Active Voice: Do Breast Cancer Survivors at Risk for Lymphedema Need to Avoid Heavy Lifting?

By Kira Bloomquist, M.H.S., P.T., and Sandra C. Hayes, Ph.D.

Kira Bloomquist, M.H.S., P.T. Sandra C. Hayes, Ph.D.
Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM.

A physical therapist, Kira Bloomquist, M.H.S., P.T., has been working in the cancer rehabilitation setting since 2003. Her current affiliation is with the Body and Cancer Program at the University Hospitals Center for Health Research (UCSF), Rigshospitalet in Copenhagen, Denmark. She currently is working on her Ph.D., focusing on heavy-load resistance exercise in breast cancer survivors at risk for lymphedema. Her dissertation research involves both UCSF and the Department of Public Health at the University of Copenhagen.

Sandra C. Hayes, Ph.D., is an exercise physiologist, principal research fellow and co-leader of a cancer survivorship research program (ihop) within the Institute of Health and Biomedical Innovation, Queensland University of Technology, Australia. Her program of research draws on experiences and training in exercise science, epidemiology and public health. She focuses her attention on understanding the physical and psychosocial concerns faced by cancer patients confronted with lymphedema, and ways in which exercise may enhance cancer recovery.

The broader exercise science literature indicates that a dose-response relationship exists between loads lifted and gains in muscular strength. Progressively higher loads, over time, contribute to greater gains (for further details on scientific bases and applications, see the related 2009 ACSM Position Stand). This physiological adaptation is particularly relevant for women with breast cancer, as losses in strength and function represent a common adverse effect of treatment. Historically, as a means of preventing lymphedema (a physically and psychosocially debilitating condition affecting at least 20 percent of breast cancer survivors), breast cancer survivors were advised to avoid participation in a range of activities, including any activity that required repetitive use of the treated arm and/or lifting any object that weighed more than a carton of milk. In 1996, Canadian exercise professional and researcher, Donald McKenzie, M.D., Ph.D., in collaboration with Susan Harris, P.T., Ph.D., FCAHS, evaluated lymphedema outcomes of a team of dragon boaters (who were also breast cancer survivors). Their findings challenged the clinical advice that physical activities involving the upper limbs should be avoided. Subsequently, a new era in lymphedema and breast cancer survivorship research was born. Two decades on, we now have a body of evidence that has consistently demonstrated that participation in regular, progressive aerobic- and/or resistance-based exercise does not increase the risk of developing lymphedema. However, breast cancer survivors considered at risk for lymphedema continue to be encouraged to avoid heavy-lifting. Thus, uncertainty remains regarding the safe upper-limits of resistance exercise loading for these women and men.

In our randomized cross-over study, as published in the February 2018 issue of MSSE, we evaluated acute responses in arm swelling and related lymphedema symptoms after a bout of low- and heavy-load resistance exercise in women with axillary node dissection and who were receiving adjuvant taxane-based chemotherapy. These 21 women were specifically chosen because the type and severity of their surgical and adjuvant treatment for breast cancer placed them at high risk for developing lymphedema. Our findings showed that the acute lymphatic response was similar, irrespective of whether low- or heavy-load resistance exercise was undertaken, and which measurement method was applied (bio-impedance spectroscopy, dual-energy x-ray absorptiometry, symptom rating). Further, there was no evidence to suggest that participation in heavy-load lifting need be avoided. These findings provide the necessary platform for future work to explore the longer-term lymphatic response to regular heavy-load resistance exercise. We already have one study under way to examine this issue.

However, even while we wait to quantify the long-term effects, findings from the study discussed above are also important. Current lymphedema prevention guidelines continue to advise “avoidance” of participating in certain activities, including one-off bouts of activities that would represent heavy-load lifting (e.g., lifting a child or carrying groceries from the car to the kitchen). Lymphedema is considered the most feared breast cancer treatment complication. Therefore, it is not surprising that this fear, along with uncertainty around what constitutes heavy-loads, would lead to disuse of the treated arm. Yet, disuse or sedentary lifestyles have been associated with increased risk of developing lymphedema. While preliminary, our findings suggest that participating in one-off bouts of heavy-load activities, at least from the perspective of the lymphatic system, is safe — even for individuals who are considered at high-risk for developing lymphedema. Of course, we advocate individualized rehabilitation exercise programs with appropriate starting loads and progressive overload.

Our hope is that these findings will help remove some of the fear breast cancer survivors may have around exercise and lymphedema. In turn, through exercise, breast cancer survivors can regain strength and prevent or reduce the magnitude of function losses that may accompany breast cancer treatment and live full and active lives.