Weight Lifting in Women with Breast
Cancer-Related Lymphedema
You may have read in the popular press that a new study was recently
published in the New England Journal of Medicine that shows that
weight lifting can prevent or cure lymphedema. Unfortunately, there
were some inaccurate reports from the press. The study of weight
lifting performed by a carefully selected group of women with
lymphedema did not show that the weight lifting cured them, or even
stopped their swelling, but they did report fewer flares. The study
results are in line with the
National Lymphedema Network's long standing guidelines on exercise
for patients with lymphedema.
Any study in the New England Journal that evaluates lymphedema is an
event for celebration, as it indicates that lymphedema is an
important topic worthy of both study and reporting in a prestigious
journal. However, the widespread inaccurate understanding and
reporting of the study results caused consternation among patients,
and has the potential to misinform the patients and healthcare
providers. Careful analysis of the study is essential to understand
both the clinical ramifications of the results and the limitations
of generalizing the results to all women with lymphedema.
The
following is an edited excerpt of an article on weight lifting in
women with lymphedema after breast cancer treatment by Lindsey
Konkel of New York University's Arthur L. Carter Journalism
Institute.
It's long been thought that weight lifting causes painful flare-ups
of lymphedema, which can occur after breast cancer surgery. During
the surgery, lymph nodes, belonging to the immune system, in the
armpit area may be damaged or removed, leading to a build-up of
lymph fluid in the arm that can cause painful swelling and lead to
infection. An estimated 20 to 40 percent of breast cancer survivors
suffer from lymphedema, a cureless condition, after surgery. Lifting
heavy objects (such as lifting weights) has generally been
discouraged among women with lymphedema, due to fears that such
activities may further injure the already damaged tissue. Weight
lifting may not increase the risk of painful flare-ups for some
women suffering from breast-cancer-related lymphedema, according to
the results of a study recently published in the New England Journal
of Medicine. "Our data indicate that careful, controlled weight
lifting can be safe for survivors," said Rehana Ahmed, a
dermatologist at the University of Minnesota Medical School, and one
of the study's authors.
The
study followed 141 breast-cancer survivors with stable lymphedema in
one arm over the course of a year. Half the participants took part
in a twice weekly, supervised strength-training program at a
community fitness center, and half engaged in no weight lifting
exercises. Weight lifting participants performed upper body
exercises such as bench press, bicep curls, and tricep pushdowns,
and lower body exercises like leg press and leg extension.
Resistance was increased after two consecutive sessions at a given
weight, if no lymphedema symptoms arose. Participants wore
well-fitted compression sleeves throughout the exercises. The study
found that women in the weight lifting group showed no significant
difference in limb swelling from women in the non-lifting group.
While 29 percent of women who didn't lift weights saw their
lymphedema symptoms worsen at some point during the study, only 14
percent of those who lifted weights did.
"This published study has stimulated a lot of great discussion in
both the medical and patient communities," says Dr. Mei Fu, an
Assistant Professor at New York University. Fu, who was not involved
in the study, is cautious not to over-generalize the findings of the
study that all women with breast-cancer-related lymphedema could
take up weight lifting with similar results. She points to the large
number of eligible patients, over 3,200, from which the authors
chose their small group of participants.
There were also fewer women with severe lymphedema in the weight
lifting group than in the non-weight-lifting group. Participants
with severe lymphedema are more likely to experience symptoms than
women with mild or moderate lymphedema, regardless of whether they
lifted weights or not, according to Fu.
Women who work intensively with their hands at home or on the job
tend to see more exacerbations of their lymphedema, says Fu, and the
participants were grouped into vague categories-professional,
service or clerical, homemaker, or retired-that did not adequately
differentiate between lifestyles based on limb use.
When
the study was first released in August, some media outlets touted
weight lifting as a way to manage or even cure the disease. It is
not a cure and should not be viewed as a way to manage or prevent
lymphedema. Ahmed emphasizes the importance of wearing a well-fitted
compression garment during exercise, starting slowly and lifting
under the supervision of a physical trainer-preferably one who has
experience working with cancer survivors to prevent injury.
"What we can infer from this study," says Fu, "is that with close
supervision and a well-fitted compression garment, patients who meet
similar criteria as described in the study are safe to perform
weight lifting."
QUESTIONS AND ANSWERS WITH DR. KATHRYN
SCHMITZ, LEAD AUTHOR, OF THE WEIGHT LIFTING AND LYMPHEDEMA STUDY
Dr. Kathryn
Schmitz, PhD. MDH, FACSM, has generously agreed to answer our
questions regarding her recently published article, Weight Lifting
in Women with Breast Cancer-Related Lymphedema
Question 1. From your experience and the outcomes of this
study, what would you say are the parameters for safe weight
lifting for breast cancer patients with lymphedema?
Answer: Prior to starting a weight training program,
breast cancer survivors with lymphedema should be evaluated by a
certified lymphedema specialist and be cleared to proceed. They
should also have a well fitting compression garment prior to
starting. Their lymphedema should not be in 'flare-up' mode
when they start.
Question 2. What are the implications of this study for
those of us whose lymphedema is not stable over a period of
several months? Does your study show that weight training
increases stability for all breast cancer patients with
lymphedema?
Answer: Women with unstable lymphedema should not do
weight training. We did not evaluate stability in our study.
However, of the 3200 women who contacted us about the study,
only 13 were excluded due to unstable lymphedema, and most of
these were because we were at the end of our recruitment window
and we could not wait for them to stablize and enter the next
'wave' of recruitment, as we did with women who showed interest
early in the recruitment window. Therefore, we think that the
number of women out there with unstable lymphedema that could
not EVER do weight training is very low.
Question 3. Did your study include any men with
post-mastectomy lymphedema? Are there any special considerations
for them in making use of the study conclusions?
Answer: No. I cannot comment on how this would go in
men, but I am not aware of any physiologic reasons that would
result in different the outcomes for men than women in this
situation.
Question 4. One of the problems we face as patients is
protecting ourselves in medical situations from professional
misinformation and harmful practices. Many of us worry that our
healthcare providers will similarly misinterpret the results of
this study and assume that all lymphedema risk reduction
practices are without foundation. What exactly would you tell
our surgeons and oncologists about the way this study should
impact their advice to breast cancer patients?
Answer: Having lymph nodes removed increases your risk of
bad outcomes from infection, inflammation, injury, and trauma.
That will always remain true. Lymphedema risk reduction
practices are well founded and should be followed, even among
women with lymphedema who do weight training.
Question 5. Earlier studies indicate that patients with
lymphedema suffer from feelings of shame, distress, and a sense
of abandonment by their medical providers. In this setting, the
affirmation of special one-on-one exercise programs,
availability of trainers and therapists on demand, free
compression garments, individualized instruction relative to
their lymphedema, and follow-up phone calls is bound to have a
powerful influence on their perceptions of their quality of
life. How did your study take this factor into account in
evaluating self-reported patient outcomes?
Answer: The women in the control group got all of the
things you describe EXCEPT for the exercise. That is why we did
this in the setting of a randomized controlled trial, to compare
outcomes in women with versus without the exercise program.
Question 6. It can be difficult for patients to locate
well-qualified lymphedema therapists, and trainers educated in
lymphedema management are even rarer. What qualifications should
patients look for in physical trainers that can offer them the
protection they need to prevent worsening of their lymphedema?
Answer: A personal trainer with a bachelors degree and a
national fitness certification AND who is cautious about
progression of intensity is going to serve survivors well.
Question 7. The study "Background" section cites weight
training as a way of increasing bone density. Was this a factor
measured in both groups, and how did they compare?
Answer: We have not analyzed that data yet, stay tuned!
Question 8. One of the fears many have expressed is that
this study will create a climate, both in the medical field and
the community at large, of regarding strength training as
essential to lymphedema management. How would you answer those
who tell us that?
Answer: I hope that weight training will be offered to
all women with lymphedema as a way of helping them to recover as
much arm function as possible and to increase the physiologic
capacity of the affected arm so that those inevitable activities
of daily living that require more of the arm than usual do not
cause the injury, inflammation, or trauma that are associated
with lymphedema flare-ups. The question is how to broadly
disseminate this program in a setting that maximizes patient
safety, which, based on the tone of your questions, is obviously
a large concern for survivors with lymphedema... and a large
concern for me too!
Question 9. For those lymphedema patients who have
required special considerations in the workplace to limit heavy
lifting, this study would seem to deny their reality. How should
employers understand these study findings in relation to such
employment issues?
Answer: A woman who has lymphedema and who has had
special considerations for lifting should continue to be given
those special considerations unless her employer is able to
provide the time and resources for that woman to participate in
a safe and effective intervention like the PAL intervention ---
and the likelihood of that happening seems pretty slim to me. I
would be distressed to learn that employers were using this
study against women with lymphedema.
Question 10. Some of us will not do well with weight
training, even though we may be neither non-compliant nor
captive to unrealistic fears about exercise. Does your study
identify those for whom weight training is not appropriate?
Answer: I agree! some women will NOT do well. We can
tell you anecdotally that the 2 women who did not do well with
weight training showed signs of problems with their lymphedema
within the first several weeks of training... so I think the
answer is that women who will not do well with weight training
will know right away and should stop. Another key point: women
who were not regularly compliant and showed up 'some of the
time' were more likely to have flare-ups .... weight training
intermittently is likely worse than no weight training.
Question 11. Does this study have any implications for
patients with primary lymphedema, lipedema, or secondary
lymphedema of the lower extremities?
Answer: NO! I am writing a grant at this time to look at
whether we can translate this program for secondary lymphedema
in the lower body.
Kathryn H. Schmitz, PhD, MPH, FACSM
Associate Professor
University of
Pennsylvania School of Medicine Center for Clinical Epidemiology and
Biostatistics Abramson Cancer Center
Dr. Schmitz is
the lead author of the article, Weight Lifiting in Women with
Breast-Cancer-Related Lymphedema, published in the New England
Journal of Medicine, August 13, 2009. Dr. Schmitz has been involved
in research focusing on the role of exercise training in preventing,
treating and rehabilitating long term and late effects of cancer
treatment among cancer survivors.
She generously agreed to answer our questions regarding her recently
published article in the New England Journal of Medicine.
