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Do Women with Breast Cancer–related Lymphoedema Need to Wear Compression While Exercising?: Results from a Systematic Review and Meta-analysis

DOI:10.1007/s12609-020-00373-0
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Sandi Hayes
Sandi Hayes
Sandi Hayes
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Ben Singh
Ben Singh
Ben Singh
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Kira Bloomquist at Copenhagen University Hospital
Kira Bloomquist
Karin Johansson at Lund University
Karin Johansson
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Abstract and Figures

Purpose of Review To undertake a systematic review and meta-analysis to evaluate the effects of wearing compression versus no compression during a single bout of exercise, and during an exercise intervention, for those with breast cancer-related lymphoedema (BCRL). A multiple database search was undertaken to identify eligible randomised controlled trials (RCTs) and non-RCTs involving those with BCRL. The primary outcome variable was lymphoedema and pooled statistics were calculated using standardised mean differences (SMDs) within or between compression and no compression groups. Recent Findings Six eligible studies were identified and rated as either moderate (n = 5) or strong (n = 1) quality. No within-group change in lymphoedema was observed after a single bout of exercise or after an exercise intervention period with compression (SMD = − 0.08 [95% CI = − 0.36, 0.21]; and SMD = − 0.20 [95% CI = − 0.63, 0.22], respectively) or without compression (SMD = 0.05 [95% CI = − 0.23, 0.34]; and, SMD = − 0.17 [95% CI = − 0.56, 0.22], respectively). There was also no between-group difference found post-exercise (single bout or intervention period) between those exercising with and without compression (SMD = − 0.08 [95% CI = − 0.28, 0.12]). Summary There appears to be no consistent benefit or adverse effect of wearing compression for BCRL during a single exercise bout or an exercise intervention period.
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LYMPHEDEMA INCIDENCE, PREVENTION AND TREATMENT (J ARMER, SECTION EDITOR)
Do Women with Breast Cancer–related Lymphoedema Need to Wear
Compression While Exercising?: Results from a Systematic Review
and Meta-analysis
Sandi Hayes
1
&Ben Singh
2
&Kira Bloomquist
3
&Karin Johansson
4
#Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Purpose of Review To undertake a systematic review and meta-analysis to evaluate the effects of wearing compression versus no
compression during a single bout of exercise, and during an exercise intervention, for those with breast cancer-related
lymphoedema (BCRL). A multiple database search was undertaken to identify eligible randomised controlled trials (RCTs)
and non-RCTs involving those with BCRL. The primary outcome variable was lymphoedema and pooled statistics were
calculated using standardised mean differences (SMDs) within or between compression and no compression groups.
Recent Findings Six eligible studies were identified and rated as either moderate (n=5)orstrong(n=1)quality. No within-
group change in lymphoedema was observed after a single bout of exercise or after an exercise intervention period with
compression (SMD = −0.08 [95% CI = −0.36, 0.21]; and SMD = −0.20 [95% CI = −0.63, 0.22], respectively) or without
compression (SMD = 0.05 [95% CI = −0.23, 0.34]; and, SMD = −0.17 [95% CI = −0.56, 0.22], respectively). There was also
no between-group difference found post-exercise (single bout or intervention period) between those exercising with and without
compression (SMD = −0.08 [95% CI = −0.28, 0.12]).
Summary There appears to be no consistent benefit or adverse effect of wearing compression for BCRL during a single exercise
bout or an exercise intervention period.
Keywords Lymphoedema .Exercise .Compression .Breast cancer
Introduction
Exercise is considered an important and effective means of
reducing morbidity and improving quality of life for those
with cancer, with much of the evidence in support of exercise
drawn from studies involving women with breast cancer [1,
2]. Specifically, consistent evidence from clinical trials shows
that mixed-mode exercise (i.e. aerobic and resistance exercise)
for women with breast cancer is safe, feasible, and effective at
improving fitness, strength, psychosocial well-being (includ-
ing anxiety and depression), and treatment-related side effects
(such as fatigue) during and following breast cancer treatment
[2]. Further, strong observational evidence links exercise post-
breast cancer with reduced risk of chronic disease (such as
cardiovascular disease and type II diabetes), breast cancer re-
currence, cancer-related mortality, and all-cause mortality
[3•]. Despite widespread endorsement of participation in reg-
ular physical activity by cancer organisations worldwide, the
majority of women experience declines in physical activity
post-breast cancer or fail to meet recommended physical
This article is part of the Topical Collection on Lymphedema incidence,
prevention and treatment
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s12609-020-00373-0) contains supplementary
material, which is available to authorized users.
*Sandi Hayes
sandi.hayes@griffith.edu.au
1
Menzies Health Institute Queensland, Griffith University,
Brisbane, Queensland, Australia
2
Inter-University Laboratory of Human Movement Biology,
University of Lyon, UJM-Saint-Etienne, A 7424,
F-42023 Saint-Etienne, France
3
University Hospitals Centre for Health Research (UCSF),
Rigshospitalet, Copenhagen, Denmark
4
Department of Health Sciences, Lund University, Lund, Sweden
https://doi.org/10.1007/s12609-020-00373-0
Published online: 20 July 2020
Current Breast Cancer Reports (2020) 12:193–201
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The standard conservative treatment is Complete Decongestive Therapy (CDT) or Combined Physical Therapy (CPT), which consists of a combination of techniques that includes skin care, manual lymphatic drainage, joint mobility exercises, compression garments and multilayer bandages; however, there are no solid data to recommend its universal use due to the characteristics of the treatment itself [9][10][11]. The prescription of compression garments for lymphedema is very varied due to the lack of evidence to support the treatment [12], whose use neither provides benefit nor is contraindicated during the practice of physical activity [13], and it can cause irritation, skin discomfort and pain, and even soft tissue and nerve injuries [14,15]. In addition, there is no optimal level of adherence to its use as it causes patients discomfort and negative emotions related to their visibility and interference with function and social situations [16]. ...
... Not using compression garments with the experimental treatment proposed in this study could be one of the justifications that support the results obtained, with a better participation of patients in the social dimension. A lack of consistent benefit or occurrence of any adverse effect of wearing a compression garment in performing physical activity is also the conclusion of the systematic review conducted by Hayes et al. [14]. ...
Impact of Activity-Oriented Propioceptive Antiedema Therapy on the Health-Related Quality of Life of Women with Upper-Limb Lymphedema Secondary to Breast Cancer—A Randomized Clinical Trial
Article
Full-text available
  • Mar 2022
Background: Alterations derived from lymphedema in the upper-limb secondary to breast cancer-related lymphedema (BCRL) decrease the health-related quality of life (HRQoL), but there is limited evidence of the impact of the different interventions on it. The aim of this research was to compare the effect of conventional treatment with another treatment based on Activity-Oriented Antiedema Proprioceptive Therapy (TAPA) on HRQoL in women diagnosed with BCRL. Methods: A prospective clinical study was designed with two parallel arms. The study population consisted of women diagnosed with BCRL in stage I and II, belonging to different institutions in Córdoba and Aragon, Spain. Sociodemographic and HRQoL-related variables, pain, tightness, heaviness and functionality were obtained before and after treatments. Results: 51 women participated in the study, 25 received the conventional treatment and 26 the TAPA, with a mean age of 59.24 ± 9.55 years. HRQoL was significantly related to upper-limb function and pain on the participants' affected side. In addition, covariance analysis (ANCOVA) showed that the TAPA treatment interfered less in the performance of activities of daily life and produced significant improvements in the social dimension of HRQoL. Conclusions: the non-use of compressive elements in the rehabilitative treatment of the BCRL that is proposed with TAPA improves aspects such as self-image and participation in social and recreational activities.
... The positive results from the implementation of physical exercise programs before even the surgery and postoperatively, have been seen in other studies [41]. Despite the fact that progressive regular exercise seems to be safe without worsening the lymphedema, no significant improvement is confirmed even if compression therapy is combined [42,43]. ...
Diagnosis, treatment and quality of life in patients with cancer-related lymphedema
Article
Full-text available
  • Sep 2021
Cancer-related lymphedema is the result of surgical operation or radiation therapy of the corresponding lymph nodes and is due to the obstruction of the lymphatic drainage in the affected area. In lymphedema the lymphatic stasis causes an inflammatory reaction that leads to the proliferation of adipose tissue and fibrosis, resulting in mild to severe permanent swelling of the affected part of the body. It is more often found in the upper extremities of women with breast cancer. It may, however, appear at one or more extremities and may include the corresponding quadrant of the trunk. It may also affect head and neck, breast, genitals and lower extremities, depending on the surgery the patient has undergone. It is often associated with obesity (BMI>40). Early diagnosis and treatment of lymphedema is related with better therapeutic outcome. Women with breast cancer confront more problems with lymphedema than with mastectomy. Its effect on patients' quality of life is relevant to changes in body image, self-esteem, feelings of weakness, fear and anxiety about disease progression, financial costs, and reduced limb function. More recent studies support the effectiveness of contemporary surgical techniques in lymphedema's treatment. In conservative management, CDT remains the treatment of choice and in combination with exercise, weight control programs and self-care training seems to significantly improve patients' quality of life.
American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control
Article
Full-text available
  • Nov 2019
Introduction: The American College of Sports Medicine convened an International Multidisciplinary Roundtable on Exercise and Cancer in March 2018 to evaluate and translate the evidence linking physical activity and cancer prevention, treatment, and control. This article discusses findings from the Roundtable in relation to the biologic and epidemiologic evidence for the role of physical activity in cancer prevention and survival. Results: The evidence supports that there are a number of biologically plausible mechanisms, whereby physical activity can influence cancer risk, and that physical activity is beneficial for the prevention of several types of cancer including breast, colon, endometrial, kidney, bladder, esophageal, and stomach. Minimizing time spent in sedentary behavior may also lower risk of endometrial, colon and lung cancers. Conversely, physical activity is associated with higher risk of melanoma, a serious form of skin cancer. Further, physical activity before and after a cancer diagnosis is also likely to be relevant for improved survival for those diagnosed with breast and colon cancer; with data suggesting that postdiagnosis physical activity provides greater mortality benefits than prediagnosis physical activity. Conclusions: Collectively, there is consistent, compelling evidence that physical activity plays a role in preventing many types of cancer and for improving longevity among cancer survivors, although the evidence related to higher risk of melanoma demonstrates the importance of sun safe practices while being physically active. Together, these findings underscore the importance of physical activity in cancer prevention and control. Fitness and public health professionals and health care providers worldwide are encouraged to spread the message to the general population and cancer survivors to be physically active as their age, abilities, and cancer status will allow.
Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of 34 RCTs
Article
Full-text available
  • Dec 2016
This individual patient data meta-analysis aimed to evaluate the effects of exercise on quality of life (QoL) and physical function (PF) in patients with cancer, and to identify moderator effects of demographic (age, sex, marital status, education), clinical (body mass index, cancer type, presence of metastasis), intervention-related (intervention timing, delivery mode and duration, and type of control group), and exercise-related (exercise frequency, intensity, type, time) characteristics. Relevant published and unpublished studies were identified in September 2012 via PubMed, EMBASE, PsycINFO, and CINAHL, reference checking and personal communications. Principle investigators of all 69 eligible trials were requested to share IPD from their study. IPD from 34 randomised controlled trials (n=4519 patients) that evaluated the effects of exercise compared to a usual care, wait-list or attention control group on QoL and PF in adult patients with cancer were retrieved and pooled. Linear mixed-effect models were used to evaluate the effects of the exercise on post-intervention outcome values (z-score) adjusting for baseline values. Moderator effects were studies by testing interactions. Exercise significantly improved QoL (β=0.15, 95%CI=0.10;0.20) and PF (β=0.18, 95%CI=0.13;0.23). The effects were not moderated by demographic, clinical or exercise characteristics. Effects on QoL (βdifference_in_effect=0.13, 95%CI=0.03;0.22) and PF (βdifference_in_effect=0.10, 95%CI=0.01;0.20) were significantly larger for supervised than unsupervised interventions. In conclusion, exercise, and particularly supervised exercise, effectively improves QoL and PF in patients with cancer with different demographic and clinical characteristics during and following treatment. Although effect sizes are small, there is consistent empirical evidence to support implementation of exercise as part of cancer care.
Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable
Article
  • Nov 2019
Purpose: The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue. Methods: A second Roundtable was convened in 2018 to advance exercise recommendations beyond public health guidelines and toward prescriptive programs specific to cancer type, treatments, and/or outcomes. Results: Overall findings retained the conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should "avoid inactivity." Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life. Implications for other outcomes, such as peripheral neuropathy and cognitive functioning, remain uncertain. Conclusions: The proposed recommendations should serve as a guide for the fitness and health care professional working with cancer survivors. More research is needed to fill remaining gaps in knowledge to better serve cancer survivors, as well as fitness and health care professionals, to improve clinical practice.
Heavy-load resistance exercise during chemotherapy in physically inactive breast cancer survivors at risk for lymphedema: a randomized trial
Article
  • Jul 2019
Background: Due to long-standing concerns that heavy-load lifting could increase the risk of developing lymphedema, breast cancer survivors have been advised to refrain from resistance exercise with heavy loads. This study prospectively evaluated the effect of heavy-load resistance exercise on lymphedema development in women receiving chemotherapy for breast cancer. Material and Methods: Physically inactive women receiving adjuvant chemotherapy for breast cancer (n = 153) were randomized to a HIGH (supervised, multimodal exercise including heavy-load resistance exercise: 85–90% 1 repetition maximum [RM], three sets of 5–8 repetitions) versus LOW (pedometer and one-on-one consultations) 12-week intervention. Outcomes (baseline, 12 and 39 weeks) included lymphedema status (extracellular fluid [bioimpedance spectroscopy] and inter-arm volume % difference [dual-energy X-ray absorptiometry], lymphedema symptoms [numeric rating scale 0–10]), upper-extremity strength (1 RM), and quality of life domains (EORTC- BR23). Linear mixed models were used to evaluate equivalence between groups for lymphedema outcomes (equivalence margins for L-Dex, % difference and symptoms scale: ±5, ±3% and ±1, respectively). Superiority analysis was conducted for muscle strength and quality of life domains. Results: Postintervention equivalence between groups was found for extracellular fluid (0.4; 90% CI −2.5 to 3.2) and symptoms of heaviness (−0.2; −0.6 to 0.2), tightness (−0.1; −0.8 to 0.6) and swelling (0.2; −0.4 to 0.8). Nonequivalence was found for inter-arm volume % difference (−3.5%; −17.3 to 10.3) and pain (−0.7; −1.3 to 0), favoring HIGH. Strength gains were superior in the HIGH versus LOW group (3 kg; 1 to 5, p < .05). Further, clinically relevant reductions in breast (−11; −15 to −7) and arm (−6; −10 to −1) symptoms were found in the HIGH group. Conclusion: Findings suggest that physically inactive breast cancer survivors can benefit from supervised heavy-load resistance exercise during chemotherapy without increasing lymphedema risk. Trial registration: ISRCTN13816000
Low-Intensity Resistance Training and Compression Garment in the Management of Breast Cancer–Related Lymphedema: Single-Blinded Randomized Controlled Trial
Article
  • Jun 2019
There is limited evidence regarding the combined effect of exercise and compression garment on breast cancer–related lymphedema (BCRL). Therefore, we investigate the effect of low-intensity resistance training alone or in combination with a compression garment on lymphedema volume, self-reported lymphedema symptoms, and shoulder mobility and function. A total of 60 women with unilateral BCRL were randomly assigned to low-intensity resistance exercises (Rex group, n = 30) or exercises and compression garment (Rex-Com-group, n = 30). Both groups take part in exercises program consisted of 10–12 repetitions at 50 to 60% of one repetition maximum (IRM), three times weekly, for 8 weeks. The primary outcome was lymphedema volume determined by percentage reduction of excess limb volume (ELV). Secondary outcomes were lymphedema symptoms (pain, heaviness, and tightness) and shoulder mobility and function using the disabilities of the arm, shoulder, and hand (DASH) questionnaire. All measurements were standardized and performed before (week 0, W0), after the intervention (week 8, W8), and at follow-up (week 12, W12). A significant reduction in percentage of ELV (p < 0.01), pain severity (p < 0.05), a sensation of heaviness (p < 0.05) and tightness (p < 0.001), and improvement in shoulder range of motion (p < 0.05) and function on DASH scores (p < 0.05) were observed at W8 and W12 in both groups. However, no between-group differences were observed over time. These findings suggest that low-intensity resistance training, irrespective of garment use, can effectively reduce limb volume and lymphedema symptoms, and increase shoulder mobility and function.
The Exercise and Sports Science Australia position statement: Exercise medicine in cancer management
Article
Objectives: Since Exercise and Sports Science Australia (ESSA) first published its position statement on exercise guidelines for people with cancer, there has been exponential growth in research evaluating the role of exercise pre-, during and post-cancer treatment. Design and methods: The purpose of this report is to use the current scientific evidence, alongside clinical experience and exercise science principles to update ESSA's position statement on cancer-specific exercise prescription. Results: Reported in this position statement is a summary of the benefits accrued through exercise following a cancer diagnosis and the strengths and limitations of this evidence-base. An exercise prescription framework is then proposed to enable the application of cancer-specific considerations for individualisation, specificity, safety, feasibility and progression of exercise for all patients. Additional specific exercise prescription considerations are provided for the presence of haematological, musculoskeletal, systemic, cardiovascular, lymphatic, gastrointestinal, genitourinary and neurological disease- and treatment-related concerns, as well as presence of co-morbid chronic disease. Further, we also identify and discuss cancer-specific pragmatic issues and barriers requiring consideration for exercise prescription. Conclusions: While for the majority, multimodal, moderate to high intensity exercise will be appropriate, there is no set prescription and total weekly dosage that would be considered evidence-based for all cancer patients. Targeted exercise prescription, which includes the provision of behaviour change advice and support, is needed to ensure greatest benefit (as defined by the patient) in the short and longer term, with low risk of harm.
A Systematic Review and Meta-Analysis of the Safety, Feasibility, and Effect of Exercise in Women With Stage II+ Breast Cancer
Article
Objective: To systematically evaluate the safety, feasibility and effect of exercise among women with stage II+ breast cancer. Data sources: CINAHL, Cochrane, Ebscohost, MEDLINE, Pubmed, ProQuest Health and Medical Complete, ProQuest Nursing and Allied Health Source, Science Direct and SPORTDiscus were searched for articles published prior to March 1, 2017. Study selection: Randomised, controlled, exercise trials involving at least 50% of women diagnosed with stage II+ breast cancer were included. Data extraction: Risk of bias was assessed and adverse event severity was classified using the Common Terminology Criteria. Feasibility was evaluated by computing median (range) recruitment, withdrawal and adherence rates. Meta-analyses were performed to evaluate exercise safety and effects on health outcomes only. The influence of intervention characteristics (mode, supervision, duration and timing) on exercise outcomes were also explored. Data synthesis: There were no differences in adverse events between exercise and usual care (risk difference: <0.01 [95% CI: -0.01, 0.01]), p=0.38). Median recruitment rate was 56% (1%-96%), withdrawal rate was 10% (0%-41%) and adherence rate was 82% (44%-99%). Safety and feasibility outcomes were similar, irrespective of exercise mode, supervision, duration, or timing. Effects of exercise for quality of life, fitness, fatigue, strength, anxiety, depression, body mass index and waist circumference compared with usual care were significant (standardised mean difference range: 0.17-0.77, p<0.05). Conclusion: The findings support the safety, feasibility and effects of exercise for those with stage II+ breast cancer, suggesting that national and international exercise guidelines appear generalizable to women with local, regional and distant breast cancer.
Lymphatic System Flows
Article
  • Jan 2018
The supply of oxygen and nutrients to tissues is performed by the blood system and involves a net leakage of fluid outward at the capillary level. One of the principal functions of the lymphatic system is to gather this fluid and return it to the blood system to maintain overall fluid balance. Fluid in the interstitial spaces is often at subatmospheric pressure, and the return points into the venous system are at pressures of approximately 20 cmH2O. This adverse pressure difference is overcome by the active pumping of collecting lymphatic vessels, which feature closely spaced one-way valves and contractile muscle cells in their walls. Passive vessel squeezing causes further pumping. The dynamics of lymphatic pumping have been investigated experimentally and mathematically, revealing complex behaviors that indicate that the system performance is robust against minor perturbations in pressure and flow. More serious disruptions can lead to incurable swelling of tissues called lymphedema.
Heavy-Load Lifting: Acute Response in Breast Cancer Survivors at Risk for Lymphedema
Article
Purpose: Despite a paucity of evidence, prevention guidelines typically advise avoidance of heavy lifting in an effort to protect against breast cancer-related lymphedema. This study compared acute responses in arm swelling and related symptoms after low- and heavy-load resistance exercise among women at risk of lymphedema while receiving adjuvant taxane-based chemotherapy. Methods: This is a randomized, cross-over equivalence trial. Women receiving adjuvant taxane-based chemotherapy for breast cancer who had undergone axillary lymph node dissection (n=21) participated in low- (60-65% 1 repetition maximum (RM), two sets of 15-20 repetitions) and heavy-load (85-90% 1RM, three sets of 5-8 repetition) upper-extremity resistance exercise separated by a one-week wash-out period. Swelling was determined by bioimpedance spectroscopy and dual energy x-ray absorptiometry, with breast cancer-related lymphedema symptoms (heaviness, swelling, pain, tightness) reported using a numeric rating scale (0-10). Order of low- versus heavy-load was randomized. All outcomes were assessed pre-, immediately post-, and 24- and 72-hours post-exercise. Generalized estimating equations were used to evaluate changes over time between groups, with equivalence between resistance exercise loads determined using the principle of confidence interval inclusion. Results: The acute response to resistance exercise was equivalent for all outcomes at all time points irrespective of loads lifted, with the exception of extracellular fluid at 72-hours post-exercise with less swelling following heavy-loads (estimated mean difference -1.00, 95% CI -3.17 to 1.17). Conclusion: Low- and heavy-load resistance exercise elicited similar acute responses in arm swelling and breast cancer-related lymphedema symptoms in women at risk for lymphedema receiving adjuvant taxane-based chemotherapy. These represent important preliminary findings, which can be used to inform future prospective evaluation of the long term effects of repeated exposure to heavy-load resistance exercise.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Compression use during an exercise intervention and associated changes in breast cancer-related lymphedema
Article
Aim: This study assessed the association between compression use and changes in lymphedema observed in women with breast cancer-related lymphedema who completed a 12-week exercise intervention. Methods: This work uses data collected from a 12 week exercise trial, whereby women were randomly allocated into either aerobic-based only (n = 21) or resistance-based only (n = 20) exercise. Compression use during the trial was at the participants discretion. Differences in lymphedema (measured by lymphedema index [L-Dex] score and interlimb circumference difference [%]) and associated symptoms between those who wore, and did not wear compression during the 12-week intervention were assessed. We also explored participants' reasons surrounding compression during exercise. Results: No significant interaction effect between time and compression use for lymphedema was observed. There was no difference between groups over time in the number or severity of lymphedema symptoms. Irrespective of compression use, there were trends for reductions in the proportion of women reporting severe symptoms, but lymphedema status did not change. Individual reasons for the use of compression, or lack thereof, varied markedly. Conclusion: Our findings demonstrated an absence of a positive or negative effect from compression use during exercise on lymphedema. Current and previous findings suggest the clinical recommendation that garments must be worn during exercise is questionable, and its application requires an individualized approach.