Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity.

OBJECTIVE: The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer-related lymphedema, for use in the context of outcome evaluation in clinical trials. DESIGN: Blinded repeated measures observational study. SETTING: Outpatient research laboratory. PARTICIPANTS: Breast cancer survivors with and without lymphedema (N=71). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The assessment of intraclass correlation coefficients (ICCs) for the Breast Cancer-Related Lymphedema of the Upper Extremity (CLUE) standardized clinical evaluation tool. RESULTS: Intrarater reliability for the CLUE tool was ICC: 0.88 (95% confidence interval [95% CI], 0.71-0.96). Interrater reliability for the CLUE tool was ICC: 0.90 (95% CI, 0.79-0.95). Concurrent validity of the CLUE score (Pearson r) was 0.79 with perometric interlimb difference and 0.53 with the Norman lymphedema overall score. CONCLUSIONS: The CLUE tool shows excellent inter- and intrarater reliability. The overall CLUE score for the upper extremity also shows moderately strong concurrent validity with objective and subjective measures. This newly developed clinical, physical assessment of upper extremity lymphedema provides standardization and a single score that accounts for multiple constructs. Next steps include evaluation of sensitivity to change, which would establish usefulness to evaluate intervention efficacy.

Does the speed of aquatic therapy exercise alter arm volume in women with breast cancer related lymphoedema? A cross-over randomized controlled trial.

OBJECTIVE: To identify whether slow aquatic exercise in the form of modified Ai Chi is more effective than conventional (faster pace) aquatic therapy at reducing arm volume in women with or at risk of breast cancer related lymphoedema. METHODS: Randomized, cross-over controlled trial with concealed allocation and blinded assessment. Eighteen women with a history of breast cancer related lymphoedema were recruited. Participants received two intervention sessions (randomized order) with one week apart. Interventions were a 50min conventional aquatic intervention or a 50min modified Ai Chi. Arm volume was measured as the difference between affected and unaffected arm; bio-impedance was measured as an index of extracellular fluid; satisfaction was measured via a 12 question form. Outcomes were measured before, immediately after and one hour after intervention. RESULTS: Comparison between interventions showed larger decreased arm volume of 140mL (95%CI 17-263) immediately after intervention in favor of the Ai Chi intervention, however it was not sustained at 1h follow-up. A post hoc analysis showed 72% of participants had a decrease in arm volume immediately after Ai Chi compared to 28% immediately after conventional aquatic therapy; with a number needed to treat of 3 (95%CI 1.4-6.6). There were no differences between interventions for bio-impedance. Satisfaction was good for both interventions. CONCLUSION: Slow pace aquatic exercise is more effective than conventional aquatic exercise immediately after intervention for arm volume. Also, undesirable increase in arm volume seems to subside after 1h, which can be beneficial if therapy does not address arm volume. TRIAL REGISTRATION: ACTRN12614000557639 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614000557639).

Intra- and Inter-Rater Reliability of Bioimpedance in the Evaluation of Lymphedema Secondary to Treatment of Breast Cancer.

The objective of the study was to evaluate the intra- and inter-rater reliability of bioimpedance in determining upper limb volume in women with lymphedema resulting from breast cancer treatment, as well as its correlation with the upper limb volume calculated by circumferential measurement. A blind cross-sectional study was performed in which 27 women (62.59 ± 10.50 years) were evaluated with upper limb lymphedema secondary to breast cancer treatment. Two examiners performed assessments in the same volunteers independently and twice, with an interval of 1 week between assessments. The collections were performed by the direct tetrapolar multifrequency segmental bioimpedance and by the circumference of the upper limb homolateral to the breast cancer. The results of the circumference showed that the homolateral limb had lymphedema. The intra- and inter-rater analysis showed excellent reliability with intraclass correlation coefficient (ICC) values ranging from 0.954 to 0.999 for the amount of liquid and excellent reliability with ICC values ranging from 0.852 to 0.999 for the electrical impedance of the upper limb with lymphedema. The correlation was strong and negative (p < 0.05) between intracellular, extracellular, and total water when associated with electrical impedance and moderate and positive (p < 0.05) when associated with upper limb volume for all frequencies. The correlations between upper limb volume and water quantities were moderate and positive (p < 0.05). The results indicate that bioimpedance is a reliable method for the evaluation of lymphedema, and the volume of the homolateral upper limb is associated with the amount of water in women with lymphedema secondary to the treatment of breast cancer.

A Randomized Trial on the Effect of Exercise Mode on Breast Cancer-Related Lymphedema.

PURPOSE: Breast cancer-related lymphedema is a common and debilitating side effect of cancer treatment. This randomized trial compared the effect of progressive resistance- or aerobic-based exercise on breast cancer-related lymphedema extent and severity, as well as participants' muscular strength and endurance, aerobic fitness, body composition, upper-body function, and quality of life. METHODS: Women with a clinical diagnosis of stable unilateral, upper-limb lymphedema secondary to breast cancer were randomly allocated to a resistance-based (n = 21) or aerobic-based (n = 20) exercise group (12-wk intervention). Women were assessed preintervention, postintervention, and 12 wk postintervention, with generalized estimating equation models used to compare over time changes in each group's lymphedema (two-tailed P < 0.05). RESULTS: Lymphedema remained stable in both groups (as measured by bioimpedance spectroscopy and circumferences), with no significant differences between groups noted in lymphedema status. There was a significant (P < 0.01) time-group effect for upper-body strength (assessed using four to six repetition maximum bench press), with the resistance-based exercise group increasing strength by 4.2 kg (95% confidence interval [CI] = 3.2-5.2) postintervention compared with 1.2 kg (95% CI = -0.1 to 2.5) in the aerobic-based exercise group. Although not supported statistically, the aerobic-based exercise group reported a clinically relevant decline in number of symptoms postintervention (-1.5, 95% CI = -2.6 to -0.3), and women in both exercise groups experienced clinically meaningful improvements in lower-body endurance, aerobic fitness, and quality of life by 12-wk follow-up. DISCUSSION: Participating in resistance- or aerobic-based exercise did not change lymphedema status but led to clinically relevant improvements in function and quality of life, with findings suggesting that neither mode is superior with respect to lymphedema effect. As such, personal preferences, survivorship concerns, and functional needs are important and relevant considerations when prescribing exercise mode to those with secondary lymphedema.