One of the most common and most troublesome consequences of breast cancer treatment is lymphedema — fluid accumulation and tissue swelling from damage to the lymph drainage system. The condition often develops after lymph node biopsy and radiation therapy affecting the armpit. Symptoms include swelling, discomfort, and a heightened susceptibility to infection in the associated arm. Breast cancer survivors have long been advised to go easy on the arm, and in particular, to avoid heavy lifting and resistance-training exercise. As a result, women with lymphedema often favor the opposite arm, or forgo upper-body exercise, and the arm becomes progressively weaker.
Now a study published in The New England Journal of Medicine (Aug. 13, 2009) has turned conventional wisdom on its head. The report, which is based on the largest clinical trial of its kind, indicates that graduated weight training doesn't exacerbate and can even ease the symptoms of lymphedema. The randomized Physical Activity and Lymphedema (PAL) trial, led by researchers at the University of Pennsylvania, builds on evidence from earlier reports suggesting that progressive resistance training does not induce or worsen lymphedema in breast cancer survivors.
What the PAL workout involved
The 90-minute workout sessions were divided into five parts: a warm-up (at least 10 minutes on a stationary bike, treadmill, rower, stair stepper, or elliptical machine); stretching (several minutes of stretches, each performed for 15 seconds to each side); strength training for the upper body and legs, with resistance provided by dumbbells and resistance machines; core exercises to strengthen abdominal and lower back muscles; and more stretching, holding each position for at least 30 seconds on each side (twice as long as the first set of stretches).
During the first supervised workout session, the women performed two resistance exercises (the dumbbell bench press and the leg press). They could progress to as many as nine resistance exercises by the fourth session, including the seated row on a resistance machine and front or side raises using dumbbells (see the example, below). For each resistance exercise, subjects started with two sets of 10 repetitions at the lowest possible weight or resistance level, and moved on gradually to further repetitions and heavier weights. If their lymphedema symptoms became worse, they discontinued upper-body exercises but kept up the rest of the routine. They resumed weight and resistance training only when a lymphedema therapist decided they were ready, and then resistance was set at the starting levels.
In the side raise for the shoulders, subjects press their backs against the wall while lifting the weights until core muscles are strong enough to hold the spine steady.
Researchers enrolled 141 breast cancer survivors who had undergone lymph-node removal at least one year before and had since developed lymphedema. At the beginning of the study and at 12 months, they measured the size of the women's arms and tested their arm and leg strength. A lymphedema therapist evaluated the tone, texture, and quality of the women's arm tissue. Participants answered questions about lymphedema-related symptoms, including swelling, pitting, leathery skin, pain, and difficulty writing.
The women were divided into two groups matched for age, strength, and symptom severity. Half were randomly assigned to receive progressive weight training; the other half (the control group) were asked not to change their exercise level for a year. Subjects were fitted with customized compression sleeves to wear during exercise.
The women in the weight-training group worked out in supervised sessions at a fitness center for 90 minutes twice a week. Each session included stretching and a cardiovascular warm-up in addition to weight training (see "What the PAL workout involved"). Upper-body exercise included lifting hand weights and pulling handles on a resistance machine. The women followed this supervised protocol for the first 13 weeks of the yearlong study. For the remaining 39 weeks, they continued the exercise regimen on their own.