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Effects of Clinical Pilates Exercises on Patients Developing Lymphedema after Breast Cancer Treatment: A Randomized Clinical Trial

Authors:

Abstract

Objective: The aim of the present study was to compare the effects of clinical Pilates exercises with those of the standard lymphedema exercises on lymphedema developing after breast cancer treatment. Materials and methods: The study comprised 60 female patients with a mean age of 53.2±7.7 years who developed lymphedema after having breast cancer treatment. The patients were randomized into two groups: the clinical Pilates exercise group (n=30), and the control group (n=30). Before, and at the 8th week of treatment, the following parameters were measured: the severity of lymphedema, limb circumferences, body image using the Social Appearance Anxiety Scale, quality of life with the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-BR23), and upper extremity function using the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. Both groups performed one-hour exercises three days a week for 8 weeks. Results: After treatment, the symptoms recovered significantly in both groups. Reductions in the severity of lymphedema, improvements in the social appearance anxiety scale scores, quality of life scores, and upper extremity functions scores in the clinical Pilates exercise group were greater than those in the control group. Clinical Pilates exercises were determined to be more effective on the symptoms of patients with lymphedema than were standard lymphedema exercises. Conclusions: Clinical Pilates exercises could be considered a safe model and would contribute to treatment programs.
Original Article
Introduction
Breast cancer is the most common type of cancer among women, and the number of women who develop breast cancer is increasing with
each passing day. Today, approximately one in every eight women in the world has a risk of developing breast cancer. Although advances in
breast cancer treatment such as radiotherapy, chemotherapy and surgical treatment reduce breast cancer-related mortality rates, they also
lead to the development of serious complications such as lymphedema (1, 2). In the literature, the incidence of lymphedema after breast
cancer treatment is reported to range from 2% to 83% (3-5).
Vignes et al. (6) reported that there was a relationship between the amount of radiotherapy administered after surgery and the frequency
of lymphedema development. Chandra et al. (7) dened lymphedema as an irreversible chronic swelling and stated that if it was detected
early, the amount of axillary radiotherapy administered could be less and the progress of lymphedema would be prevented. Several re-
searchers reported that patients with breast cancer who presented to cancer research centers developed lymphedema caused by postopera-
tive radiotherapy administered to axillary lymph nodes (8-11).
Lymphedema is classied into three groups according to the clinical stage. Both of the upper extremities are measured at regular intervals
using a tape measure, starting from the nail root of the middle nger, up to the axillary region, and then the measurements are compared.
If the dierence between the two upper extremities is:
• less than 3 cm, lymphedema is classied as mild,
• between 3 and 5 cm, lymphedema is classied as moderate
• more than 5 cm, lymphedema is classied as severe (11, 12).
Effects of Clinical Pilates Exercises on Patients
Developing Lymphedema after Breast Cancer
Treatment: A Randomized Clinical Trial
Hülya Özlem Şener1, Mehtap Malkoç2, Gülbin Ergin3, Didem Karadibak3, Tuğba Yavuzşen4
1Department of Physiotherapy and Rehabilitation, İzmir University School of Health Sciences, İzmir, Turkey
2Department Physical erapy and Rehabilitation, Eastern Mediterranean University School of Health Sciences, Cyprus
3School of Physical erapy and Rehabilitation, Dokuz Eylül University School of Medicine, İzmir, Turkey
4Department of Clinical Oncology, Dokuz Eylül University Institute of Oncology, İzmir, Turkey
Address for Correspondence :
Hülya Özlem Şener, e-mail: hulyaozlemsener@gmail.com Received: 13.05.2016
Accepted: 18.07.2016
J Breast Health 2017; 13: 16-22
DOI: 10.5152/tjbh.2016.3136
16
ABSTRACT
Objective: e aim of the present study was to compare the eects of clinical Pilates exercises with those of the standard lymphedema exercises on
lymphedema developing after breast cancer treatment.
Materials and Methods: e study comprised 60 female patients with a mean age of 53.2±7.7 years who developed lymphedema after having
breast cancer treatment. e patients were randomized into two groups: the clinical Pilates exercise group (n=30), and the control group (n=30).
Before, and at the 8th week of treatment, the following parameters were measured: the severity of lymphedema, limb circumferences, body image
using the Social Appearance Anxiety Scale, quality of life with the European Organization for Research and Treatment of Cancer (EORTC) quality
of life questionnaire (QLQ-BR23), and upper extremity function using the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure.
Both groups performed one-hour exercises three days a week for 8 weeks.
Results: After treatment, the symptoms recovered signicantly in both groups. Reductions in the severity of lymphedema, improvements in the
social appearance anxiety scale scores, quality of life scores, and upper extremity functions scores in the clinical Pilates exercise group were greater
than those in the control group. Clinical Pilates exercises were determined to be more eective on the symptoms of patients with lymphedema than
were standard lymphedema exercises.
Conclusions: Clinical Pilates exercises could be considered a safe model and would contribute to treatment programs.
Keywords: Lymphedema, clinical Pilates, breast cancer, physiotherapy, Combined Decongestive erapy
Another measurement technique used in lymphedema classication
is volumetric measurement. In this measurement, if the dierence be-
tween the two extremities is:
• less than 250 mL, lymphedema is classied as mild,
• between 250 and 500 mL, lymphedema is classied as moderate
• more than 500 mL, lymphedema is classied as severe (13).
In the literature, many publications have indicated that patients who
underwent surgery for breast cancer and then had radiotherapy, chemo-
therapy, hormone therapy and/or medical therapy developed lymph-
edema due to tissue brosis, and their shoulder girdle joint movements
deteriorated or became restricted. ese publications report that in
particular, shoulder exion, abduction, and external rotation angles
decreased, that patients’ activities of daily living were restricted, and
that their quality of life was adversely aected (14-17).
Due to the lymphedema developing after the breast cancer surgery
and radiotherapy, in addition to the reduction in arm function, dete-
rioration is observed in body image and in posture accordingly. e
ow rate of the lymphatic uid throughout the body depends on the
intermittent external pressure by skeletal muscles. erefore, research-
ers emphasize that the treatment of a patient with lymphedema should
include the reactivation of the patient’s arm functions and also the
exercises that activate the whole body (18-21).
Studies conducted to investigate breast cancer and breast cancer-related
lymphedema reported that physical activity contributed to patients’ quality
of life and emotional status extremely positively and that it would be very
necessary and useful to increase the diversity of physical activities. Imple-
menting dierent exercise models, group works, social activities and Pilates
training are reported to be useful for patients with breast cancer (22).
e exercise program for patients with lymphedema should also include
cardiovascular exercises contributing to the development of aerobic t-
ness, breathing exercises stimulating the lymph system in the thoracic
region, and the appropriate amount of resistance exercises to improve
muscle strength and endurance. erefore, the exercise program to be
selected should be multipurpose, but not boring for the patient. In order
to use the same terminology with health professionals, it will be useful to
use termed exercise models. In recent years, although attention has been
paid to some exercise models such as Pilates, yoga, tai chi, and aquatic
exercises, studies on this issue are few (23, 24). In the literature, it is
reported that core stability-based clinical Pilates exercises in particular
activate all the body muscles. us, it is reported that when combined
with breathing exercises, the intermittent external pressure that results
from muscle contraction would stimulate ductus thoracicus due to the
contraction of the diaphragm and facilitate the lymphatic ow, and thus
reduce lymphatic load, and promote the immune system (22-25).
However, with the exception of one study that reported that lymph-
edema could be prevented if Pilates exercises were implemented, there
are no studies in the literature in which Pilates exercises were used for
the treatment of lymphedema (26). erefore, the present study was
planned to examine the impact of clinical Pilates exercises on the sever-
ity of lymphedema that developed after breast cancer treatment, grip
strength, shoulder function, quality of life, and social image concerns,
and to compare the eectiveness of clinical Pilates exercises with that
of standard lymphedema physiotherapy education. e main hypoth-
esis of this present study was that core stability-based clinical Pilates
exercises that can activate all the body muscles would reduce the sever-
ity of lymphedema developing after breast cancer.
Materials and Methods
Design
All the participants were evaluated at Dokuz Eylül University School
of Physical erapy and Rehabilitation. Informed consent was ob-
tained from patients who participated in this study.
Inclusion criteria:
• Presence mild, moderate or severe lymphedema in upper extremities
after breast cancer treatment
• aged over 18 years
Exclusion criteria:
• Presence of metastatic breast cancer
• Presence of diagnosis of severe heart failure and / or arrhythmia
• Presence of infection in the aected limb
• Presence of severe psychological disorders
• Presence of severe pain of unknown cause in the axillary region
• Presence of musculoskeletal problems in the upper extremity before
the treatment of breast cancer
• Presence of other health problems that would prevent participation
in the evaluation and treatment program
Informed consents were obtained from all the participants included in the study.
e study was approved by the ethics committee (decision April 12,
2012; number 2012 / 14-14).
Randomization
Based on their admission to the clinic without looking at the sever-
ity of lymphedema, the patients were asked to draw one of the two
cards colored blue or red, and thus they were assigned to the two
study groups through this simple random sampling method. ose
who drew red cards were assigned to the clinical Pilates exercise group
(n=2) and those who drew blue cards were assigned to the control
group (n=30). When the study started, there were 32 patients in the
clinical Pilates exercise group. However, two patients were excluded
from the study because one developed liver metastasis and the other
discontinued treatment. erefore, the study was completed with 60
patients, 30 in the clinical Pilates group and 30 in the control group.
Randomization Scheme
Eligible subjects n=60
Patients undergoing surgey for breast cancer.
Adjuvant therapy is completed at least 1 year
before and on developing lymphedema.
April 2012-March 2014
Surgury+adjuvant therapy (radiotherapy±chemotherapy±hormonotherapy)
Clinical Pilates Groups
n=30
Exercises were performed in groups of
5-8 persons 3 times a week for 8 weeks
Clinical Pilates group data included in
8th week analyses (n=30)
Standard lymphedema exercises (ey
were followed by telephone calls)
Control group data included in 8th
week analyses (n=30)
Assessments were performed before the treatment (n=60)
Measurements and Questionnaires: Pain grip strength and shoulder joint angles values, and
Social Appearrance Anxiety, European Organization for Research and Treatment Quality of
Life Questionnaire - Breast Cancer Module and DASH scores
Control Group
n=30
17
Şener et al. Effects of Clinical Pilates on Lymphedema
Measurements and Questionnaires
All evaluations were done by another physiotherapist to avoid mis-
takes. Cases and controls were chosen as the concurrent controls in
an attempt to prevent bias. e patients’ heights and weights were
measured and recorded in centimeters (cm) and kilograms (kg) respec-
tively. Other relevant data such as sex, site of cancer, post mastectomy
duration were obtained via face-to-face interviews.
Grip strength was measured using a Jamar hand dynamometer. Mea-
surements were consecutively repeated three times while the patient
was in the standing position, with the arm close to the body and the
elbow bent at 90 degrees. e highest one of these three measurements
was recorded (27).
Upper limb circumferences were measured with a tape measure start-
ing from the proximal nail fold of the middle nger up to the armpit
at 5 cm intervals when the patient was in the supine position (28).
Upper extremity range of motion measurements were performed using
a goniometer. Flexion, abduction, and internal and external rotation
angles of the shoulder joint were measured when the patient was in the
supine position (29).
Social Appearance Anxiety was assessed using the Social Appearance
Anxiety (SAA) Scale. e scale was developed as a self-report scale to
measure a patient’s cognitive, behavioral and emotional anxieties. e
SAA Scale is a 16-item, 5-point Likert-type scale. High scores indi-
cated poor performance. e Turkish validity and reliability study of
the scale was performed by Doğan (30).
e European Organization for Research and Treatment Quality of
Life Questionnaire – Breast Cancer Module (EORTC QLQ-BR23)
was developed to assess challenges of daily life faced by patients with
breast cancer and was used to assess the Quality of Life of the partici-
pants. It is a 4-point Likert scale ranging from 1 (not at all) to 4 (very
much). e total high scores obtained from the QLQ-BR 23 question-
naire with which patients’ quality of daily lives is analyzed indicate
diculties in performing daily living activities, functional activities
and reduction in the quality of life. e Turkish validity and reliability
study of the scale was conducted by Demirci et al. (31).
To assess the functional level of upper limbs, the 30-item DASH ques-
tionnaire was administered. e measurements were compared after
all the items were given scores ranging from 0 (no disability) to 100
(the most severe disability). A lower score indicated an improvement
in functional status. e score for the disability/symptom scale was
dened as the DASH score (32).
Assessments were performed before the treatment and at the 8th week
of the treatment. Both groups wore pressure garments during exercises.
Clinical Pilates exercise group; before starting the clinical Pilates
exercise program, the patients were trained on Pilates exercises and
postures. Exercises were performed in groups of 5-8 persons 3 times
a week for 8 weeks. During training, the patients were taught how to
create lumbopelvic stability (core stabilization), which is the basis for
Pilates exercises, and spinal stabilization and appropriate posture tech-
niques. Each patient was taught how to create lumbar and spinal stabi-
lization in the prone, supine, and side-lying positions using a stabilizer.
Clinical Pilates exercises were performed as group training sessions and
included the following exercises:
• Roll Down, upper-extremity proprioceptive neuromuscular facilita-
tion (PNF) methods, Dumb Waiter, Cleopatra, Toy Soldier, Chester
stretch, and swinging exercises in the standing position
• Spine stretch, the Saw, Mermaid, and oblique roll up exercises in the
sitting position
• Abdominal preparation, Hundreds, one-leg stretch, double-leg
stretch, scissors, shoulder bridge, and hip twist exercises in the supine
position
• Clam, arm openings, sidekick, lift lower, and leg lift exercises in the
side-lying position
• Swan Dive, one-leg kick, and swimming exercises in the prone posi-
tion
After four weeks, this exercise program was continued by adding a yel-
low elastic resistance band exercises. rough exercises performed by
concentrating on spinal stabilization, the ductus thoracicus was stimu-
lated and lymphatic ow was induced through continuous contrac-
tion of muscles in this region where the lymph nodes are intense. By
adding hand-arm-shoulder movements in all positions and pumping
activities (opening and closing of ngers), it was aimed to accelerate
the lymphatic ow.
e patients in the clinical Pilates exercise group, which was supervised
by physiotherapists, were also asked to practice a home program every
day that included manual lymphatic drainage training, wall extension,
and Wand exercises used to improve shoulder exibility and skin care
training.
Control Group; lumbopelvic stability (core stabilization) was taught
to the control group patients. ey were taught how to protect core
stabilization while performing activities of daily living and they were
recommended to maintain a home exercise program. ey were also
taught how to conduct manual lymphatic drainage included in the
complex decongestive therapy method, skincare, and shoulder exercis-
es, and were instructed to perform each exercise every day. To increase
their shoulder function and to reduce joint limitations, the partici-
pants were taught wall extension and Wand exercises, head and neck
exercises, and exercises to improve shoulder girdle stability. In addition
they were recommended to perform pumping activities and breathing
exercises. e participants were given a brochure that described these
exercises and were recommended to repeat these exercises at least 10
times. ey were also advised to pay attention to skin care and to walk
1 hour every day. e participants were followed up through telephone
calls.
Statistical analysis
e data of this study were analyzed using the Statistical Package for
the Social Sciences for Windows software version 16.0 (SPSS Inc.; Chi-
cago, IL, USA). e anthropometric data are presented as means and
standard deviation. e numerically determined data are expressed in
numbers and percentages. To compare the dierence between the two
groups, the independent samples t-test was used. For the analysis of
the intra-group pre- and post-treatment results, the dependent samples
t-test was used. In addition, for the analysis of survey results calculated
at certain periods and rates, the Wilcoxon test was used, which is the
non-parametric counterpart of the t-test. A p value of <0.05 was con-
sidered statistically signicant.
Results
e study was completed with 60 patients, 30 in the clinical Pilates
group and 30 in the control group.
18
J Breast Health 2017; 13: 16-22
e patients’ pre-treatment demographic characteristics were similar
in both groups and there was no statistically signicant dierence be-
tween them (Table 1).
When the patients were compared to determine how much time later
they developed lymphedema after the completion of the treatment
(surgery, radiotherapy, chemotherapy) implemented following the di-
agnosis of breast cancer, no statistically signicant dierence was de-
termined between them (p>0.05). e groups were similar in terms of
the duration of lymphedema development (Table 1).
Of the patients in the dierent treatments, 66.7% of the clinical Pi-
lates exercise group and 43.3% of the control group received complex
decongestive therapy.
When the two groups were compared in terms of their pre- and post-
treatment scores for pain in the lymphedematous arm; severity of
lymphedema; grip strength; shoulder range of motion; and disabilities
of the arm, shoulder and hand (DASH); quality of life with breast
cancer (QLQ-BR23); and social appearance anxiety (SAA), although
there were signicant improvements in all aspects in the clinical Pilates
exercise group (p<0.05), the control group had no improvements in
grip strength, shoulder exion, and external rotation angles (p>0.05)
(Table 2).
e main objective of the study was to evaluate the ecacy of clini-
cal Pilates exercises in reducing the severity of lymphedema. Swelling
caused by lymphedema is not even across the limb. erefore, mea-
surement of lymphedema must be performed from distal to proximal
at frequent intervals. In the present study, measurements were per-
formed bilaterally in the upper extremities at 5 cm intervals starting
from the nail root of the middle nger up to the axilla. e eective-
ness of the treatment was assessed by measuring the severity of edema
at the beginning and end of the treatment. When the two groups were
compared in terms of the reduction of the severity of edema in line
with the data related to the upper extremity measurements, clinical
Pilates exercises were found more eective than standard exercises. Sta-
tistical comparisons revealed that measurements of each region of the
upper extremity in the clinical Pilates group were more signicant than
those in the control group (p<0.05) (Table 3).
However, when the two groups were compared in terms of reduction
in the severity of lymphedema after treatment, there were signicant
decreases in all regions except the axillary region (p<0.05), which sup-
ports the fact that the severity of lymphedema decreased more in pa-
tients in the clinical Pilates group (Table 4).
Discussion and Conclusions
In Turkey, breast cancer ranks the rst of the 10 most common cancers
among women (33).
erefore, in the present study, the ecacy of clinical Pilates exercis-
es in the treatment of lymphedema that develops after breast cancer
treatment was investigated. At the end of the present study, it was de-
termined that lymphedema decreased, and upper limb function and
quality of life increased in the clinical Pilates exercises group supervised
by physiotherapists, and that clinical Pilates exercises were more eec-
Table 1. Comparison of demographic and
anthropometric characteristics of the participants.
Lymphedema Development Time in Patients (after
completion of radio- and chemotherapy)
Clinical Pilates
exercise group Control group
(n=30) X±SD (n=30) X±SD p
Age (years) 53.17±7.66 54.03±12.57 0.748
Height (cm) 1.61±0.06 1.61±0.07 0.891
Body weight (kg) 73.57±11.61 77.83±11.41 0.156
BMI (kg/m2) 28.53±4.51 30.35±4.99 0.144
Lymphedema
Development time
in years 5.0±3.57 4.95±4.87 p>0.05
Table 2. Comparison of the Clinical Pilates exercise group with the control group in terms of their pre- and
post-treatment pain (VAS), grip strength and shoulder joint angles values, and Social Appearance Anxiety (SAA),
European Organization for Research and Treatment Quality of Life Questionnaire (EORTC) - Breast Cancer
Module (QLQ-BR23) and DASH scores
Clinical Pilates exercise Clinical pilates
group (n=30) Control group (n=30) and control groups
GROUPS Pre-treatment Post-treatment Pre-treatment Post-treatment Post-treatment
X ± SD X ± SD P* X ± SD X ± SD P* P***
VAS (pain) 3.47±3.18 0.67±0.84* <0.01* 2.30±3.30 0.87±1.43* 0.02* 0.51
Grip Strength (kg) 17.53±6.71 19.80±6.16* 0.01* 20.73±6.63 21.90±5.38* 0.08 0.05*
Shoulder Flexion (0-180°C) 165.33±21.45 179.17±2.65* 0.01* 172.67±14.13 177.50±6.40* 0.08 0.19
Shoulder Abduction (0-180°C) 155.50±35.70 177.17±7.39* 0.01* 163.67±25.90 173.50±16.56* 0.01* 0.27
Shoulder Ext. Rotation (0-45°C) 77.17±22.65 88.67±3.46* 0.05* 81.83±15.00 85.67±10.73* 0.22 0.15
SAA** 24.83±7.98 19.67±3.66** <0.01** 27.57±9.08 26.17±8.09** 0.04** <0.01**
QLQ-BR 23** 32.44±10.27 38.51±8.42** 0.04** 34.10±9.63 38.37±7.48** 0.02** 0.94
DASH (0-100)** 44.24±15.33 37.99±15.02** <0.01** 34.82±11.96 32.15±12.11** <0.01** 0.39
*: Paired Samples Test, p<0.05; **: Wilcoxon Signed-Rank Test, p<0,05; ***: post-treatment Comparison of the two groups, p<0.05*; VAS: Visual Analogue Scale 19
Şener et al. Effects of Clinical Pilates on Lymphedema
tive than standard exercises according to the comparison of the results
of both groups.
Lymphedema after breast cancer treatment is caused by inammation,
infection, and disruption of the lymphatic system due to radiation-
related brosis of soft tissues, which disrupts patients’ upper extremity
functions (34, 35). All patients included in this present study under-
went surgery. Ninety-six percent of the patients underwent radio-
chemo-medical therapy and / or hormonal therapy. e duration of
lymphedema development among them was close to each patient’s.
Schmitz et al. (35) argued that exercise training increased the capac-
ity of the muscular and cardiovascular systems by loading controlled
physiologic stress onto the body, and could improve collaterals as in
the arterial system, which would thus facilitate lymphatic ow in pa-
tients with lymphedema (36).
Several studies conducted to investigate lymphedema after breast can-
cer treatment reported that physical activity generally contributed
to patients’ quality of life and emotional status extremely positively.
However, they also reported that increasing the diversity of physical
activities was of great importance because this may create alternative
exercise options in the treatment of lymphedema. It has been reported
that dierent exercise models, group exercise, social activity-oriented
exercises, and Pilates training might be useful in patients with lymph-
edema (19, 20, 22, 24, 26).
A review of the literature in line with this information revealed that
patients with breast cancer used Pilates exercises to improve their qual-
ity of life, shoulder function, and body image. However, no detailed
exercise program was implemented in the treatment of lymphedema,
a chronic disease that develops after breast cancer treatment. Studies
demonstrated that when combined with breathing exercises, Pilates
exercises were capable of activating the whole body together and pro-
mote the quality of life and functionality by improving body image;
therefore, they could be used in the treatment of chronic diseases such
as lymphedema that deteriorate life quality (26, 37-39).
Table 3. Comparison of clinical Pilates exercise and control group patients’ pre- and post-treatment upper limb
circumferences measured starting from proximal nail fold of the middle finger up to the armpit of the arm with
lymphedema at 5-cm intervals
Clinical Pilates group Control group
Pre-treatment Post-treatment Pre-treatment Post-treatment
GROUPS X ± SD X ± SD P* X ± SD X ± SD P*
Proximal nail fold 4.93±0.39 4.77±0.34 0.01* 5.33±0.46 5.32±0.44 0.32
5 cm 6.60±0.91 6.50±0.82 0.18 7.13±0.97 6.95±0.71 0.02*
10 cm 19.92±2.11 18.73±3.49 0.02* 21.32±2.36 21.13±2.20 0.01*
15 cm 18.38±2.23 17.67±2.96 0.03* 20.33±3.82 19.65±3.94 0.06
20 cm 20.25±4.38 19.80±3.48 0.24 23.08±3.99 22.63±3.76 0.01*
25 cm 24.13±4.06 23.48±3.78 0.02* 26.68±4.56 26.20±4.39 <0.00*
30 cm 27.68±4.41 26.98±4.14 0.02* 30.22±4.49 29.73±4.29 <0.01*
35 cm 28.98±4.22 28.27±4.12 0.01* 31.40±4.18 31.00±3.99 0.03*
40 cm 29.38±4.49 28.70±4.41 0.09 32.38±4.47 32.15±4.38 0.06
45 cm 31.60±5.00 30.65±4.59 0.01* 34.78±5.47 34.45±5.41 0.01*
50 cm 33.67±4.67 32.43±4.20 0.01* 36.80±5.16 36.38±4.82 0.07
55 cm 34.97±4.28 33.72±3.87 0.01* 37.48±5.06 37.03±4.90 <0.01*
60 cm 36.22±4.16 34.98±3.73 0.01* 36.68±3.76 36.57±3.78 0.38
Proximal nail fold, 10cm-, 15cm-, 25cm-, 30cm-, 35cm-, 45cm-, 50cm-, 55cm-, 60cm- levels are statistically significant (*p<0.05).
5cm-, 10cm-, 20 cm-, 25 cm-, 30 cm-, 35cm-, 45cm-, 55cm- levels are statistically significant (*p<0.05).
Table 4. Comparison of the two groups in terms of
the severity of lymphedema after treatment
GROUPS Clinical Pilates Control group
group X ± SD X ± SD p
Proximal nail fold 4.77±0.34 5.32±0.44 <0.01*
5 cm 6.50±0.82 6.95±0.71 0.02*
10 cm 18.73±3.49 21.13±2.20 0.02*
15 cm 17.67±2.96 19.65±3.94 0.03*
20 cm 19.80±3.48 22.63±3.76 0.04*
25 cm 23.48±3.78 26.20±4.39 0.01*
30 cm 26.98±4.14 29.73±4.29 0.01*
35 cm 28.27±4.12 31.00±3.99 0.01*
40 cm 28.70±4.41 32.15±4.38 0.04*
45 cm 30.65±4.59 34.45±5.41 0.05*
50 cm 32.43±4.20 36.38±4.82 0.01*
55 cm 33.72±3.87 37.03±4.90 0.06*
60 cm 34.98±3.73 36.57±3.78 0.20
Proximal nail fold, 5 cm-, 10 cm-, 15 cm-, 25 cm-, 30 cm-, 35 cm-, 40 cm-, 45 cm-,
50 cm-, 55 cm-, levels are statistically significant (*p<0.05).
20
J Breast Health 2017; 13: 16-22
In the present study, which was conducted to investigate the eects
of clinical Pilates exercises as a treatment option in patients who de-
velop lymphedema after breast cancer treatment with group exercises,
the patients’ socialization improved, their awareness of their own body
increased after they learned how to control their body in general, and
their quality of life improved. Moreover, the severity of lymphedema
decreased due to improvements in functionality and the constant
union of mind and body through body stability. In the present study,
the results obtained by the patients in the clinical Pilates exercise group
were compared with those obtained by the control group, which per-
formed standard lymphedema exercises, and it was determined that
clinical Pilates exercises were more eective than standard lymphede-
ma exercises in all the parameters investigated.
ese eects result from the fact that spinal stabilization, which is the
basis for clinical Pilates exercises, can be maintained in all activities of
daily life. It is considered that spinal stabilization contributes to con-
tinuous contraction of the muscles of the trunk and the diaphragm,
and thus stimulates ductus thoracicus and abdominal lymph nodes in
patients with lymphedema, which facilitates lymphatic ow, and acts
as a pump that accelerates the ow of lymph when combined with
limb exercises (21, 36, 40). In addition, the patients’ awareness and
union of mind and body were increased, and through isolated muscle
exercises, they were taught that they themselves could control their
muscles. In line with this cognitive restructuring, this stabilization of
the trunk maintained its eects on all the body movements, and pa-
tients who learned how to correct inappropriate movements during
exercises developed a positive perception of recovery. e survey results
obtained after the treatment also supported this view. e results indi-
cate that both functional independence and quality of life improved.
e results of this present study indicate that clinical Pilates exercises
had positive eects on the amount of lymphedema, functional sta-
tus, grip strength, and quality of life of patients with lymphedema.
Patients in both the clinical Pilates and control group were recom-
mended to wear pressure garments on the arm with lymphedema dur-
ing the treatment sessions. In conclusion; given the positive eects of
clinical Pilates exercises on patient with breast cancer who developed
lymphedema after their treatment in terms of functionality, mood and
quality of life, it was decided that it would be appropriate to include
clinical Pilates exercises in physiotherapy programs as a safe exercise
model. It was also considered that Clinical Pilates exercises would be a
good exercise regimen for patients with lymphedema and they might
adopt them as a lifestyle exercise model. However, if this view is to be
supported, new studies should be performed with a greater number
of patients
Ethics Committee Approval: Ethics committee approval was received for this
study from Dokuz Eylül University İzmir Clinical Research Ethics Committee
(decision dated April 12, 2012 and Research Protocol No: 2012 / 14-14).
Informed Consent: Written informed consent was obtained from patients who
participated in this study.
Author Contributions: Concept - H.O.S, M.M., D.K.; Design - H.O.S.,
M.M.; Supervision M.M.; Funding - D.K.; Materials - T.Y.; Data Collection
and/or Processing - H.O.S.; Analysis and/or Interpretation - H.O.S., G.E.; Lit-
erature Review - H.O.S.; Writing - H.O.S.; Critical Review - H.O.S., M.M.
Acknowledgement: We thank all participants who agreed to participate in the
study.
Conflict of Interest: No conflict of interest was declared by the au-
thors.
Financial Disclosure: e authors declared that this study has received no -
nancial support.
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22
J Breast Health 2017; 13: 16-22
... After 8 weeks of yoga classes in 12 patients, both shoulder abductor strength and balance were enhanced (Loudon et al., 2016). Sener et al(2017) randomly divided 60 patients into Pilates training and routine groups. After 8 weeks, the severity of lymphedema in the intervention group was reduced, and the quality of life score and upper limb function score was higher than those in the control group, indicating that Pilates is more effective. ...
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... В ряде статей в качестве стратегии реабилитации женщин с раком груди использовался пилатес. Согласно результатам проанализированных исследований, специальная система упражнений оказала положительное влияние на ряд физических (объем активных движений плечевого пояса, выраженность болевого синдрома и лимфатического отека плеча) и эмоциональных (качество жизни, настроение, физическая активность) параметров [19,20]. В связи с этим, исходя из данных исследований, пациенткам со злокачественной опухолью молочной железы можно рекомендовать регулярные занятия пилатесом в качестве альтернативы лечебной физкультуре. ...
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To critically analyse the benefits of Pilates on health outcomes in women SEARCH TERMS: 'Pilates' and 'Pilates Method' DATA SOURCES: CINAHL, MEDLINE, PubMed, Science Direct, SPORTDiscus, PEDro, Cochrane Central Register of Controlled Trials, and Web of Science were searched up to July 2014 STUDY SELECTION: Published RCTs were included if they comprised female participants with a health condition and a health outcome was measured, Pilates needed to be administered and the manuscript was published in English in a peer-reviewed journal from 1980 to July 2014 DATA EXTRACTION: Two authors independently applied the inclusion criteria to potential studies. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. A best evidence grading system was employed to determine the strength of the evidence DATA SYNTHESIS: Thirteen studies met the inclusion criteria. PEDro scale values ranged from three to seven (mean, 4.5; median, 4.0), indicating a relatively low quality overall. In this sample, Pilates for breast cancer was most often trialled (n=2). The most frequent health outcomes investigated were pain, (n=4) quality of life, (n=4) and lower extremity endurance (n=2) with mixed results. Emerging evidence was found for reducing pain, and improving quality of life and lower extremity endurance CONCLUSIONS: There is a paucity of evidence on Pilates for improving women's health during pregnancy or for conditions including breast cancer, obesity or low back pain. Further high quality RCTs are warranted to determine the effectiveness of Pilates for improving women's health outcomes. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Article
Survivors of breast cancer may experience deterioration of physical function. This is important because poor physical function may be associated with premature mortality, injurious falls, bone fracture, and disability. We conducted a post hoc analysis to explore the potential efficacy of slowly progressive weight lifting to reduce the incidence of physical function deterioration among survivors of breast cancer. Between October 2005 and August 2008, we conducted a single-blind, 12-month, randomized controlled trial of twice-per-week slowly progressive weight lifting or standard care among 295 survivors of nonmetastatic breast cancer. In this post hoc analysis of data from the Physical Activity and Lymphedema Trial, we examined incident deterioration of physical function after 12 months, defined as a ≥ 10-point decrease in the physical function subscale of the Medical Outcomes Short-Form 36-item questionnaire. The proportion of participants who experienced incident physical function deterioration after 12 months was 16.3% (24/147) in the control group and 8.1% (12/148) in the weight lifting group (relative risk, 0.49; 95% CI, 0.25 to 0.96; P = .04). No serious or unexpected adverse events occurred that were related to weight lifting. Slowly progressive weight lifting compared with standard care reduced the incidence of physical function deterioration among survivors of breast cancer. These data are hypothesis generating. Future studies should directly compare the efficacy of weight lifting with other modalities of exercise, such as brisk walking, to appropriately inform the development of a confirmatory study designed to preserve physical function among survivors of breast cancer. © 2015 by American Society of Clinical Oncology.
Article
We previously evaluated the risk of breast cancer-related lymphedema (LE) with the addition of regional lymph node irradiation (RLNR) and found an increased risk when RLNR is used. Here we analyze the association of technical radiation therapy (RT) factors in RLNR patients with the risk of LE development. From 2005 to 2012, we prospectively screened 1476 women for LE who underwent surgery for breast cancer. Among 1507 breasts treated, 172 received RLNR and had complete technical data for analysis. RLNR was delivered as supraclavicular (SC) irradiation (69% [118 of 172 patients]) or SC plus posterior axillary boost (PAB) (31% [54 of 172]). Bilateral arm volume measurements were performed pre- and postoperatively. Patients' RT plans were analyzed for SC field lateral border (relative to the humeral head), total dose to SC, RT fraction size, beam energy, and type of tangent (normal vs wide). Cox proportional hazards models were used to analyze associated risk factors for LE. Median postoperative follow-up was 29.3 months (range: 4.9-74.1 months). The 2-year cumulative incidence of LE was 22% (95% confidence interval [CI]: 15%-32%) for SC and 20% (95% CI: 11%-37%) for SC plus PAB (SC+PAB). None of the analyzed variables was significantly associated with LE risk (extent of humeral head: P=.74 for <1/3 vs >2/3, P=.41 for 1/3 to 2/3 vs >2/3; P=.40 for fraction size of 1.8 Gy vs 2.0 Gy; P=.57 for beam energy 6 MV vs 10 MV; P=.74 for tangent type wide vs regular; P=.66 for SC vs SC+PAB). Only pretreatment body mass index (hazard ratio [HR]: 1.09; 95% CI: 1.04-1.15, P=.0007) and the use of axillary lymph node dissection (HR: 7.08, 95% CI: 0.98-51.40, P=.05) were associated with risk of subsequent LE development. Of the RT parameters tested, none was associated with an increased risk of LE development. This study underscores the need for future work investigating alternative RLNR risk factors for LE. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
We sought to assess the association of breast cancer-related lymphedema (BCRL) with the ability to perform upper extremity activities of daily living (ADL) in our patient population. 324 breast cancer patients who had received treatment for unilateral breast cancer at our institution between 2005 and 2014 were prospectively screened for lymphedema. Bilateral arm measurements were performed pre-operatively and during post-operative follow-up using a Perometer. Patients completed an extensive quality of life (QOL) questionnaire at the time of each study assessment. Lymphedema was defined as a relative volume change (RVC) of ≥10% from the patient's pre-operative baseline measurement. Linear regression models were used to evaluate the relationship between post-operative arm function score (as a continuous variable) and RVC, demographic, clinical, and QOL factors. By multivariate analysis, greater fear of lymphedema (p < 0.0001), more pain (p < 0.0001), body mass index >25 (p = 0.0015), mastectomy (p = 0.0001), and having an axillary node dissection (p = 0.0045) were all associated with lower functional scores. Higher emotional well-being score (p < 0.0001) and adjuvant chemotherapy (p = 0.0005) were associated with higher post-operative functional score. Neither low-level volume changes (5-10 % RVC) nor BCRL (RVC ≥10 %) were associated with ability to perform upper extremity ADL as measured by self-report (p = 0.99, p = 0.79). This prospective study demonstrates that low-level changes in arm volume (RVC 5-10 %) as well as clinically significant BCRL (RVC ≥10 %) did not impact the self-reported ability to use the affected extremity for ADL. These findings may help to inform clinicians and patients on the importance of prospective screening for lymphedema and QOL which enables early detection and intervention.
Article
Radiation therapy is associated with acute treatment-related complications that can lead to decreased quality of life (QOL). Exercise has been shown in other cancer treatment settings to improve negative outcomes. We conducted a prospective pilot study to explore the association between exercise, patient-reported outcomes, and acute radiation therapy toxicities. Women receiving curative breast radiation therapy were enrolled. Each patient completed an exercise behavior/QOL survey before or during the first week of treatment and again during the last week of treatment. Exercise behavior was quantified with the Godin Leisure Time Exercise Questionnaire (metabolic equivalent [MET] hours per week). Measurements to evaluate upper extremity lymphedema and shoulder range of motion were completed. Skin toxicity was assessed weekly. Patient-reported outcomes were measured using standardized questionnaires. Forty-five patients were enrolled. Mean patient age was 54 (range, 28-73) years. Mean METs in the exercise cohort (≥9 METs/wk) was 21 per week (range, 11-38, n = 14); 3 per week (range, 0-8, n = 25) in the nonexercise cohort (<9 METs/wk). Women in the exercise cohort showed improvements in treatment-induced quality of life and fatigue (not significant) despite more extensive surgical, medical, and radiation treatment. No differences in treatment-related toxicities, pain, or sleep scores were noted. Lymphedema was mild (<3 cm) in the entire patient cohort. The vast majority of current exercise oncology literature implicates physical activity as an independent predictor of QOL in cancer patients. Our study noted similar trends, but they were not statistically significant. This may be due to our finding that patient-reported outcomes with radiation therapy are relatively high compared with other treatment modalities and remain stable throughout treatment. Thus, it may be that radiation therapy has a limited impact on QOL in breast cancer patients. Exercise may be best used as a targeted therapy in patients at high risk for poor QOL or radiation-related toxicities at baseline. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Article
Upper body pain and dysfunction are common in survivors of breast cancer. Disorders of the upper body can result directly from breast cancer or from the surgery, chemotherapy, radiotherapy, or hormonal therapies used in its treatment. Although considerable information is available regarding impairments such as pain and restricted shoulder range of motion associated with breast cancer and its treatment, relatively little information is available about the specific neuromuscular, musculoskeletal, lymphovascular, and other diagnostic entities that underlie those impairments. This article will detail the common and specific causes of upper body pain and dysfunction in breast cancer survivors, including postsurgical pain, rotator cuff disease, adhesive capsulitis, arthralgias, cervical radiculopathy, brachial plexopathy, mononeuropathy, postmastectomy pain syndrome, lymphedema, axillary web syndrome, deep vein thrombosis, and cellulitis. Diagnostic specificity is a key first step to safely and effectively restore function and quality of life to breast cancer survivors.
Article
Summary The prevalence of chronic arm oedema was deter- mined among all 1249 women treated for breast cancer but without tumour recurrence and living and registered in the Worthing District Health Authority area; 1151 women (92%) responded to a validated questionnaire. The mean interval since treatment was 9.5 years. Of 1077 women treated for unilateral breast cancer, 302 (28%) reported arm swelling. There was a significant (p = 0.01) increase in prevalence with time since treatment in patients who received post-operative radiotherapy. Overall, arm oedema was twice as common among women treated by radiotherapy (odds ratio adjusted for type of operation 2.45, 95% Cl 1.86-3.27), and among patients treated by mastectomy compared to lumpectomy (odds ratio adjusted for radiotherapy 2.13, 95% Cl 1.13-4.43). Arm oedema is thus a common complication of breast cancer treatment, and patients should be alerted to this possibility at the time of initial treatment.
Article
Purpose: To provide advanced practice nurses with a greater understanding of the pathophysiology, clinical manifestations, diagnosis, and management of lymphedema. Data sources: Comprehensive literature review of the relevant clinical journals, systematic reviews, and medical textbooks. Conclusions: Lymphedema is a poorly known and understood condition. If not properly diagnosed and promptly treated, lymphedema can cause significant morbidity and mortality. Diagnosis is based on suggestive history and characteristic findings on physical exam that ideally would be confirmed by lymphoscintigraphy. The primary goal in lymphedema treatment is the removal of excess plasma proteins from the interstitial tissues. The goals of management are to decrease the extremity size, maintain the decreased size, prevent complications, and improve function and overall sense of psychological well-being. Implications for practice: The ability to properly diagnose lymphedema is crucial to prevent the significant morbidity and mortality that is associated with this condition. It is imperative that patients with lymphedema are referred to specially trained healthcare professionals to ensure optimal treatment.