18783

Study Purpose

To determine if water exercise was more effective than land exercise and the current standard of care to reduce limb volume, body mass index (BMI), and perceptions of swelling in female cancer survivors with secondary lymphedema

Intervention Characteristics/Basic Study Process

The water exercise group participated in water training once a week in 25-meter indoor pool that was 140 cm deep. The water temperature was 28–2°C, and exercises were led by a physiotherapist. The 50-minute program included a warm-up exercise (10 minutes), mobility/stretch exercises (10 minutes), movements to increase heart rate (10 minutes), strength training (10 minutes), and slow-down mobility exercises (10 minutes). All participants wore compression sleeves/hosiery.

The land exercise group participated in gymnastics once a week. The leader adjusted training if women could not jump, who instead did exercise closer to floor. The 50-minute program included a warm-up exercise (10 minutes), mobility/stretch exercises (10 minutes), movements to increase heart rate (10 minutes), strength training (10 minutes), and slow-down mobility exercises (10 minutes). All participants wore compression sleeves/hosiery.

The standard care program group performed self-care/skin care, mobility exercises for their arm or leg, and placed their swollen limb above heart level. Participants self-massaged their arm/leg, wore compression sleeves/hosiery, and performed occasional manual lymphatic drainage (MLD).

Sample Characteristics

N = 88
AGE = 58–63 years (SD = 11)
FEMALES: 100%
KEY DISEASE CHARACTERISTICS: Breast cancer survivors with secondary arm lymphedema (n = 69), of which 99% underwent surgical nodal dissections during breast cancer surgery (sentinel lymph node biopsy [46%]) and 93% underwent external beam radiation; gynecologic cancer survivors with secondary leg lymphedema (n = 14), of which 60% underwent lymph node dissection with surgery and 100% underwent external beam radiation
OTHER KEY SAMPLE CHARACTERISTICS: Self-reported level of physical activity (walking, jogging, strength training, bicycling) and height and weight for calculation of BMI were provided by all participants prior to intervention. Participants reported comorbidities (specifically hypertension, cardiovascular), frequency of MLD prior to intervention, and self-report of relevant medications (diuretics, anti-hypertensives, anticoagulates)

Setting

SITE: Multi-site
SETTING TYPE: Multiple settings
LOCATION: Two hospitals and one primary healthcare unit in the middle, east, and north of Sweden

Phase of Care and Clinical Applications

PHASE OF CARE: Late effects and survivorship

Study Design

Non-randomized, controlled, clinical intervention study conducted at three different sites comparing water exercise, land exercise, and standard of care

Measurement Instruments/Methods

Limb volume = water displacement or circumference with tape measurement
Range of motion = goniometry
Disability of Arm, Shoulder, and Hand (DASH) questionnaire
Hip Osteoarthritis Outcome Score (HOOS) questionnaire
Demographic, clinical, and health data = study-specific questionnaire
General well-being = visual digital scale ranged from 1–7
Body-image = seven questions from validated body awareness verbal Likert-type scale
Study-specific lymphedema questionnaire (108 questions)
Self-report of height and weight were used for the calculation of BMI.

Results

A higher proportion of participants in the water exercise group compared to land the exercise group experienced reduced arm volume (p = 0.029); however, no statistically significant difference in the size of reduction existed between exercise groups after the intervention (p = 0.185). Women with arm lymphedema in the water exercise group experienced reduced arm volume after intervention (p = 0.046), which was not seen in the other groups. For leg lymphedema, no difference in volume following the intervention existed. Only the water exercise group reported a lower frequency of limb swelling after the intervention (p = 0.031). A significant decrease in BMI (p = 0.047) was observed in the water exercise group but not in the other groups after the intervention. After the intervention, participants with arm lymphedema in the land exercise group had improved DASH scores (p = 0.049) and external rotation of shoulder (p = 0.012), with no changes in other groups after the intervention from baseline. The groups with leg lymphedema had no improvement in HOOS scores or joint movement. Well-being was high at baseline for all three groups and remained without any statistically significant differences during the study period.

Conclusions

Physical exercise does not worsen lymphedema and, based on the results from this study, female cancer survivors with secondary arm lymphedema experience decreased volume, BMI, and self-reported frequency of swelling after water exercise compared to land exercise. Conclusions about the value of land or water exercise as an intervention for female cancer survivors with secondary leg lymphedema cannot be drawn from this study because of the small number of subjects in that group.

Limitations

Small sample (< 100)
Risk of bias (no blinding)
Risk of bias (no random assignment)
Risk of bias (sample characteristics)
Measurement validity/reliability questionable
Findings not generalizable
Subject withdrawals ≥ 10%
Water exercises were performed in colder water (less than 29°C); warmer water often increases mobility, and physiotherapy for lymphedema is performed in warmer water (33–34°C).
The study included only one follow-up at end of intervention.
Limb volume was measured either with circumference or water displacement based on the facility/intervention group.
The number of leg lymphedema survivors was too small to draw conclusions.
Unclear if HOOS was previously used in same type of study
Assignment to intervention group was based on city.
Women were asked if they wanted to participate (self-selection bias).
Pre-study criteria for compliance rate/participation of at least seven times served as a confounding factor.
BMI was based on self-report of height and weight.
The number of dropped participants in the text does not mention the standard group of four participants who were lost to follow-up.
Almost full adherence to wearing compression
Unclear when post-intervention measures were taken
Unclear on the use of compression and if some used compression who normally did not
The resultant reduction in limb volume may be related to the introduction of a compression garment rather than the exercise program.

Nursing Implications

Water exercise can be beneficial to female cancer survivors with secondary arm lymphedema. Further interdisciplinary research is needed to design studies that will lead to the development of guidelines/protocols specific to exercise for cancer survivors with secondary arm and leg lymphedema.