Early exercise after breast cancer surgery may help improve upper limb disability

A randomized trial in the United Kingdom found that women at risk for postoperative upper limb disability after breast cancer surgery had better functional outcomes when assigned to a structured exercise program, with no associated increase in complications or adverse events.

Women undergoing breast cancer surgery who are at increased risk for upper limb disability may benefit from early postoperative exercise, a randomized trial found.

Researchers in the United Kingdom performed a randomized controlled trial at 17 National Health Service cancer centers to assess the effect of adding a guided exercise program to usual care among women who had breast cancer surgery and were at increased risk for postoperative upper limb disability. Usual care was defined as information leaflets, while the guided exercise program included stretching, strengthening, physical activity, and behavioral change techniques to support exercise adherence, with the goals of restoring range of movement in the shoulder, improving strength, and increasing physical activity.

The exercise program was introduced seven to 10 days after surgery, and patients had additional appointments at one and three months, with a maximum of six sessions permitted over a year. The study's main outcome measure was score on the Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months, which was analyzed by intention to treat with scores ranging from 0 (no disability) to 100 (most severe disability). Secondary outcomes were DASH subscales, pain, complications, health-related quality of life, and use of resources. The study results were published Nov. 11 by The BMJ.

Overall, 392 women at risk for postoperative upper limb morbidity participated in the study, 196 assigned to usual care with structured exercise and 196 assigned to usual care alone. The mean age was 58.1 years, and 21% had a history of shoulder problems. Of the 392 patients, 97% were eligible for intention-to-treat analysis. Among 191 patients in the exercise group, 181 (95%) attended at least one appointment. At 12 months, they had improved upper limb function compared to the usual care group, with a mean DASH score of 16.3 versus 23.7 (adjusted mean difference, 7.81 [95% CI, 3.17 to 12.44]; P=0.001). Patients in the exercise group also had lower pain intensity (P=0.02); fewer arm disability symptoms (P=0.001); and no increase in complications, lymphedema, or adverse events. In an economic analysis, costs were lower per patient in the exercise group and the intervention was cost-effective versus usual care.

Patients and physiotherapists could not be blinded to treatment assignment, and the economic analysis involved only a subset of the sample, among other limitations, the authors noted. Their results indicate that the exercise program tested in their trial “was safe to deliver, clinically impactful, and cost effective, providing the best quality evidence to date in support of prescription of early exercise for women at high risk of shoulder problems and upper limb morbidity after non-reconstructive breast cancer treatment,” they wrote. “Future research directions could evaluate application of our preoperative screening criteria for the identification of women at higher risk of developing post-treatment limb related disability who could benefit from this cost effective exercise programme.”