Kinetics; 1998.
12. Stanton AW, Badger C, Sitzia J. Non-invasive assessment of the lymphedematous limb. Lymphology. 2000;33:122–35.
13. Karges JR, Mark BE, Stikeleather SJ, Worrell TW. Concurrent validity
of upper-extremity volume estimates: comparison of calculated
volume derived from girth measurements and water displacement
volume. Phys Ther. 2003;83:134–45.
251
14. Sander AP, Hajer NM, Hemenway K, Miller AC. Upper-extremity
volume measurements in women with lymphedema: a comparison
of measurements obtained via water displacement with geometrically
determined volume. Phys Ther. 2002;82:1201–12.
15. Karges J. Assessing the relationship between water displacement and
circumferential measurements in determining upper extremity
volume in women with lymphedema [thesis]. Indianapolis:
University of Indianapolis; 1996.
16. Williams AF, Franks PJ, Moffatt CJ. Lymphoedema: estimating the size
of the problem. Palliat Med. 2005;19:300–313.
17. Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH,
Soballe P. Preoperative assessment enables the early diagnosis
and successful treatment of lymphedema. Cancer. 2008;112:2809–19.
18. Lawenda BD, Mondry TE, Johnstone PA. Lymphedema: a primer on
the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009;59:8–24.
19. Loscalzo J, Creager MA, Dzau VJ. Vascular medicine. Boston: Little:
Brown; 1992. p. 1099–104.
20. Brennan MJ, Miller LT. Overview of treatment options and review of
the current role and use of compression garments, intermittent
pumps, and exercise in the management of lymphedema. Cancer.
1998;28:2821–7.
21. Mortimer PS. Managing lymphoedema. Clin Exp Dermatol. 1995;20:
98–106.
22. Lane KN, Dolan LB, Worsley D, McKenzie DC. Upper extremity lymphatic function at rest and during exercise in breast cancer survivors
with and without lymphedema compared with healthy controls.
J Appl Physiol. 2007;103:917–25.
23. Johansson K, Tibe K, Weibull A, Newton RC. Low intensity resistance
exercise for breast cancer patients with arm lymphedema with or
without compression sleeve. Lymphology. 2005;38:167–80.
24. Stanton AW, Northfield JW, Holroyd B, Mortimer PS, Levick JR.
Validation of an optoelectronic limb volumeter (Perometer).
Lymphology. 1997;30:77–97.
25. Cornish BH, Chapman M, Hirst C, Mirolo B, Bunce IH, Ward LC, et al.
Early diagnosis of lymphedema using multiple frequency bioimpedance. Lymphology. 2001;34:2–11.