Exercise and metabolic disease/BCRL/Exercise Training

Thorough assessment and screening for cancer comorbidities and contraindications should be carried out with all cancer patients before an exercise program is started. At a minimum the screening tool developed by Exercise and Sports Science Australia (ESSA) should be used.

Recently, research has been published challenging the myth of the role of exercise, especially vigorous upper limb exercise, in encouraging the onset of BCRL. Traditionally, physical therapists, surgeons and other allied health professionals have avoided prescribing vigorous, repetitive or excessive upper body exercise in breast cancer patients for fear of increasing the risk of developing lymphedema ^[1] However, recent publications have refuted this longstanding belief in concluding that in fact exercise may not enhance the likelihood of developing BCRL nor exacerbate the condition ^{[1] [2] [3] [4] [5] [6] [7]} but instead create positive health benefits in this patient population.

In women with breast cancer, exercise involving combined aerobic and resistive upper extremity activity does not cause a clinically significant difference in arm circumference and arm volume between the ipsi- and contralateral upper limbs. Therefore it does not bring on the onset of lymphedema in this patient cohort nor does it exacerbate the existing condition. ^[1-6] A possible reason for this mode of exercise to instead play a role as a treatment modality in the stimulation of contraction of the lymph vessels in the upper limb and regaining control of the sympathetic drive to these lymph vessels which may induce a long term positive effect on lymphedema.^[5] It is also important to emphasize the generic benefits of exercise in improving self-reported physical functioning, general health and vitality. A good example is women feel more confident in utilising their affect arm in everyday activities of daily living, such as lifting objects.^[5]

Weight training involving slow progressive resistance exercises also shows no significant effect on arm swelling, but in fact results in a decreased incidence of exacerbations of lymphedema with lowered symptoms and improved strength gains.^[7] It appears that long term exercise interventions up to 6 months duration involving progressive resistance training also encourages similar outcomes.^[2] The apparent increases in upper body limb volumes, which are consistent in both arms, is likely accounted for by the significant gains in upper body strength.^[4]

In response to current research on the effects of exercise on BCRL, the out-dated theory regarding its negative effects is bringing forth the re-evaluation of the generic clinical guidelines that survivors of breast cancer should avoid physical activity out of fear augmenting the risk of lymphedema.^[2] Furthermore, prospective research should focus on determining the optimal exercise program to incur the most effective benefits in creating positive rehabilitative and health outcomes in this cohort.^[5]

More information on exercise training for cancer patients can be found on the National Cancer Institutes website, the Australian Association for Exercise and Sport Science has also published a position statement on exercise training for cancer patients.

Contraindications and Precautions to Exercise Training and testing for Patients with Cancer^[8]

The American College of Sports Medicine's (ACSM) guidelines for containdications for patients with cancer are as follows;

Please note that this has been published for patients with cancer not cancer survivors, these guidelines still need to be taken into consideration when training a patients with BCRL.

Factors relating to cancer treatment;

• No exercise on days of intravenous chemotherapy or within 24 hours of treatment
• No exercise before blood draw
• Severe tissue reaction to radiation therapy
• Caution if on treatments that affect the lungs and/or heart: recommend medically supervised exercise testing and training
• Mouth sores/ulcerations: avoid mouthpieces for testing:use face masks

Hematologic;

• Platelets <50,000
• White blood cells <3,000
• Hemoglobin <10g.dL-1

Musculoskeletal;

• Bone, back or neck pain of recent origin - investigate any pain or cramping
• Unusual muscle weakness - osteopenia: avoid high impact exercise if risk of fracture
• Severe cachexia
• Unusual/extreme fatigue - mild to moderate fatigue: closely monitor response to exercise
• Poor functional status

Systemic;

• Acute infections - avoid exercise until asymptomatic for >48hrs
• Febrile illness - fever >38°C
• General malaise

Gastrointestinal;

• Severe nausea - compromised food and/or fluid intake: consult with a nutritionist or dietition
• Vomiting or diarrhea within the last 24-36hrs
• Dehydration
• Poor nutrition

Cardiovascular;

• Chest pain - caution if at risk of cardiac disease - medically supervised exercise testing and training
• Resting HR >100bpm or <50bpm - if on antihypertensive medications that affect HR, THR may not be attainable; avoid overexertion
• Resting SBP >145 mm Hg and/or DBP >95 mm Hg
• Resting SBP <85 mm Hg
• Irregular HR
• Ankle swelling
• Lymphedema: wear compression garments on limb when exercising

Pulmonary;

• Severe dyspnea - mild/moderate dyspnea: avoid max tests
• Cough, wheezing
• Chest pain increased by deep breath

Neurologic;

• Significant decline in cognitive status - if mild cognitive changes: make sure patient is able to understand and follow instructions
• Dizziness/lightheadedness
• Disorientation
• Blurred vision
• Ataxia - poor balance/peripheral sensory neuropathy: use well supported positions for exercise

Benefits of Exercise for BCRL Patients

There are a range of important reasons to consider exercise as a form of therapy for secondary lymphedema due to breast cancer treatment.^[5] These include;

• Improved quality of life ^{[4][5][9][10]}
• Muscular hypertrophy of resistance training including improvements in strength^[4][7][9]
• Prevention of lifestyle diseases^[4]
• Decreased body fat^[4]
• Increased functionality^[4]
• Increased bone mineral density^[1][4]
• Reduction in cardiovascular risk factors^[4]
• Increased physical work capacity of the affected arm - protection from injuries occuring from normal activities of daily living^[7]
• Increased muscular strength decreases the relative effect of normal daily stresses to the upper extremity^[7]
• Increased aerobic fitness^[1][9]
• Improvements in fatigue^[9]
• Social and interpersonal interactions^[10]
• Improvements in soft tissue and joint mobility, which can decrease the impact of tissue fibrosis on lymphatic and venous flow^[11]
• Early introduction of exercise can prevent the deterioration of shoulder joint range of motion in breast cancer patients who experienced lymph node dissection^[3]
• Speeds up recovery from surgery^[3]
• Stimulates the skeletal muscle pump to pump lymphatic and venous fluid and also stimulates the contraction of the lymph vessels, therefore prevents the accumulation of lymphatic fluid and improves lymphatic flow^[5]
• Assists in the recovery of cancer survivors^[10]
• Reduces the decline of palliative patients^[10]

For further information on Exercise benefits see Exercise is Medicine

For further information on using exercise for cancer prevention see Cancer Council Australia PS: Physical Activity and cancer prevention.

References

1. ↑ Harris, S.R. and S.L. Niesen‐Vertommen, Challenging the myth of exercise‐induced lymphedema following breast cancer: A series of case reports. Journal of Surgical Oncology, 2000. 74(2): p. 95-98.
2. ↑ Ahmed, R.L., et al., Randomized controlled trial of weight training and lymphedema in breast cancer survivors. Journal of Clinical Oncology, 2006. 24(18): p. 2765-2772.
3. ↑ Chan, D.N.S., L.Y.Y. Lui, and W.K.W. So, Effectiveness of exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: systematic review. Journal of Advanced Nursing, 2010. 66(9): p. 1902-1914.
4. ↑ Lane, K., D. Jespersen, and D. McKenzie, The effect of a whole body exercise programme and dragon boat training on arm volume and arm circumference in women treated for breast cancer. European journal of cancer care, 2005. 14(4): p. 353-358.
5. ↑ McKenzie, D.C. and A.L. Kalda, Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study. Journal of Clinical Oncology, 2003. 21(3): p. 463.
6. ↑ McNeely, M.L., et al., Effect of acute exercise on upper-limb volume in breast cancer survivors: a pilot study. Physiotherapy Canada, 2009. 61(4): p. 244-251
7. ↑ Schmitz, K.H., et al., Weight Lifting in Women with Breast-Cancer–Related Lymphedema. New England Journal of Medicine, 2009. 361(7): p. 664-673.
8. ↑ Gordon, N. F. (2009). ACSM's guidelines for exercise testing and prescription Lippincott Williams & Wilkins.
9. ↑ Milne, H.M., et al., Effects of a combined aerobic and resistance exercise program in breast cancer survivors: a randomized controlled trial. Breast cancer research and treatment, 2008. 108(2): p. 279-288.
10. ↑ Hayes, S.C., et al., Australian Association for Exercise and Sport Science position stand: optimising cancer outcomes through exercise. Journal of Science and Medicine in Sport, 2009. 12(4): p. 428-434
11. ↑ Brennan, M.J. and L.T. Miller, 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. 83(S12B): p. 2821-2827.