1. Fuerst, Mark L.

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ORLANDO, FL-Guided exercise with a physical therapist after lymph node dissection helps women with breast cancer to quickly regain range of motion in their arms, according to a new study.

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When lymph nodes are removed or damaged during surgery, fluid can build up in tissues and cause lymphedema, which can impair arm movement. Loss of range of motion can occur soon after surgery and last for many months and is often disabling. Lymph node dissection, axillary or sentinel, often results in restrictions of arm movement, including range of motion, and these restrictions can be temporary or permanent, said lead author Electra D. Paskett, PhD, Professor of Cancer Research at Ohio State University and Associate Director for Population Sciences at the Comprehensive Cancer Center in Columbus, at a presscast ahead of the 2018 Cancer Survivorship Symposium (Abstract 123).


"We hope this study brings awareness to the need to follow up with women who have had lymph node surgery and experience range of arm motion problems as a result," said Paskett. "Exercise certainly helped most women quickly get back their full range of arm motion, but because most health insurance plans do not cover this type of intervention, there has been little effort to try to find remedies that are effective."


Clinical Trial Specifics

Paskett and colleagues conducted a phase III, randomized clinical trial, the Lymphedema Education and Prevention study, to determine whether a lymphedema prevention program would also impact range of motion in both the affected arm as well as the unaffected arm. They looked at whether education, with or without tailored exercise, including a visit to a physical therapist, could help prevent lymphedema in women with breast cancer who have axillary lymph node dissection.


"Most women who have had lymph node dissection get an instruction sheet on exercise after they are discharged from surgery, but little else," said Paskett. "As a breast cancer survivor myself who experienced swelling after surgery, I thought it was important to try to determine if women were receiving adequate follow-up to deal with certain health issues including the loss of the range of motion in their arms."


The researchers randomly assigned 568 women from 41 participating sites to either an "education only" group (253 women) who received information about lymphedema signs and symptoms and risk-reduction strategies or an education plus exercise group (315 women) who received education plus arm stretching and breathing exercises and a visit with a physical therapist. The education plus exercise group had a session with a lymphedema specialist, usually a physical therapist, which included lymph flow, strengthening, and breathing exercises; elastic compression sleeve and gauntlet; hand weights; and a take-home video showing exercises, as well as reinforcing educational materials.


The women received surveys to fill out before their surgery, after surgery, at 1 year after their surgery, and at 18 months after their surgery to assess their arm range of motion at five levels-from very little to full range. The researchers examined range of motion in the affected arm, adjusting for baseline BMI, surgery type (full mastectomy vs. partial mastectomy/lumpectomy/ excisional biopsy), type of lymph node dissection, affected arm being dominant arm, and receipt of radiation therapy and/or chemotherapy.


Before surgery, fewer women in the education plus exercise group than in the education-only group reported full range of arm motion (left arm: 58% vs. 75%; right arm: 57% vs. 76%). While range of motion generally improved over time in both groups, women in the exercise group reported faster improvement.


One year after surgery, more women in the exercise group had full range of arm motion (91% left arm, 90% right arm) as compared to the education-only group (84% and 83%, respectively). At 18 months after surgery, 93 percent of women in both groups reported having regained full range of motion in both arms.


A secondary analysis from the study explored how much range of motion improved in the affected arm where the surgery was performed. The researchers found a 32 percent improvement in range of motion at 12 months in the exercise group compared to a 6 percent improvement in the education-only group and a 37 percent improvement in the exercise group at 18 months as compared to a 13 percent improvement in the education-only group.


Paskett concluded that "all women receiving lymph node dissection should receive physical therapy to regain range of motion quickly after surgery and help maintain physical functioning."


The researchers plan to study how variations in surgical techniques could lower the incidence or duration of lymphedema. They will also analyze their data on range of motion to see if body mass plays a role in speed of recovery after lymph node dissection.


ASCO Expert Timothy Gilligan, MD, Associate Professor of Medicine at the Cleveland Clinic Taussig Cancer Institute, commented: "Knowing that exercise after surgery can help women with breast cancer quickly restore their full range of arm motion is an important step forward in their care. This study shows how important it is for women to receive physical therapy after surgery to remove lymphatic tissue."


Mark L. Fuerst is a contributing writer.