Abstract
Upper limb impairments are common in women following surgery for breast cancer. Range
of movement (ROM) exercises are commonly prescribed, but the optimal timing to begin
these exercises is not clear. The aim of this systematic review and meta-analysis
was to evaluate the effectiveness of early ROM exercises (Early ROM) compared to delayed
ROM exercises (Delayed ROM) or usual care (UC) in reducing common complications in
women following breast cancer surgery. Cochrane Central Register of Controlled Trials,
Pubmed, EMBASE, CINAHL, and PEDro were searched from date of inception until the 15th
of February 2021, to identify randomized controlled trials which compared Early ROM
to either Delayed ROM or UC in women following surgery for breast cancer. Outcomes
included shoulder range, wound outcomes and lymphedema incidence. Risk of bias was
evaluated with the PEDro scale. Data analysis was conducted in R (version 3.6.0),
with a priori sensitivity analyses conducted for studies with low risk of bias and
published after the year 2000. Of the 703 articles retrieved, 20 trials (2442 participants)
were eligible for inclusion. There were few differences between groups in ROM, except
for flexion ROM when more recent evidence was considered. Total drainage time and
hematoma incidence were significantly higher in the Early ROM group compared to Delayed
ROM (WMD 1·2 days [95%CI 0·7,1·7], and RR 1·6 [95%CI 1·1,2·3], respectively). When
considering more recent evidence, there were no differences between groups for these
outcomes. There were no differences between groups in other wound outcomes. Lymphedema
incidence was higher in the Early ROM group compared to Delayed ROM in the short-term
only (RR 3·7 [95% CI 1·3;10·9]), and there was no difference when compared to UC.
The quality of evidence using the GRADE approach was generally low to very low. This
review found that when considering more contemporary evidence, the timing of exercise
may influence ROM, but not wound outcomes. Further research is recommended to understand
the effect on lymphedema incidence. No funding was sought for this review. A protocol
for this systematic review was posted on the Open Science Framework prior to commencement
(DOI: 10.17605/OSF.IO/Q5FHS).
Keywords
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References
- Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.CA Cancer J Clin. 2021; 71: 209-249https://doi.org/10.3322/caac.21660
AIHW. Cancer in Australia 2019. Canberra; 2019.
- New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient.G Chir. 2015; 36: 145-152https://doi.org/10.11138/gchir/2015.36.4.145
- Sentinel lymph node biopsy in breast cancer: a clinical review and update.J Breast Cancer. 2017; 20: 217-227https://doi.org/10.4048/jbc.2017.20.3.217
- Surgical management of the breast. Breast conservation and mastectomy.Surg Clin North Am. 2013; 93: 411-428https://doi.org/10.1016/j.suc.2012.12.006
- Prevalence of breast cancer treatment sequelae over 6 years of follow-up.Cancer. 2012; 118: 2217-2225https://doi.org/10.1002/cncr.27474
- Long-term follow-up on shoulder and arm morbidity in patients treated for early breast cancer.Acta Oncologica (Stockholm, Sweden). 2020; 59: 851-858https://doi.org/10.1080/0284186X.2020.1745269
- Shoulder and arm morbidity in sentinel node-negative breast cancer patients: a systematic review.Breast Cancer Res Treatment. 2014; 144: 21-31https://doi.org/10.1007/s10549-014-2846-5
- Exercise interventions for upper-limb dysfunction due to breast cancer treatment.Cochrane Database Syst Rev. 2010; https://doi.org/10.1002/14651858.CD005211.pub2
- Breast Cancer Surgical Management in Queensland Public and Private Hospitals.2017 ([internet] [cited 22/05/2019]. Available from:)
- Effectiveness of exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: systematic review.J Adv Nurs. 2010; 66: 1902-1914https://doi.org/10.1111/j.1365-2648.2010.05374.x
- Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy.Cochrane Database Syst Rev. 2015; Cd009765https://doi.org/10.1002/14651858.CD009765.pub2
- Effectiveness of early rehabilitation on range of motion, muscle strength and arm function after breast cancer surgery: a systematic review of randomized controlled trials.Clin Rehab. 2019; 33: 1876-1886https://doi.org/10.1177/0269215519873026
- Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review.Arch Phys Med Rehabil. 2015; 96: 1140-1153https://doi.org/10.1016/j.apmr.2015.01.006
- Efficacy of physical therapy methods and exercise after a breast cancer operation: a systematic review.Crit Rev Phys Rehab Med. 2001; 13https://doi.org/10.1615/CritRevPhysRehabilMed.v13.i2-3.40
- Methods to improve rehabilitation of patients following breast cancer surgery: a review of systematic reviews.Breast Cancer (Dove Medical Press). 2015; 7: 81-98https://doi.org/10.2147/bctt.S47012
- The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a randomized controlled study.BMC Cancer. 2007; 7: 166https://doi.org/10.1186/1471-2407-7-166
- Shoulder amplitude movement does not influence postoperative wound complications after breast cancer surgery: a randomized clinical trial.Breast Cancer Res Treatment. 2020; 184: 97-105https://doi.org/10.1007/s10549-020-05826-9
- Strengths of early physical rehabilitation programs in surgical breast cancer patients: results of a randomized controlled study.Eur J Phys Rehab Med. 2014; 50: 275-284
- The effectiveness of a clinical and home-based physical activity program and simple lymphatic drainage in the prevention of breast cancer-related lymphedema: a prospective randomized controlled study.Eur J Oncol Nurs. 2017; 31: 12-21https://doi.org/10.1016/j.ejon.2017.09.004
- Long term effects of manual lymphatic drainage and active exercises on physical morbidities, lymphoscintigraphy parameters and lymphedema formation in patients operated due to breast cancer: a clinical trial.PLoS one. 2018; 13e0189176https://doi.org/10.1371/journal.pone.0189176
- Effects of progressive upper limb exercises and muscle relaxation training on upper limb function and health-related quality of life following surgery in women with breast cancer: a Clinical Randomized Controlled Trial.Ann Surg Oncol. 2019; 26: 2156-2165https://doi.org/10.1245/s10434-019-07305-y
- Randomised controlled trial of exercise to prevent shoulder problems in women undergoing breast cancer treatment: study protocol for the prevention of shoulder problems trial (UK PROSPER).BMJ Open. 2018; 8e019078https://doi.org/10.1136/bmjopen-2017-019078
- Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up.Acta Oncologica (Stockholm, Sweden). 2009; 48: 1102-1110https://doi.org/10.3109/02841860903061683
- Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.Syst Rev. 2015; 4: 1https://doi.org/10.1186/2046-4053-4-1
Redemski T. Rehabilitation for women undergoing breast cancer surgery: a systematic review evaluating the effectiveness and safety of early, unrestricted exercise programs on upper limb function. 2020. DOI: 10.17605/OSF.IO/Q5FHS.
- The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ. 2021; 372https://doi.org/10.1136/bmj.n71
- Improving the translation of search strategies using the Polyglot Search Translator: a randomised controlled trial.J Med Libr Assoc. 2020; 108: 195-207https://doi.org/10.5195/jmla.2020.834
- World Health Organisation International Clinical Trials Registry Platform.2020 ([cited 07/07/2020] Available from:)
- Clarivate Analytics.2018
- Reliability of the PEDro scale for rating quality of randomized controlled trials.Phys Ther. 2003; 83: 713-721https://doi.org/10.1093/ptj/83.8.713
- Agreement betweenthe Cochrane risk of bias tool and Physiotherapy Evidence Database (PEDro) scale: a meta-epidemiological study of randomized controlled trials of physical therapy interventions.PLoS One. 2019; 19https://doi.org/10.1371/journal.pone.0222770
- Rating quality of evidence and strength of recommendations: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336https://doi.org/10.1136/bmj.39489.470347.AD
- McMaster.University & Evidence Prime Inc., 2020
- Therapeutic effects of aerobic and resistance exercises for cancer survivors: a systematic review of meta-analyses of clinical trials.Br J Sports Med. 2018; 52: 1311https://doi.org/10.1136/bjsports-2017-098285
- The Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis is straightforward and considerably outperfoms the standard DerSimonian-Laird method.BMC Med Res Methodol. 2014; 14https://doi.org/10.1186/1471-2288-14-25
- A simple method to estimate preduiction intervals and predictive distributes: summarizing meta-analyses beyond means and confidence intervals.Res Synth Methods. 2019; 10: 255-266https://doi.org/10.1002/jrsm.1345
- How to perform a meta-analysis with R: a practical tutorial.Evidence-Based Mental Health. 2019; 22: 153-160
- Clinimetrics: physiotherapy evidence database (PEDro) scale.J Physiother. 2020; 66: 59https://doi.org/10.1016/j.jphys.2019.08.005
- Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy.Breast Cancer Res Treatment. 2002; 75: 35-50https://doi.org/10.1023/a:1016571204924
- Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema.Breast Cancer Res Treatment. 2002; 75: 51-64https://doi.org/10.1023/a:1016591121762
Effectiveness of an early healthcare program and post-operative management of the upper limb in women with breast cancer. 2018 [cited 08/07/2020]. Available from: https://anzctr.org.au/ACTRN12618000719235.aspx.
The multicenter, randomized control trial of outpatient rehabilitation after breast cancer surgery 2020 [cited 07/07/2020]. Available from: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000044380.
- Postoperative pain after breast cancer surgery: the UK Prevention of Shoulder Problems Trial (UK PROSPER).Psychosomatic Med. 2019; 81: A209-AA10https://doi.org/10.1097/PSY.0000000000000699
- The effectiveness of early rehabilitation in patients with modified radical mastectomy.Cancer Nursing. 2008; 31: 160-165https://doi.org/10.1097/01.NCC.0000305696.12873.0e
- Effectiveness of a self-administered, home-based exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection: a preliminary study.Breast Cancer Res Treatment. 2008; 109: 285-295https://doi.org/10.1007/s10549-007-9649-x
- Implications of a postoperative rehabilitation program on quality of life in women with primary breast cancer treated with sentinel lymph node biopsy or complete axillary lymph node dissection.Ann Surg Oncol. 2008; 15: 3342-3349https://doi.org/10.1245/s10434-008-0161-2
- A randomised controlled trial of two programmes of shoulder exercise following axillary node dissection for invasive breast cancer.Physiotherapy. 2008; 94: 265-273https://doi.org/10.1016/j.physio.2008.09.005
- Influence of full functional exercises on affected side of upper limb edema in patients after radical mastectomy.Chin Nursing Res. 2015; 29: 436-439https://doi.org/10.3969/j.issn.1009-6493.2015.04.016
- Shoulder movement after surgery for invasive breast carcinoma: randomized controlled study of postoperative exercises.RBJO. 2004; 26: 125-130
- A randomized controlled trial on the prevention of seroma after partial or total mastectomy and axillary lymph node dissection.Breast Cancer (Tokyo, Japan). 1998; 5: 67-69https://doi.org/10.1007/bf02967417
- Effect of shoulder immobilization on wound seroma and shoulder dysfunction following modified radical mastectomy: a randomized prospective clinical trial.Br J Surg. 1989; 76: 311-312https://doi.org/10.1002/bjs.1800760329
- Wound drainage following radical mastectomy: the effect of restriction of shoulder movement.Br J Surg. 1979; 66: 302-305https://doi.org/10.1002/bjs.1800660503
- Immediate versus delayed shoulder exercises after axillary lymph node dissection.Am J Surg. 1990; 160: 481-484https://doi.org/10.1016/s0002-9610(05)81008-6
- Axillary lymphadenectomy. A prospective, randomized trial of 13 factors influencing drainage, including early or delayed arm mobilization.Arch Surg. 1990; 125: 378-382https://doi.org/10.1001/archsurg.1990.01410150100018
- Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: a prospective randomized study.Ann Surg Oncol. 1997; 4: 293-297https://doi.org/10.1007/bf02303577
- Shoulder function following early mobilization of the shoulder after mastectomy and axillary dissection.Netherlands J Surg. 1985; 37: 105-108
- Influence of the timing of physiotherapy upon the lymphatic complications of axillary dissection for breast cancer.Int Surg. 1987; 72: 166-169
- Prevention of seromas in mastectomy wounds.Arch Surg. 1995; 130: 99-101https://doi.org/10.1001/archsurg.1995.01430010101021
- Efficacy of massage and mobilization of the upper limb after surgical treatment of breast cancer.Bulletin du Cancer. 1997; 84: 957-961
- Rehabilitation of the mastectomy patient: a randomized, blind, prospective study.Arch Phys Med Rehab. 1989; 70: 21-24
- A randomised controlled trial of two programs of shoulder exercise following axillary node dissection for invasive breast cancer.Physiotherapy. 2008; 94: 265-272https://doi.org/10.1016/j.physio.2008.09.005
- Upper limb physical function and adverse effects after breast cancer surgery: a prospective 2.5-year follow-up study and preoperative measures.Arch Phys Med Rehab. 2014; 95: 875-881https://doi.org/10.1016/j.apmr.2013.12.015
- What is clinically important in lymphoedema management? A systematic review.Rehab Oncol. 2018; 36: 13-27https://doi.org/10.1097/01.REO.0000000000000093
- Validated outcome in the grafting of autologous fat to the rbeast: the VOGUE study. Development of a core outcome set for research and audit.Plastic Reconstruct Surg. 2018; 141: 633ehttps://doi.org/10.1097/PRS.0000000000004273
- Outcomes and outcome measures reported in clinical studies of therapeutic mammaplasty: a systematic review protocol.BMJ Open. 2021; 11e046438https://doi.org/10.1136/bmjopen-2020-046438
- Axillary node clearance: who wants to immobilize the shoulder?.Eur J Surg Oncol. 1996; 22: 569-570https://doi.org/10.1016/s0748-7983(96)92164-2
- Is Xbox 360 Kinect-based virtual reality training as effective as standard physiotherapy in patients undergoing breast cancer surgery?.Supp Care Cancer. 2020; 28: 4295-4303https://doi.org/10.1007/s00520-019-05287-x
- Treatment related impairments in arm and shoulder in patients with breast cancer: a systematic review.PLoS One. 2014; 9: e96748https://doi.org/10.1371/journal.pone.0096748
- Prevention of seroma formation after axillary dissection in breast cancer: a systematic review.Eur J Surg Oncol. 2011; 37https://doi.org/10.1016/j.ejso.2011.04.012
- 15 years of tracking physiotherapy evidence on PEDro, where are we now?.Br J Sports Med. 2015; 49https://doi.org/10.1136/bjsports-2014-094468
- The COMET (Core Outcome Measures in Effectiveness Trials) initiative: its role in improving Cochrane Reviews.Cochrane Database Syst Rev. 2012; https://doi.org/10.1002/14651858.ED000041
Zhang H. A core outcome set for clinical trials of breast cancer related lymphedema (BCRL) 2020 [cited 07/12/2020]. Available from: https://www.comet-initiative.org/Studies/Details/1383.
- A prospective surveillance model for rehabilitation for women with breast cancer.Cancer. 2012; 118: 2191-2200https://doi.org/10.1002/cncr.27476
Article Info
Publication History
Published online: June 23, 2022
Accepted:
June 17,
2022
Received:
January 10,
2022
Identification
Copyright
Crown Copyright © 2022 Published by Elsevier Inc. All rights reserved.
