BRIEF REVIEW
BREAST CANCER–RELATED LYMPHEDEMA AND
RESISTANCE EXERCISE: A SYSTEMATIC REVIEW
NICOLE L. NELSON
Clinical and Applied Movement Sciences, Brooks College of Health, University of North Florida, Jacksonville, Florida
ABSTRACT
Downloaded from http://journals.lww.com/nsca-jscr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/30/2022
Nelson, NL. Breast cancer–related lymphedema and resis-
tance exercise: a systematic review. J Strength Cond Res
30(9): 2656–2665, 2016—Breast cancer–related lymphe-
dema (BCRL) is characterized by the accumulation of fluid
in the interstitial tissues in the arm, shoulder, neck, or torso
and attributed to the damage of lymph nodes during breast
cancer treatments involving radiation and axillary node dis-
section. Resistance exercise training (RET) has recently
shown promise in the management of BCRL. The aims of
this review were twofold: (a) To summarize the results of
recent randomized controlled trials (RCTs) investigating the
effect of resistance exercise in those with, or at risk for,
BCRL. (b) To determine whether breast cancer survivors
can perform RET at sufficient intensities to elicit gains in
strength without causing BCRL flare-up or incidence. A
search was performed on the electronic databases
PubMed, MEDLINE, SPORT Discus, and Science Direct,
up to July 10, 2015, using the following keywords: breast
cancer–related lymphedema, strength training, resistance
training, systematic review, and breast cancer. Manual
searches of references were also conducted for additional
relevant studies. A total of 6 RCTs, involving 805 breast
cancer survivors, met the inclusion criteria and corre-
sponded to the aims of this review. The methodological
quality of included RCTs was good, with a mean score
6.8 on the 10-point PEDro scale. The results of this review
indicate that breast cancer survivors can perform RET at
high-enough intensities to elicit strength gains without trig-
gering changes to lymphedema status. There is strong evi-
dence indicating that RET produces significant gains in
muscular strength without provoking BCRL.
KEY WORDS strength training, resistance training
Address correspondence to Nicole L. Nelson, nicole.nelson@unf.edu.
30(9)/2656–2665
Journal of Strength and Conditioning Research
Ó 2016 National Strength and Conditioning Association
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2656 Journal of Strength and Conditioning Research
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INTRODUCTION
B
reast cancer is the most common cancer type
among women in the United States and is the
second leading cause of cancer death (26).
Approximately 1 in every 8 women will develop
breast cancer at some time during her lifetime. Improvements
in early detection, diagnosis, and treatment have improved
the 5-year relative survival rate to above 80% (5). Despite the
tremendous enhancement of current breast cancer care, sur-
vivors are at risk for several treatment complications, perhaps
the most concerning being breast cancer–related lymphede-
ma (BCRL). Breast cancer–related lymphedema is a chronic
and progressive issue characterized by the accumulation of
fluid in the interstitial tissues in the arm, shoulder, neck, or
torso. This accumulation is attributed to the disruption of the
lymphatic pathways from surgical resection and, or radiation
of lymphatic vessels or nodes during breast cancer treatment
(20). Breast cancer–related lymphedema most commonly de-
velops within 3 years of treatment; however, there are studies
in which this condition is reported to develop up to 20 years
after treatment (21). Reported incidence of lymphedema
among breast cancer survivors varies and is believed to be
dependent on the type of treatment received (e.g., axillary
lymph node dissection vs. sentinel lymph node biopsy); how-
ever, recent estimates indicate that more than 1 in 5 breast
cancer survivors will develop BCRL (9). The associated
swelling may range from mild to disabling and is associated
with feelings of discomfort, heaviness, and weakness in the
arm, pain, and an increased risk for infection (20). These
symptoms further impair functional and self-care abilities of
the individuals, causing significant psychological distress and
reduced quality of life (QOL).
Common clinical advice emphasizes protection of the
affected arm in an effort to reduce the risk of overstressing
a compromised lymphatic system. Although these recom-
mendations are judicious, this advice may lead to physical
activity (PA) avoidance and declines in strength of the
affected limb. Over time, fears of exacerbation may lead to
low self-efficacy, reduced QOL, deconditioning, and obesity.
To compound matters, overweight and obesity, and a sed-
entary lifestyle, are known risk factors for development and
of BCRL progression (13–15).
Although there is no cure for BCRL, decongestive therapy
is considered the gold standard for the management of BCRL

and is performed by trained lymphedema therapists. Decon-
gestive therapy often involves manual lymphatic drainage
followed by compression bandaging to control arm volume
(9). Compression garments are occasionally used as a long-
term management method of BCRL; however, compliance
is often an issue, as these garments are considered uncomfort-
able and difficult for the patients to put on by themselves (17).
Recent evidence indicates that resistance exercise training
(RET) can be an effective management strategy for BCRL not
only by improving functional capacity but also by improving
lymph flow through the pumping effect stimulated by
muscular contraction (10,11). Additionally, maintaining or
augmenting muscular strength and improving body composi-
tion may offset some of the deleterious effects of cancer treat-
ment (e.g., frailty, reduced bone mineral density, fatigue) (4,12).
The primary objective of this review was to explore the
evidence regarding the efficacy of resistance exercise among
those with or at risk for BCRL. Specifically, this review
aimed to answer the question, “Can women who are at risk
for, or currently have, BCRL increase muscular strength
without increasing BCRL incidence or symptoms?”
METHODS
This review was aligned to the PRISMA (preferred reporting
items for systematic reviews and meta-analyses) statement
(19). PRISMA includes a 27-item checklist that focuses on
ensuring a transparent and complete reporting of health care
interventions.
Search Strategy
The records of 4 electronic databases were searched from
their inception until July 10, 2015. The databases examined
included PubMed, MEDLINE, SPORT Discus, and Science
Direct. A manual search of references was also performed to
identify additional relevant studies. Key words searched
included resistance training, strength training, and breast
cancer–related lymphedema.
Eligibility Criteria
Studies evaluating the effects of resistance training were included
in this review based on the following criteria: (a) participant
studies involving breast cancer survivors with, or at risk for
BCRL, with no limitations on participant age, or nationality; (b)
intervention research in which resistance training was used as
the sole intervention, or as part of the intervention; (c) control
research in which there was a comparison group involving RET
of another intensity or another mode of exercise, or a nonexer-
cising control; (d) outcome-research in which strength out-
comes and changes in lymphedema status were reported; (e)
study design–published randomized controlled trials (RCTs).
Studies were excluded if they were not reported in English.
Review Process
All retrieved studies were cross-referenced and duplicate studies
were deleted. Relevant titles were highlighted, with abstracts
and full texts reviewed for inclusion by 1 reviewer (N.N.).
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Data Extraction
The following data were extracted: authors, year of publi-
cation, description of the resistance training protocol used in
the intervention (volume, intensity, frequency, length of the
trial), strength measures and outcomes, change in lymphe-
dema status, description of the comparison group, assess-
ment times, study results, and conclusions of the authors.
Methodological Quality and Strength of Evidence
The methodological quality of studies within this systematic
review was assessed using the PEDro scale (25). The scale
has been shown to have good levels of validity and reliability
(18). The PEDro scale evaluates the risk of bias and statisti-
cal reporting of RCTs and comprises 11 items: 8 items relat-
ing to methodological quality (e.g., random allocation,
concealed allocation, etc) and 2 items relating to statistical
reporting (e.g., between-group comparisons, and point esti-
mates and variability). An eligibility criterion relating to
external validity is the first item and is not considered part
of the total score. The total PEDro score ranges from 0 to 10
points, with a score 6 or greater considered of high quality
(HQ), RCTs receiving less than 6 were considered of low
quality (LQ).
The overall strength of evidence was assessed against
a modified version of the grading system presented by van
Tulder et al. (27). Strong evidence was based on results
derived from a minimum of 2 HQ studies. Moderate evi-
dence was based on results derived from 1 HQ study and
at least 1 LQ study. Limited evidence included results from
multiple LQ studies or from 1 HQ study. Very limited evi-
dence included results from 1 LQ study.
Lymphedema Status and Outcome Measures
Lymphedema status at baseline varied among the trials
included in this review. Similarly, measures of lymphedema
status and muscular strength varied. Table 1 presents the
BCRL status at baseline and the strength and lymphedema
measures used in each trial.
RESULTS
Quality
The methodological quality and reporting of the included
trials is presented in Table 2. The total PEDro score ranged
from 4 to 8. Five trials were considered to be of HQ and to
have a low risk of bias (6,7,16,23,24), whereas 1 was consid-
ered of LQ (1). Each of the included RCTs satisfied the items
concerning random allocation, baseline comparability,
between-group comparisons, and point estimates and vari-
ability. The items that were least frequently satisfied included
blinded participants and blinded therapists.
Description of Studies
The initial search yielded 669 potential articles. Once dupli-
cates were removed, 267 abstracts were screened. Among
these, 26 full articles were retrieved and reviewed. Of these
articles, 6 met the inclusion criteria (1,6,7,16,23,24). Figure 1
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TABLE 1. Lymphedema status, outcome measures, and use of compression garments.*

Objective
Lymphedema lymphedema Use of compression garment
Study status at baseline measures Muscular strength/endurance measures during RET

Ahmed et al. (1) Thirteen had BCRL AC (cm) Strength Those with BCRL were
at baseline encouraged to wear CG
during RET
1RM bench press and leg press
Cormie et al. (6) Met criteria for BIS Strength 25% wore a CG
BCRL
Affected AV (ml)
Grip strength affected arm
Interlimb AV
1RM chest press, seated row and leg press
difference (%)
TM

Affected AC (cm) Endurance

Interlimb AC
Max reps 70% 1RM chest press, seated row, and leg
difference (%) press
Courneya et al. (7) At risk for BCRL Interlimb WV Strength NR
difference (%)

8RM horizontal bench press and leg extension
Kilbreath et al. (16) At risk for BCRL BIS Strength hand-held dynamometer. Measures taken while NR
seated with shoulder flexed to 908 and elbow extended
Affected AC (cm)
Forward flexion
Interlimb AC
Abduction
difference (%)

Horizontal flexion

Horizontal extension
Schmitz et al. (24) Met criteria for Interlimb WV Strength Required to wear CG during
BCRL difference (%) RET

1RM bench press and leg press
Schmitz et al. (23) At risk for BCRL Interlimb WV Strength Required to wear CG during
difference (%) RET

1RM bench press and leg press

*RET = resistance exercise training; BCRL = breast cancer–related lymphedema; AC = arm circumference; 1RM = 1 repetition maximum; CG = compression garment; BIS =
bioimpedance spectroscopy; AV = arm volume; reps = repetitions; WV = water volume; NR = not reported.

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TABLE 2. Methodological quality and reporting of eligible studies (n = 6).*

PEDro scale itemsz

Study PEDro score (0–10)† 1 2 3 4 5 6 7 8 9 10 11

Ahmed et al. (1) 4 Y Y N Y N N N N N Y Y

Cormie et al. (6) 7 Y Y Y Y N N N Y Y Y Y
Courneya et al. (7) 7 Y Y Y Y N N N Y Y Y Y
Kilbreath et al. (16) 8 Y Y Y Y N N Y Y Y Y Y
Schmitz et al. (23) 7 Y Y Y Y N N Y Y N Y Y
Schmitz et al. (24) 8 Y Y Y Y N N Y Y Y Y Y

*Y = yes; N = no.
†Scores of 6 or greater considered of high quality, scores of less than 6 considered of low quality.
zPEDro scale items: (a) eligibility criteria and source of participants; (b) random allocation; (c) concealed allocation; (d) baseline
comparability; (e) blinded subjects; (f) blinded therapists; (g) blind assessors; (h) adequate follow-up; (i) intention-to-treat; (j) between-
group comparisons; (k) point estimates and variability.

depicts a summary of the selection process. The primary rea- The 6 included trials were published between 2006 and
sons for exclusion were as follows: the intervention did not 2013 and included 805 breast cancer survivors who either
involve a form resistance exercise, the study did not report had BCRL at the start of the trial or were considered to be at
muscular strength or endurance outcomes, and the study did risk for developing BCRL. The interventions involved RET
not report lymphedema measures. alone, or RET was used in conjunction with stretching. The
per-study sample sizes ranged
from 46 to 242 participants.
The majority of the trials
involved intervention partici-
pants performing RET 2 days
per week. The lengths of the
interventions involving super-
vised RET ranged from 8
weeks to 17 weeks. Four studies
performed follow-up assess-
ments, at either 6 months or 1
year after intervention
(7,16,23,24). Table 3 presents
an account of muscular
strength/endurance outcomes
and changes to lymphedema
status.
Comparisons
Among the 6 investigations
included, 1 trial compared the
effects of low-intensity upper-
body (beginning with no weight
or very light weight) RET along
with flexibility training with
a nonexercising control group
(16). Two trials compared the
effects of moderate (55–70%
1RM) to high intensity (75–
Figure 1. Flow diagram of selection process using PRISMA Guidelines. 85% 1RM) RET against either
an aerobic exercise group or

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BCRL and Resistance Exercise

TABLE 3. Key data for randomized controlled trials.*

Length of trial
Journal of Strength and Conditioning Research

Study and and assessment

the

participants Intervention Control points Key outcomes Authors’ conclusions

Ahmed et al. (1), RET, n = 23 No exercise First 3 mo Strength: significant differences in 6 mo 2 d wk21 RET did not
n = 46, mean supervised leg press and bench press in favor increase incidence, AC, or
age 52 y of the RET gp (p , 0.001) symptoms of BCRL compared
with controls
2 d wk21 9 UBE + LBE n = 23 3–6 mo BCRL: no reported increases in
unsupervised BCRL symptoms in RET gp. Three
reported flare-ups in the control gp
UBE begin with no weight AP: 6 mo
or 1/2 lb wrist wts
If no symptoms progress at
the next session by the
smallest increment
LBE MVC 8–10 rep
TM

After first 2–3 W increase

from 2 sets to 3 sets
Cormie et al. (6), (i) High load RET, n = 22 No exercise 3 mo Strength: both RET gps had Women with BCRL can lift heavy
n = 6, mean significantly greater gains in weights without fear of BCRL
age = 57.2 y strength (1RM chest press, seated exacerbation
row, leg press) and endurance
(chest press, seated row, leg
press) compared with the control
gp
2 d wk21 8 UBE + LBE n = 19 AP: 3 mo BCRL: no btwn-gp differences for
any swelling measure
1–4 sets 6–10 reps 75–
85% 1RM
(ii) Low load RET, n = 21
2 d wk21 8 UBE + LBE
15–20 reps 55–65% 1RM
Progress by 5–10% if able
to perform more reps than
the specified reps

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 Corneya et al. (7), RET, n = 82 Control gp (1): 17 wk Strength: RET was superior to usual AET and RET improved self-
n = 242, mean n = 78 care for improving bench press and esteem, physical fitness, body
age = 49.2 y leg extension (p , 0.001 for both composition, and chemotherapy
comparisons) completion rate without causing
BCRL or significant adverse
events
3 d wk21 9 UBE + LBE 3 d wk21 AET AP: 17 wk BCRL: RET did not cause BCRL
2 sets 8–12 reps 60–70% Intensity: 60%
1RM V_ O2max for
first 6 W
70% V_ O2max
6–12 wk
Progress by 10% when 80% V_ O2max
reps .12 beyond 12
wk
Duration:
15 min first 3
W, increase
by 5 min
every 3 wk
Control gp (2):
n = 82
Usual care
Kilbreath et al. RET + stretching, n = 81 No exercise 8 wk Strength: significant increase in RET did not precipitate BCRL
(16), n = 160, shoulder abduction strength in RET
mean age = gp at 8 wk compared with the

Journal of Strength and Conditioning Research

53.5 y control group

the
1 wk supervised + HP 4 n = 79 AP: 8 wk and 6 No significant btwn-gp differences at
UBE mo 6 mo
Begin with 1–1.5 kg BCRL: no btwn-gp differences
2 sets 8–15 reps
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Progress based on RPE =

15
(continued on next page)

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BCRL and Resistance Exercise

Schmitz et al. (24), RET, n = 71 No exercise 13 wk Strength: RET gp had greater Slowly progressed RET had no
n = 141, mean supervised + significantly greater increases in significant effect on limb
age = 57 y 39 wk 1RM bench press and leg press (p swelling and resulted in
Journal of Strength and Conditioning Research

, 0.001 for both comparisons)

the

unsupervised decreased incidence of

2 d wk21 9 UBE + LBE
Over first 5 wk increase
from 2 to 3 sets
UBE beginning with no wt
or 1 lb
LBE MVC 8–10 reps
TM
exacerbations of BCRL,
reduced symptoms, and
increased strength
n = 70 AP: 1 y BCRL: increase of 5% or more in
interlimb volume difference was
prespecified as a lymphedema
exacerbation. The proportion of
women experiencing an
exacerbation was 11% in the RET
and 12% in the control gp (p = 1.0)

Progress by smallest
increment if able to
perform 10 reps for 2
consecutive sessions
Schmitz et al. (23), RET, n = 72 No exercise 13 wk Strength: RET gp showed Slowly progressed RET
n = 154, mean supervised + significantly greater increases in compared with no exercise did
age = 55 y 39 wk 1RM bench press (p , 0.001) and not result in increased
unsupervised leg press (p = 0.02) compared with incidence of BCRL
the control gp
2 d wk21 9 UBE + LBE n = 75 AP: 1 y BCRL: incident BCRL onset
prespecified as an increase in
interlimb volume difference of 5%
or more. The proportion of women
experiencing BCRL onset was
11% in the RET gp and 17% in the
control gp (p = 0.04)
3 sets 10 reps
UBE begin with no wt or 1 lb
LBE MVC 8–10 reps
Progress by smallest
possible increment after
completing 3 sets of 10 for
2 consecutive sessions

*RET = resistance training; gp = group; AC = arm circumference; BCRL = breast cancer–related lymphedema; UBE = upper-body exercises; LBE = lower-body exercises; wts =
weights; AP = assessment point; MVC = maximal voluntary contraction; reps = repetitions; 1RM = 1 repetition maximum; btwn = between; AET = aerobic training; HP = home
program; RPE = rating of perceived exertion.

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a nonexercising control group (6,7). Three trials compared the
effects of progressive RET involving intervention participants
beginning the trial with low-intensity upper-body and
moderate-intensity lower-body resistance against nonexercis-
ing controls (1,23,24). The conclusion statements are based on
the aforementioned adapted version of van Tulder’s classifica-
tion system and range from limited evidence to strong
evidence.
Comparison 1: Low-Intensity Upper-Body RET + Flexibility.
There is limited evidence (1 HQ trial; 160 participants) that
low-intensity shoulder RET and flexibility exercise elicits
significantly greater strength gains in shoulder flexion and
abduction with no change to lymphedema status when
compared with no exercise (16).
Comparison 2: Moderate-to-High Intensity RET vs. Aerobic
Exercise or No Exercise. There is strong evidence (2 HQ
trials; 304 participants) that moderate-to-high intensity RET
elicits significantly greater gains in strength without the risk
of increased lymphedema symptoms when compared with
no exercise (6,7). Furthermore, there is limited evidence (1
HQ trial; 62 participants) that moderate-to-high intensity
RET is superior for improving upper- and lower-body
strength, without provoking BCRL, when compared with
moderate-intensity aerobic exercise (7).
Comparison 3: Low-Intensity Upper-Body and Moderate-
Intensity Lower-Body RET. There is strong evidence (2 HQ
and 1 LQ trials; 341 participants) that lower-intensity upper-
body RET, combined with moderate-intensity lower-body
RET, produces no significant increase in the risk for BCRL
measures, and elicits significantly greater upper- and lower-
body strength when compared with no exercise (1,23,24).
Adverse Effects
No major adverse effects were reported in any of the 6 trials
included.
DISCUSSION
This systematic review is the first to explicitly investigate
whether women who have, or are at risk for, BCRL can
perform resistance training at sufficient intensities to
improve muscular strength without increasing BCRL symp-
toms or incidence of BCRL. Six studies were considered
eligible, and based on the PEDro score, 5 were considered of
HQ and 1 of LQ. Despite widespread misconceptions that
breast cancer survivors should avoid upper-body exercise,
there is no evidence to suggest that RET increases the
incidence or is associated with BCRL exacerbations. More-
over, there is strong evidence that resistance training has
favorable effects in women who are at risk for, or currently
have, BCRL.
Preliminarily RET recommendations regarding the prin-
ciples of progression, frequency, intensity, and volume can
be gained from this systematic review. First, it seems that
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proper progression for this population should involve
participants lifting weight with proper technique for the
prescribed number of repetitions, with the intention of
increasing the load by small increments (5–10%) when the
participant can successfully lift the weight with relative ease
for the prescribed number of repetitions.
With respect to frequency, optimal training frequency
likely depends on the current fitness level of the breast
cancer survivor. However, participants performing 2 to 3
RET sessions per week on nonconsecutive days demon-
strated statistically significant improvements in strength
compared with control subjects (1,6,7,23,24).
There were significant variances for the training variables
of intensity and volume among the included trials, and future
RCTs are needed to fully elucidate the optimal RET dose for
breast cancer survivors who are at risk for, or currently have,
BCRL. It should be noted, however, that none of the
included trials reported an association between RET and
BCRL incidence or symptoms regardless of the RET
protocol used. Additionally, all 6 investigations reported
improvements in strength, regardless of training volume or
intensity. Interestingly, Courneya et al. (7) reported that
moderate-intensity RET adherence was associated with in-
creases in lean body mass (r = 0.25; p = 0.037). Moreover,
the changes in lean body mass were associated with im-
provements in QOL (r = 0.19; p = 0.022), self-esteem (r =
0.19; p = 0.022), and depression (r = 20.19; p = 0.019).
Three trials in this review indicated that, after receiving
initial instruction, participants performing unsupervised RET
experienced no increases in lymphedema status and dem-
onstrated significant strength improvements (1,23,24). From
a cost perspective, this may increase exercise adherence.
Additionally, once the constraints of maintaining a fixed
schedule are removed, participants are free to exercise at
their convenience. To this end, once breast cancer survivors
have undergone thorough instruction of exercise technique
by a fitness professional, they should be encouraged to per-
form this mode of exercise on their own.
It is worth noting that the National Lymphedema (NLN)
Network Medical Advisory Committee recommends use of
compression garments during exercise, particularly among
breast cancer survivors who have lymphedema (8). Among
trials reporting on the use of compression garments in this
review, 2 investigations required participants to wear com-
pression garments during RET (23,24), whereas 1 trial gave
participants the choice of wearing compression garments,
whereby 25% opted to wear them (6). Interestingly, in the
trial not requiring garments, no changes to lymphedema
status were reported among participants not wearing the
compression garments. Accordingly, future trials should
investigate the necessity of garments, as these are often re-
ported to be restrictive and uncomfortable during exercise.
Although tremendous advances have been made regard-
ing our understanding of resistance training and BCRL,
there are some notable research gaps and challenges that
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 BCRL and Resistance Exercise
BCRL researchers face. First, current evidence is lacking
regarding the programming variables of order, exercise
selection, and rest periods. Second, to reduce the risk of
musculoskeletal injury in this population, future study should
investigate the utility of including exercises that consider
endurance, strength, range of motion (ROM), and function
of specific areas that may be affected by breast cancer
treatments (e.g., rotator cuff muscles (3), core function,
respiratory diaphragm muscles). Third, factors such as
obesity, age, nutrition, and level of deconditioning are
variables known to influence exercise-related outcomes in
apparently healthy and at-risk populations. These factors
have not been fully explored within the context of BCRL;
whereby subgroup analysis may reveal specific associations
that might influence exercise prescription. Fourth, the
psychosocial variables that may influence participation in
PA and exercise (e.g., fear avoidance, coping strategies) are
not fully understood in this population and are worthy of
further study. Fifth, ACSM guidelines recommend a combi-
nation of aerobic and resistance training for individuals with
cancer as each confers unique health benefits (2). To date,
there is a paucity of data regarding the combined effects of
RET and aerobic conditioning among those with or at risk
for BCRL. Finally, to strengthen the evidence regarding the
effects of exercise in this population, universally accepted
BCRL diagnostic criteria, measurement methods, and termi-
nology must be established.
This review is not without limitations. First, there was
only 1 reviewer who performed the literature search and
handled data extraction; as such, bias is an inherent
limitation. Second, this review included a relatively small
number of investigations (n = 6) trials. Third, there was
significant heterogeneity of training volume and exercise
selection, and strength outcomes (i.e., 1RM bench press
and leg press, shoulder abduction and flexion, weight lifted
at final session compared with beginning of the study),
which limits the pooling of data and the robustness of con-
clusions. Finally, RCTs that were not reported in English
were not considered for this review; as such, studies relevant
to this topic may have been missed. For these reasons, cau-
tion must be used when interpreting the results of this sys-
tematic review.
PRACTICAL APPLICATIONS
Based on the findings of this review, a few preliminarily
recommendations can be made regarding RET among those
with or at risk for BRCL. It seems that 2 to 3 days of
progressive RET, performed on nonconsecutive days, is an
effective method to develop strength without risk of
incidence or exacerbation of lymphedema among breast
cancer survivors. In this review, all 6 studies reported on the
safety of RET, with no evidence of serious adverse effects
associated with this mode of training. Notwithstanding,
there are a few safeguards that practitioners should be made
aware of before initiating RET:
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2664 Journal of Strength and Conditioning Research
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Initiate RET at a low level of intensity and use a conser-
vative model of progression.

Be cognizant of early signs of potential injury or symp-
tom flare-up (e.g., increased muscle soreness, excessive
fatigue, redness, or heaviness in the involved arm, bone,
and joint pain).

Select exercises that are appropriate for the breast can-
cer survivor’s training experience and consider ROM
restrictions that may result from surgery and/or radia-
tion therapy.

Set realistic training goals.

Prescribe RET based on current fitness level and desires
of the participant.

All individuals with BCRL or those who are at risk for
BCRL should have medical approval before beginning
any exercise, particularly in the presence of cardiovas-
cular, pulmonary, or metabolic disease.
Practitioners and researchers must be aware that the
aforementioned recommendations are derived from the
limited available evidence. To better understand the effects
of RET among breast cancer survivors with, or at risk for
BCRL, further research is necessary. Specific areas of
investigation should include the influence of biopsychosocial
factors (fear avoidance, age, obesity, and overweight) known
to influence RET outcomes in other populations and
determining optimal training dose, rest periods, and exercise
selection.
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