Restriction of the range of arm elevation exercises for one week after surgery for breast cancer can reduce the incidence of lymphoedema

Abstract

Question

: Does restriction of full shoulder mobilisation for one week reduce the incidence and severity of lymphoedema in women after axillary lymph node dissection (ALND) for breast cancer?

Design

: Randomised, controlled trial with concealed allocation and blinded assessment of some outcomes.

Setting

: Two hospitals in the United Kingdom.

Participants

: Adult women with early breast cancer admitted for surgery that included axillary lymph node dissection. Previous breast cancer, axillary surgery and local radiotherapy were exclusion criteria. Randomisation of 116 participants allotted 58 to a standard exercise regimen and 58 to the same regimen with restricted arm and shoulder movement for the first week.

Interventions

: All participants were prescribed four 10-minute exercise sessions per day, in which individual exercises were repeated slowly and rhythmically 3 to 4 times. The exercises included unresisted shoulder and elbow range-of-motion exercises while upright. The early mobilisation group commenced full shoulder mobilisation within two days after surgery. The exercises were modified for the delayed mobilisation group so that the arm was not elevated above horizontal for the first 7 days after surgery. Exercises encouraging full range of shoulder movement were introduced in the second week. The exercises were supervised during the hospital admission and were prescribed to continue for one year at home.

Outcome measures

: The primary outcome was the incidence of lymphoedema, defined as a 200 ml or greater difference in arm volume compared to the unoperated arm. Secondary outcome measures were the severity of lymphoedema again determined by volume, wound drainage volumes, range of shoulder motion, grip strength, and quality of life scores related to shoulder disability and breast cancer therapy.

Results

: 109 participants completed the study. After one year, 16 women in the early mobilisation group but only 6 women in the delayed mobilisation group had developed lymphoedema. Thus one case of lymphoedema was prevented for every 6 women managed with the exercise regimen that delayed shoulder mobilisation (95% CI 3 to 35). Lymphoedema severity and wound drainage were both significantly greater in the early mobilisation group. The groups did not differ significantly on the remaining secondary outcomes.

Conclusion

: The incidence of lymphoedema can be reduced by restricting exercises so that the arm is not elevated above horizontal for one week after ALND.