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Cochrane systematic review
Early postoperative exercise improves shoulder range of motion in women with breast cancer compared with delayed exercise, but increases wound drainage volume and duration
  1. Sharon Kilbreath
  1. Faculty of Health Sciences, University of Sydney, Sydney, Australia
  1. Correspondence to Sharon Kilbreath
    C42 - Cumberland Campus, The University of Sydney Lidcombe, NSW 2141, Australia; sharon.kilbreath{at}sydney.edu.au

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Upper limb impairments are commonly reported following surgery for breast cancer, particularly surgery that involves the axilla. Common impairments include shoulder stiffness and reduced range of movement, upper limb discomfort and pain, and for some, swelling. These impairments can have an impact on the quality of life. McNeely and colleagues have undertaken a rigorous systematic review to determine the benefits of exercise in addressing shoulder mobility, pain and prevention of lymphoedema without causing seromas or increased wound drainage. Following a protracted search, the authors identified 24 studies that met their inclusion criteria, of which 10 were of sound methodological quality. Exercise-based interventions were conducted around the time of surgery as well as during and following the medical treatments.

Encouragingly, the review concluded that exercise is beneficial with no serious harm. Postoperative stretches appear to lead to better range of motion at the glenohumeral joint. However, if overhead stretches are commenced prior to removal of the drain, more wound drainage may occur. Resistance training will lead to improvement in strength of the upper limb muscles. Stretches around the time of surgery, and other exercises undertaken at a later date during adjuvant therapies and after the cancer treatment did not result in lymphoedema. The vigour with which the exercises were performed postoperatively, particularly in the postoperative phase, was often not well described.

For nurses and other health professionals, this review does provide clear evidence that upper limb stretches and active movement overhead can be undertaken by women treated for breast cancer, and particularly those at high risk of upper limb problems (ie, women who have undergone axillary node dissection). The studies on which this review was based span over two decades. However, in that time, surgery and radiotherapy for breast cancer have undergone significant changes. Importantly, the introduction of sentinel node biopsy has reduced the impact of surgery on upper limb function, enabling women to return to their normal activities sooner with less impairment than following an axillary node dissection.1 It would be of interest to partition out the effect of treatments on women who had undergone sentinel node biopsy versus axillary node dissection. Is it only women with axillary node dissection who would require a structured intervention?

The role of resistance training has not been explored in well-designed exercise trials for women who are in the early postoperative phase. Thus, the conclusion that there was no evidence that upper limb exercise carried out following surgery resulted in more patients developing arm lymphoedema needs to be considered with caution. As progressive resistance training and any other vigorous exercise have not been reported for women postoperatively, it is unknown whether this form of resistance training does lead to increased lymphoedema if introduced in this acute period. Further research is required to address this issue.

One question that arises from this review is whether the focus on the glenohumeral joint and muscles about this joint actually addressed, in full, the upper limb symptoms that women experience. It is from the questionnaires and interviews that we determine to what extent living with chronic upper limb impairments has an effect on the women. Of the 38 analyses undertaken, most of the analyses were based on physical measures which may or may not reflect women's perception of the impairment. Previous studies have shown that women often perceive the severity of the impairment to be greater than what the physical measure of the same impairment would indicate.2 What this systematic review has illuminated is the reliance on physical measurement of impairments rather than on self-report of the same symptoms as outcome measures. Perhaps attention also needs to be on what are the self-reported impairments women that experience at different time points.

The last issue to touch upon is the report of the interventions. Historically, resistance training is well described with clear indication of what was done; less clear are the descriptions of the interventions for stretching and other treatments. Notably, physiotherapy is not a treatment but a profession. This issue has been raised previously by Shamley and colleagues.3 To ascertain what is the most effective treatment, the interventions including stretching protocols need to be fully described.

In conclusion, this review was well conducted and provides evidence for the use of exercise to address upper limb impairments. It does, however, raise other issues that require further research.

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  • Competing interests None.

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