Table 1 Summary table of evidence

Ammitzbøll [1] (2019)

Denmark

RCT

N = 158

Exercise IG; n = 82

Age, mean ± SD: 53 ± 10

Stage, n (%):

I: 12 (15)/II: 48 (59)/III: 15 (18)/N/A: 7 (9)

Sx type, n (%):

LUMP + ALDN: 43(52)/MX + ALDN:39(48)

Systemic treatment, n (%)

RT: 82 (100)/Adj Ch: 48 (59)

Neoadj Ch: 25 (30)/HT: 64 (78)

Usual-care CG; n = 76

Stage, n (%):

I: 16 (21)/II: 35 (46)/III: 18 (24)/N/A: 7 (9)

Sx type, n (%):

LUMP + ALDN: 41(54) MX + ALDN: 35(46)

Systemic treatment, n (%)

RT: 82 (100)/Adj Ch: 45 (59)

Neoadj Ch: 21 (28)/HT: 51 (67)

Exercise intervention group

Resistance exercises program (covered all major muscles groups of the UL and lower limbs, and core strength and stability)

Phase 1 (w1-w20)

Initiation: 3rd post-op w

Frequency: 3 days/w

Phase 2 (w21-w50)

Initiation: after phase 1

Frequency: 3 days/w

Exercise sessions duration: 50–55 min (10–15-min warm-up, 40 min of resistance training)

Usual-care control group

No intervention provided but were allowed to participate in municipality-led rehabilitation programs without restrictions

Arm VOL-ILVD (water displacement)

LE-related symptoms: heaviness, tightness and swelling

(NRS-11)

Muscle strength (7RM-test and dynamometer)

Shoulder movement (goniometer)

Interlimb mass difference-ILMD (DXA and arm scan)

Clinical examinationLE

(Stanton & al. criteria)

Clinically relevant LE

(> 3% increased ILVD, NRS-11 ≥ 2 and 2 or more clinical criteria)

Ammitzbøll [2]

(2019)

Denmark

RCT

N = 158

Exercise IG; n = 82

Age, mean ± SD: 53 ± 10

Stage, n (%): I: 12 (15)/II: 48 (59)/III: 15 (18) N/A: 7 (9)

Sx type, n (%):

LUMP + ALDN: 43(52)/MX + ALDN:39(48)

Systemic treatment, n (%)

RT: 82 (100)/Adj Ch: 48 (59)

Neoadj Ch: 25 (30)/HT: 64 (78)

Usual-care CG; n = 76

Stage, n (%):

I: 16 (21)/II: 35 (46)/III: 18 (24)/N/A: 7 (9)

Sx type, n (%):

LUMP + ALDN: 41(54)/MX + ALDN: 35(46)

Systemic treatment, n (%)

RT: 82 (100)/Adj Ch: 45 (59)

Neoadj Ch: 21 (28)/HT: 51 (67)

Exercise intervention group

Resistance exercises program (covered all major muscles groups of the UL and lower limbs, and core strength and stability)

Phase 1 (w1-w20)

Initiation: 3rd post-op w

Frequency: 3 days/w

Phase 2 (w21-w50)

Initiation: after phase 1

Frequency: 3 days/w

Exercise sessions duration: 50–55 min (10–15-min warm-up, 40 min of resistance training)

Usual-care control group

No intervention provided but were allowed to participate in municipality-led rehabilitation programs without restrictions

HRQOL

(EORTC QLQ C-30 v3; FACIT-f)

Symptom clustered: pain-sleep-fatigue

(EORTC QLQ-C30 v3)

Anderson [3]

(2012)

USA

RCT

N = 104

Intervention arm; n = 52

Age group, n (%):

 < 50: 21 (40)/50–64: 23 (44)

65–74: 4 (8)/ > 75: 4 (8)

Stage, n (%):

I: 25 (48)/II: 19 (37)/III: 8 (15)/N/A: 1(2)

Sx type, n (%): LUMP: 23 (44)/MX: 28 (54)/N/A: 1 (2)

Type of node dissection, n (%):

SND only: 10 (19)/AND: 39 (75)

Neither: 1 (2)/N/A: 2 (4)

Systemic treatment, n (%):

Ch: 31(60)/HT: 26(50)/RT: 31(60)

Comparison arm; n = 52

Age group, n (%)

 < 50: 23 (44)/50–64: 19 (37)

65–74: 7 (13)/ > 75: 3 (6)

Stage, n (%):

I: 26 (50)/II: 21 (40)/III: 4 (8)/N/A: 1(2)

Sx type, n (%):

LUMP: 25 (48)/MX: 24 (46)/N/A: 3 (6)

Type of node dissection, n (%):

SND only: 9 (17)/ALND: 40 (77) Neither: 0/N/A: 3 (6)

Systemic treatment, n (%):

Ch: 31(60)/HT: 23(44)/RT: 36(69)

Intervention arm

Comprehensive program consisting of tailored exercises and LE prevention module

Initiation: 4-12w post-op

Intensive phase (m1-3)

Frequency: 2 days/w

Phase 2 (m4-6): Transition to HB exercises

(Supervised exercises 1 day/w)

Phase 3 (m7-12): HB exercises

Exercise sessions duration: 65 min (5-min warm-up, 30-min of walking, 20 min of strengthening exercises and 10 min of stretching)

Comparison arm

Usual care consisting of patient ED (LE awareness, tips about PA and nutrition, recommendations for improving function and strength)

Arm VOL

(Water displacement)

Function

(6MWT)

HRQOL

(FACT-B)

Bendz [4]

(2002)

Sweden

RCT

N = 230

Group A; n = 115

Age, mean ± SD: 58 ± 11

Stage: N/A

Sx type, n (%):

MX: 31 (31)/MX + RT: 5 (5)

QT: 20 (20)/QT + RT: 45 (44)

Group B; n = 115

Age, mean ± SD: 58 ± 11

Stage: N/A

Sx type, n (%):

MX: 22 (21)/MX + RT: 7 (7)

QT: 23 (22)/QT + RT: 52 (50)

Group A

Early shoulder exercises (to be started on the 1st pod)

Day 1–13: Early shoulder exercises including intermittent hand contractions and basic ROM exercises/From Day 14: Comprehensive ROM exercise program

Group B; n = 115

Delayed shoulder exercises

Day 1–13: No further information was provided/From Day 14: Comprehensive ROM exercise program

Frequency: 3 times daily

5 times in every set

Arm VOL (water displacement)

Shoulder ROM (Myrin goniometer)

Grip strength (vigorimeter)

Patient-reported measures of pain, heaviness and tension (VAS scale)

Beurskens [5]

(2007)

Netherlands

RCT

N = 30

Physiotherapy group; n = 15

Age, mean ± SD: 53.7 ± 13.0

Stage: N/A

Sx type, n (%):

BCS + ALDN: 3 (20)/MX + ALDN: 12 (60)

Systemic treatment, n (%):

Ch: 2 (13)/HT: 1 (7)/RT + Ch: 6 (40)

Ch + HT: 1 (7)/RT + HT: 1 (7)

RT + HT + Ch: 1 (7)

Control group; n = 15

Age, mean ± SD: 55.4 ± 9.3

Stage: N/A

Sx type, n (%):

BCS + ALDN: 4 (27)/MX + ALDN: 11(73)

Systemic treatment, n (%):

RT: 2 (13)/Ch: 2 (13)/HT: 1 (7)

RT + Ch: 8 (53)/Ch + HT: 1 (7)

RT + HT: 1 (7)

Physiotherapy group

PT sessions (advice and exercises for arm/shoulder, posture correction, coordination exercises, exercises for muscular strength, improvement of general physical condition, exercises to prevent LE and instruction for ST massage of the scar if required

Initiation: 2w following surgery

Duration: 3 months

Frequency: 1–2/w for the first 3w and then once a fortnight or less + 10 min of home exercises daily

Control group

Leaflet flyer with advice and exercises for the arm/shoulder and had no further contact with the physiotherapist

Initiation: 1st w following surgery

Arm/shoulder pain

(VAS)

Shoulder mobility

(digital inclinometer)

Disabilities in daily life

(DASH)

Arm edema

(water displacement)

Grip strength

(hand-held dynamometer)

Quality of life (SIP questionnaire short version)

Box [6]

(2002)

Australia

RCT

N = 65

Treatment group; n = 33

Age, mean ± SD: 53.03 ± 9.49

Stage: N/A

Sx type (%): BCS + ALND: 46.9/MRM: 53.1

Control group; n = 32

Age, mean ± SD: 59.00 ± 10.95

Stage: N/A

Sx type (%): BCS + ALND: 51.5/MRM: 48.5

Treatment group

Physiotherapy Management Care Plan (PMCP)

Included a thorough preop

assessment and explanation with postop reviews to monitor shoulder ROM, progress exercise program, LE awareness ED and individualized intervention as required

Control group

Exercise instruction booklet

Shoulder ROM

(goniometer)

Function

(12-items functional questionnaire)

Box [7]

(2002)

Australia

RCT

N = 65

Treatment group; n = 33

Age, mean ± SD: 53.03 ± 9.49

Stage: N/A

Sx type (%): BCS + ALND: 46.9/MRM: 53.1

Control group; n = 32

Age, mean ± SD: 59.00 ± 10.95

Stage: N/A

Sx type (%): BCS + ALND: 51.5/MRM:48.5

Treatment group; n = 33

Physiotherapy Management Care Plan (PMCP)

Included a thorough preop

assessment and explanation with postop reviews to monitor shoulder ROM, progress exercise program, LE awareness ED and individualized intervention as required

Control group; n = 32

Exercise instruction booklet

Arm size-CIRC

Arm VOL

(water displacement)

Multi-frequency bioimpedance-MFBIA (spectroscopy)

Incidence of secondary LE (based on preop CIRC, preop VOL and MFBIA ratio)

Cho [8]

(2016)

South Korea

RCT

N = 48

BC patients with AWS

PTMLD group; n = 24

Age, mean ± SD: 50.7 ± 9.6

Stage, n (%):

I: 5 (24)/III: 16 (76)

Sx type, n (%): MX: 12 (57)/LUMP: 7 (33)

Breast recons: 2 (10)

Systemic treatment, n (%):

Ch: 9 (43)/RT: 21(100)/HT: 14 (67)

PT group; n = 24

Age, mean ± SD: 46.6 ± 6.8

Stage, n (%):

I: 12 (60)/III: 8 (40)

Sx type, n (%): MX: 16 (80)/LUMP: 3 (15)

Breast recons: 1 (5)

Systemic treatment, n (%):

Ch: 11 (55)/RT: 19(95)/HT: 12 (60)

PTMLD group

PT program combined with MLD

Supervised PT program

UE strengthening and stretching exercises combined with MT session (ST mobs and stretching, shoulder stretching exercises, shoulder girdle mobs and PROM exercises

Initiation: At least 4w after BSx

Duration: 4w

Frequency: 3 times/w

MLD

Frequency: 5 days/w for 4w

MLD sessions duration: 30 min

PT group; n = 24

PT program solely

Arm VOL (CIRC tape measurements)

Muscular strength (dynamometer)

Active ROM (inclinometer)

Pain (NRS-11)

Arm disability (DASH)

QoL (EORTC QLQ-C30 v3, EORTC QLQ-BR23)

Visible cording

(Subjective assessment by a rehab doctor)

Cinar [9]

(2008)

Turkey

RCT

N = 57

Treatment group; n = 27

Age, mean ± SD: 51.1 ± 13.0

Stage, n (%): N/A

Sx type: MRM

Systemic treatment, n (%):

Ch: 29 (97)/RT: 14 (47)

HB exercise program; n = 30

Age, mean ± SD: 52.6 ± 12.2

Stage, n (%): N/A

Sx type: MRM

Systemic treatment, n(%): Ch:23(85)/RT:10(4)

Treatment group

Early shoulder ROM exercises (to be started on the 1st post-op day) and PT program

PT program

Included ROM, stretching and strengthening exercises

Initiation: Following drains removal

Duration: 15 supervised sessions and 8w self-A

HB exercise program group

Postoperative exercise forms to perform at home

ROM (Myrin goniometer)

Arm VOL

(CIRC tape measurements)

Function

(10-item functional questionnaire)

de Almeida Rizzi [10]

(2020)

Brazil

RCT

N = 62

Free ROM group; n = 31

Age, mean ± SD: 49.90 ± 10.11

Stage, n (%):0: 10 (33)/I: 4 (13)/II: 3 (10)

IIB: 7 (23)/III: 5 (17)/IIIB: 1(3)/IV: 0 (0)

Sx type, n (%):

Breast sparing Sx: 14 (47)

MX: 16 (53)/Breast recons: 30(97)

Type of node dissection, n (%):

SNB: 15 (50)/ALND: 14 (47)

Systemic treatment, n (%):

Neoadj Ch: 13 (43)

Limited ROM group; n = 31

Age, mean ± SD: 54.46 ± 10.68

Stage, n (%): 0: 11 (37)/I: 4 (13)/II: 7 (23)

IIB: 5 (17)/III: 2 (7)/IIIB: 0 (0)/IV: 1 (3)

Sx type, n (%):

Breast sparing Sx: 10 (33)

MX: 20 (67)/Breast recons: 30(97)

Type of node dissection, n (%):

SNB: 21 (70)/ALND: 7 (23)

Systemic treatment, n(%):Neoadj Ch:10(33)

Both groups

Exercise protocol consisting of neck and UL stretching exercises and shoulder ROM exercises

Initiation: 1st pod

Day1-14: Exercises 1–6

From Day15: Exercises 1–8

Free ROM group

Were allowed to perform the protocol exercises and ADL in free amplitude

Limited ROM group

Had ROM maintenance limited to 90° until the 30th post-op day, then started free ROM exercises

Dehiscence

(Inspection, palpation and tape measure)

Seroma

(Inspection and palpation, medical record)

Infection

(Inspection and palpation, medical record)

Necrosis

(Inspection and medical record)

Shoulder ROM (Goniometer)

Pain (VAS)

Upper limb function (DASH)

De Groef [11]

(2017)

Belgium

RCT

N = 147

Intervention group; n = 72

Age, mean ± SD:53.9 ± 11.5

Stage, n (%):

0: 7 (10)/I: 16 (22)/II: 36 (50)/III: 13 (18)

IV: 0 (0)

Sx type, n (%): MX: 46 (64)/BCS: 26 (36)

Systemic treatment, n (%):

RT, IMC and medial supraclavicular:72(100)

RT, axilla: 8(11)/Ch: 60(83)

Neoadj Ch:29(40)

Target therapy: 22(31)/HT: 57(79)

Control group; n = 75

Age, mean ± SD: 54.7 ± 11.9

Stage, n (%):0: 2 (3)/I: 20 (27)/II: 37(48)/III:14(19)/IV:2 (3)

Sx type, n (%): MX: 50 (67)/BCS: 25 (33)

Systemic treatment, n (%):

RT, IMC and medial supraclavicular:75(100)

RT, axilla: 9(12)/Ch:55(73)

Neoadj Ch:21(28)

Target therapy: 9 (12)/HT: 62 (83)

Both groups

Individual standard PT program consisting passive mobs, stretching and transverse strain of pectoral muscles, scar tissue massage, exercises schemes, posture and movement control and shoulder AROM

Initiation: after surgery

Duration: 4 months

Exercise sessions duration: 30 min

Frequency: 2 session/w, reducing to once/w after the first 2 months

Intervention group

Individual standard PT program + MT

Initiation: 2 months post-surgery

Duration (MT): 2 months

Freq of MT sessions: once/w

Control group

Individual standard PT program + placebo t_x consisting of static bilateral hand t_x at the upper body and arm

Initiation: 2 months post-surgery

Duration (placebo): 2 months

Frequency: once/w

Placebo t_x duration: 30 min

Point prevalence of pain

(Yes/No question)

Pain intensity (VAS)

Pressure hypersensitivity

(Digital algometer)

Pain quality

(McGill Pain Questionnaire)

Point prevalence of impaired shoulder function

(DASH score of more than 15%)

Shoulder function (DASH)

Quality of life (SF-36)

De Rezende [12]

(2006)

Brazil

RCT

N = 60

Directed exercises group; n = 30

Age, mean ± SD: 54.00 ± 10.11

Stage, n (%):

I: 5 (17)/IIA: 4 (13)/IIB: 5 (16)

IIIA: 4 (13)/IIIB: 8 (27)/IIIC: 2 (7)/IV: 2(7)

Sx type, n (%):

Halsted RMX: 5(17)/MRM: 16 (53)/QT: 9(30)

Systemic treatment, n (%):

Previous Ch: 8 (27)

Free exercises group; n = 30

Age, mean ± SD: 55.40 ± 11.24

Stage, n (%):

I: 6 (20)/IIA: 10 (33)/IIB: 6 (20)

IIIA: 3 (10)/IIIB: 3 (10)/IIIC: 0 (0)/IV: 2 (7)

Sx type, n (%):

Halsted RMX: 1(3)/MRM: 21(70)/QT:8 (27)

Systemic treatment, n (%):

Previous Ch: 9 (30)

Directed exercises group

19 ROM-exercises program performed in groups of 5 to 20 women and supervised by a team of PT and students

Initiation: 1st post-op day

Duration: 3 days/w for 42 days

Exercise sessions duration: 40 min

Free exercises group

Same ROM exercises program without a previously defined sequence or number of repetitions

Shoulder ROM

(Manual goniometer)

Lymphatic disturbance

(Drainage VOL)

Arm CIRC (tape measure)

Devoogdt [13]

(2018)

Belgium

RCT

N = 160

Experimental group; n = 79

Age, mean ± SD: 56 ± 13

Stage, n (%):

0: 1 (1)/I: 21 (27)/II: 38 (48)/III: 13 (17)

IV: 6 (8)

Sx type, n (%):

MX + ALDN: 52 (66)/BCS + ALDN: 27(34)

Systemic treatment, n (%):

Ch: 50 (63)/Target therapy:14(18)/HT:55(70)

Control group; n = 81

Age, mean ± SD: 55 ± 11

Stage, n (%):

0: 0 (0)/I: 26 (32)/II: 39 (48)/III: 12 (15)

IV: 4 (5)

Sx type, n (%):

MX + ALDN: 56 (69)/BCS + ALDN: 25(31)

Systemic treatment, n (%):

Ch: 58 (72)/Target therapy: 7(9)/HT:66(82)

Both groups

During hospitalization: Received information about the prevention of LE + exercise therapy (mobilizing exercises)

After hospitalization: 30-min individual exercise sessions

Duration: 6 months

Frequency: 2 times/w, gradually diminished to 1/2w

Experimental group

Protocol described above + MLD

Initiation: one week after removal of axillary drains

Duration of MLD: 20 weeks

Frequency of exercise sessions during this period: one to 3 times/w and then gradually decreased to once/w

Control group

Protocol described above without MLD

Incidence of arm LE

(Water displacement, arm CIRC)

Point prevalence of arm LE (water displacement, arm CIRC)

Point prevalence of subjective arm and trunk LE

(Questioned at interview)

Arm VOL difference (water displacement)

Shoulder ROM-abd, flexion, ext and int rotation

(Goniometer, tape measure)

HRQoL (SF-36)

Problems in functioning (Lymph-ICF)

Fatima [14]

(2022)

Pakistan

RCT

N = 30

Treatment group; n = 15

Control group; n = 15

Overall mean age (y), mean ± SD: 46 ± 10.75

Sx type: All participants were scheduled to undergo unilateral MRM and axillary clearance

Treatment group

Preoperative EX protocol

Initiation: Pre-operative period

Freq: 2–3 times/day, 2–5 sessions/w

REPS: ROM EX 10–12; stretching EX 8–10

Duration: Preoperative period and was repeated after the 1st and 3rd pod; continued with routine care in the postop period (unclear)

Control group

Routine care (ROM EX)

Initiation: Pre-operative period

Freq: 2–3 times/day

REPS: 10–12

Duration: unclear

Pain intensity (NPRS)

Shoulder ROM (Goniometer)

Ability to perform ADLs

(Groningen Activity Restriction Scale-GARS)

Feyzioğlu [15]

(2020)

Turkey

RCT

N = 40

Kinect-based rehabilitation group; n = 20

Age, mean ± SD: 50.84 ± 8.53

Stage, n (%): N/A

Sx type: Unilateral BSx + ALND

Systemic treatment, n (%):

Ch: 4 (21)/RT: 13 (68)/HT: 2 (11)

Standardized physiotherapy group; n = 20

Age, mean ± SD: 51.00 ± 7.06

Stage, n (%): N/A

Sx type: Unilateral BSx + ALND

Systemic treatment, n (%):

Ch: 2 (12)/RT: 13 (77)/HT: 2 (12)

Both groups

Breathing, ROM and pumping exercises, limitations for shoulder ROM amplitudes, weightlifting, jumping and running up to 6w post-op

Initiation: 1st post-op day

Duration: 2w

KBR group

Xbox 360 Kinect video game program combined with tissue massage and passive mobs

SPT group

Standard UE PT program including scar tissue massage and mobilizations

Initiation: 2nd post-op w

Duration: 2 days/w for 6 w

Program sessions duration: 45 min

Pain intensity (VAS)

Shoulder ROM (Digital goniometer)

Shoulder muscle strength

(Handheld dynamometer)

Handgrip strength

(Hydraulic hand dynamometer)

Upper extremity function (DASH)

Fear of movement (TKS)

Heiman [16]

(2021)

Sweden

RCT

N = 400

Intervention group; n = 200

Age (median; range): 61 (52–68; 30–84)

Stage, n(%):I:92(51.4)/II:83(46.4)/III:4(2.2)

Sx type, n(%): BCS:147(80.3)/MX:36(19.7)

Type of node dissection, n (%):

SNB: 161 (88)/ALND: 11 (6.0)

Control group; n = 200

Age (median; i.g.r; range): 63 (54–71; 38–89)

Stage, n (%): I: 75 (38.7)/II: 108 (55.7)/III: 10 (5.2)/IV: 1 (0.5)

Sx type, n (%): BCS: 154 (78.2)/MX:43 (21.8)

Type of node dissection, n (%): SNB: 176 (89.3)/ALND: 9 (4.6)

Intervention group

Instructions by a PT to add 30 min of aerobic PA daily + 2 follow-up calls

Initiation: 1-3w before Sx

Duration: up to 4w after discharge from hospital

Control group

Routine care (did not receive any advice regarding PA)

Both groups

Received standardized information from a PT regarding early mobs and shoulder movement before hospital discharge

Physical recovery

(self-reported questionnaires, SGPALS)

Mental recovery

(self-reported questionnaire)

Duration of hospital stay

Unplanned reoperations and readmissions

(retrieved from medical records)

Postoperative complications (CCI)

Joo [17]

(2021)

Korea

RCT

N = 56

Early shoulder exercise group; n = 28

Age, mean ± SD: 44.50 ± 6.70

Sx type, n (%): MX + Immediate Brecons: 28 (100)

Type of node dissection, n (%): SNB: 26 (92.86)/ALND: 2 (7.14)

Arm restriction group; n = 28

Age, mean ± SD: 44.10 ± 8.35

Sx type, n (%): MX + Immediate Brecons: 28 (100)

Type of node dissection, n (%): SNB: 22 (78.57)/ALND: 6 (21.43)

Early shoulder exercise group

Shoulder ROM exercise routine

Initiation: 2nd pod

Duration: unclear

Arm restriction group

Any type of arm exercise was restricted until drains removal

Drainage volume

Duration of drain placement

Kilbreath [18]

(2012)

Australia

RCT

N = 160

Exercise group; n = 81

Age, mean ± SD: 53.5 ± 12.1

Stage, %: I: 17/II: 44/III: 38

Sx type, %: MX + SNB: 48/ALDN: 62

Systemic treatment, %: Ch: 68/RT: 79

Control group; n = 79

Age, mean ± SD: 51.6 ± 11.0

Stage, n (%): I: 19/II: 37/III: 44

Sx type, %: MX: 47/ALDN: 58

Systemic treatment, %: Ch: 71/RT: 76

Both groups

Postop care including information outlining arm exercises and prevention of LE

Initiation: 4-6w post-surgery

Duration: 8 w

Exercise group:

Resistance training and passive stretching for shoulder muscles + HB program of resistance training and stretching

Initiation: 4–6 w post-surgery

Duration: 8w

Frequency: once/w

Control group

No exercises or advice was provided

Self-reported arm symptoms

(EORTC-BR23)

Breast symptoms (EORTC-BR23)

Shoulder ROM

(Digital inclinometer)

Upper shoulder muscle strength

(hand-held dynamometer)

Presence of LE

(Bioimpedance spectroscopy)

Kilbreath [19]

(2006)

Australia

RCT

N = 22

Exercise group; n = 14

Age, mean ± SD: 52.7 ± 14.0

Stage: N/A

Sx type, n (%): MX + ALDN: 8 (57)/WLE + ALDN: 6 (43)

Systemic treatment, n (%): RT: 9(64)/

Ch: 7(50)

Control group; n = 8

Age, mean ± SD: 51.5 ± 10.2

Stage: N/A

Sx type, n (%): MX + ALDN: 4 (50)/WLE + ALDN: 4 (50)

Systemic treatment, n (%): RT:7(88)/

Ch:6 (75)

Exercise group

Usual care + shoulder ROM, strengthening and stretching exercises

Initiation: 4 to 5w post-surgery

Frequency: performed daily and supervised once/w by a PT

Control group

Usual care (monitoring by a breast care nurse, may be seen by a PT to review UL exercises and by an OT who discussed prevention of lymphedema) provided at the hospital, were discharged 2 to 7 days post-surgery

Quality of life

(EORTC-QLC-C30, EORTC-QLC-BR23)

Presence of LE

(Arm CIRC measurements)

Shoulder ROM (inclinometer)

Maximal isometric shoulder strength (dynamometer)

Klein [20]

(2021)

Israel

RCT

N = 160

Intervention group; n = 73

Age, mean ± SD: 53.3 ± 12.7

Stage, n (%): IA: 40 (55.6)/IB: 2 (2.8)/IIA: 12(16.7)/IIB:4(5.6)/IIIA:0/IIIC: 1(1.4)

Sx type, n (%): LUMP: 4 (4.6); LUMP + SNB: 23 (31.9); LUMP + ALND: 7 (9.7); PMMX + SNB: 14 (19.4); PMMX + ALND: 1 (1.4); PMMX + Brecons: 23 (31.9)

Systemic treatment, n (%):

Neoadj Ch: 17 (23.6)/Adj Ch: 33 (45.8)/RT: 51 (70.8)/IORT: 8 (11.1)

Control group; n = 87

Age, mean ± SD: 51.2 ± 13.1

Stage, n (%): IA: 34 (40.0)/IB: 5 (5.9)/IIA: 7 (8.2)/IIB:2(2.4)/IIIA: 1(1.2)/IIIC: 0

Sx type, n (%): LUMP: 15 (17.6); LUMP + SNB: 16 (18.8); LUMP + ALND: 0; PMMX + SNB: 21 (24.7); PMMX + ALND: 4 (4.7); PMMX + Brecons: 29 (34.1)

Systemic treatment, n (%):

Neoadj Ch: 18 (21.1)/Adj Ch: 27 (31.8)/RT: 45 (52.9)/IORT: 4 (4.7)

Intervention group

PT treatment that included therapeutic, stretching and strengthening exercises + patient education

Initiation: 2nd pod

Duration: unclear

Control group

Usual nursing care (guidance on postoperative complications and instructions in case of persistence of symptoms more than 3w)

Follow-up: 1, 3 and 6 m post-op

Pain (NPRS)

UL function (QuickDASH)

Shoulder ROM

(Goniometer application)

Presence of LE or AWS

(Patient self-reported)

Lauridsen [21] (2005)

Denmark

RCT

N = 139

Group A; n = 72

Age (age range):

MRM + RT: 49 (40–70)/MRM: 60 (37–74)

BCS: 54 (31–79)

Stage: N/A

Sx type, n (%):

MRM + RT:20(28)/MRM: 21(29)/BCS: 31(43)

Systemic treatment, n (%):

Ch: 26 (36)/RT: 23(32)/HT:25(35)

Group B; n = 67

Age (age range):

MRM + RT: 51 (29–70)/MRM: 63 (32–77)

BCS: 54 (32–69)

Stage: N/A

Sx type, n (%):

MRM + RT: 23 (34)/MRM: 13(19)/BCS: 31(46)

Systemic treatment, n (%):

Ch: 21 (31)/RT: 17(25)/HT: 17(25)

Group A

Team instructed PT program consisting of relaxation and strengthening exercises, combined to vein pump therapy and stretching of scar tissue

Initiation: 6th to 8th post-op w

Duration: 2 days/w for 6w

Exercise sessions duration: 60 min

Group B

‘’Standard treatment of the ward’’ and were offered the same PT program after the 26th post-op w

Shoulder function

(Constant Shoulder Score)

Presence of ‘’strings’’ in the axilla

(Physical assessment)

Odynets [22]

(2021)

Ukraine

RCT

N = 77

Group A; n = 38

Age, mean ± SD: 57.10 ± 1.37 Stage, n (%): I: 9 (24.0)/II: 29 (76.0)

Sx type, n (%): Madden MX: 38 (100)

Group B; n = 39

Age, mean ± SD: 57.40 ± 1.24 Stage, n (%): I: 10 (26.0)/II: 29 (74.0)

Sx type, n (%): Madden MX: 39 (100)

Group A

Progressive muscular relaxation and visualization exercises + yoga intervention

Initiation: 2-3w after surgery

Duration: 1 m

Group B

Yoga intervention only

Initiation: 2–3 w after surgery

Duration: 1 m

Pain experience and intensity

(McGill Pain Questionnaire and VAS)

Majed [23]

(2020)

USA

RCT

N = 69

BC women undergoing MRM

Intervention group; n = 35

Age group, n (%):

35–42: 14 (47)/43–48: 10 (33)

49–55: 6 (20)

Control group; n = 34

Age group, n (%):

35–42: 14 (47)/43–48: 10 (33)

49–55: 6 (20)

Intervention group

Phase 1 and 2

Measurements: QoL-BC survey and shoulder ROM

Intervention: one-to-one ED in addition to routine hospital care. Demonstration of the exercises by the researcher with a return demonstration by the patient was done

Phase 3 (post-surgery)

Deep breathing + shoulder exercises. Shoulder flexion was limited to 90° of assisted AROM

until the drains were

removed, gradually increased after the 3rd pod

Control group

Routine hospital care that did not include any exercise training or ED. Routine hospital care included explanation by the surgeon on the surgical procedure

Quality of life

(Breast Cancer Patient

Version (QoL-BC))

Shoulder ROM (Goniometer)

Pace do Amaral [24]

(2012)

Brazil

RCT

N = 131

MT + UL exercises group; n = 65

Age, mean ± SD: 55.0 ± 11.4

Stage, n (%):

I/II: 46 (72)/III/IV: 18 (28)

Sx type, n (%): BCS: 15 (23)/RM: 50 (77)

Systemic treatment, n (%):

Ch: 22(88)/RT: 13(52)/HT: 15(60)

UL exercises group; n = 66

Age, mean ± SD: 56.7 ± 11.7

Stage, n (%):

I/II: 38 (58)/III/IV: 28 (42)

Sx type, n (%): BCS: 13 (20)/RM: 53 (80)

Systemic treatment, n (%):

Ch: 27 (90)/RT: 24(80)/HT: 18(60)

Both groups

Initiated PT on the 1st pod

MT + UL exercises group

UL exercises sessions, followed by an MT protocol consisting of scapular and glenohumeral joint mobs and therapeutic massage

Duration: 1 month

Frequency: twice a week

MT sessions duration: 20 min

UL exercises group

Outpatient physical therapy program combining UL exercises to precautions to prevent LE

Initiation: 3rd post-op day

Duration: 1 month

Frequency: 3 times a week

Exercise sessions duration: 45 min

Shoulder ROM (goniometer)

Upper limb function

(Modified-University of California at Los Angeles Shoulder Rating Scale)

Postoperative complications

(Observations made by the main investigator)

Paskett [25]

(2021)

USA

RCT

N = 568

LEAP group; n = 315

Age, year, median (range): 58 (27–88)

Grade, n (%): Low: 65 (22.0)/Intermediate: 138 (46.6)/High: 93 (31.4)

Sx type, n (%): PMX or LUMP: 199 (64.8); MX: 108 (35.2)/Missing: 5

Type of node dissection, n (%): SLND: 158 (50.6)/ALND: 67 (21.5)/SLND + ALND: 87 (27.9) Systemic treatment, n (%):

Ch: 109 (34.9)/RT: 214 (68.6)

EO group; n = 253

Age, year, median (range): 59 (24–83)

Grade, n (%): Low: 54 (22.5)/Intermediate: 93 (38.8)/High: 93 (38.8)

Sx type, n (%): PMX or LUMP: 155 (65.1); MX: 83 (34.9)/Missing: 4

Type of node dissection, n (%): SLND: 100 (41.3)/ALND: 64 (26.4)/SLND + ALND: 78 (32.2) Systemic treatment, n (%):

Ch: 95 (39.3)/RT: 166 (68.6)

LEAP group

LE education and prevention (LE etiology, signs, symptoms, treatments, preventive self-care practices) and exercise program (breathing, stretching, strengthening and ROM EX)

Initiation: ≤ 6w after Sx

Freq: daily

Exercises duration: 15 min

Duration: unclear

EO group

LE education and prevention only

Follow-up: 6, 12 and 18 months after Sx

Presence of LE (arm CIRC)

Severity of LE (change in arm CIRC at the site of greatest difference)

Shoulder ROM (self-reported)

Adherence to study protocol

Petito [26]

(2014)

Brazil

RCT

N = 77

Early group; n = 40

Age, mean ± SD: 55 ± 8

Sx type, n (%): MX: 24 (59)/QT: 17 (42)

Late group; n = 40

Age, mean ± SD: 53 ± 12

Sx type, n (%): MX: 21 (57)/QT: 16 (43)

Exercise program (both groups)

9 exercises outside hospital with illustrated manual

Duration: 105 post-operative days

Frequency: daily at home

Early group

Initiation: 1st post op day

Late group

Initiation: After drain removal (postoperative day 7–10, mean postoperative day: 9)

Evaluation incision (presence of seroma formation and dehiscence)

ROM (goniometer)

Rizzi [27]

(2021)

Brazil

RCT

N = 60

Free ROM group; n = 30

Age (y), mean ± SD: 55.06 ± 10.56

Stage, n (%):0:6(20.0)/I:23(76.7)/II: 1 (3.3)

Sx type, n (%): QT + symmetrization: 26 (86.7); Margin re-excision + symmetrization: 4 (13.3)

Type of node dissection, n (%):

SNB: 23 (76.7)/ALND: 1 (3.3)

Systemic treatment, n (%):

Neoadj Ch: 5 (16.7)

Limited ROM group; n = 30

Age (y), mean ± SD: 52.53 ± 9.08

Stage, n (%):0:3(10.0)/I:23(76.7)/II:4(13.3)

Sx type, n (%): QT + symmetrization: 29 (96.7); Margin re-excision + symmetrization: 1 (3.3)

Type of node dissection, n (%):

SNB: 2 (66.6)/ALND: 5 (16.7)

Systemic treatment, n (%):

Neoadj Ch: 7 (23.3)

Both groups

Exercise protocol (UL ROM and cervical muscles stretching EX)

Initiation:1st pod

Day1-14: Exercises 1–6

From Day15: Exercises 1–8

Duration: unclear

Free ROM group

Were allowed to perform the protocol exercises and ADL in free amplitude

Limited ROM group

Had ROM maintenance limited to 90° until the 30th post-op day, then started free ROM exercises

Follow-up: PO 60 and 90

Shoulder ROM (Goniometer)

Pain intensity (Analog verbal scale)

UL function (DASH)

Presence of dehiscence, seroma, infection or necrosis

(inspection and/or palpation)

Sagen [28]

(2009)

Norway

RCT

N = 207

No activity restriction group (NAR); n = 104

Age, mean ± SD: 54 ± 90.6

Sx type, n (%): BSx: 46 (44)/BCS: 57 (55)

Systemic treatment, n (%):

RT, nodes: 47 (45)/RT, breast: 78 (75)

Ch: 42 (40)/HT: 48 (46)

Activity restriction group; n = 100

Age, mean ± SD: 55 ± 90.6

Sx type, n (%): BSx: 51 (51)/BCS: 49 (49)

Systemic treatment, n (%):

RT, nodes: 40 (40)/RT, breast: 73 (73)

Ch: 38 (38)/HT: 50 (50)

NAR group

Supervised physical therapy program which emphasized moderate progressive resistance exercise training

Duration: 6 months

Frequency: 2–3 times a week

Exercise duration: 45 min

AR group

Physical therapy program with restricted activities of the OA avoiding heavy (> 3 kg) and strenuous activity

Program: 6 different passive manual techniques emphasizing flexibility and light massage of the affected shoulder, arm and scar

Duration: 6 months

Frequency: 1/week

Program duration: 45 min

Development of arm LE

(VOL diff in mL)

Pain and sensation of heaviness

(VAS)

Schultz [29]

(1997)

Sweden

RCT

N = 163 with MRM

Early postoperative shoulder exercise group; n = 89

Age, median (range): 59 (35–83)

Delayed postoperative shoulder exercise group; n = 74

Age, median (range): 62 (41–84)

Early postoperative shoulder exercise group

Active shoulder exercise (anteflexion, abduction, rotation)

Initiation: 1st postop day

Frequency: 3 times/day

Delayed postoperative shoulder exercise group

Active shoulder exercise (anteflexion, abduction, rotation)

Initiation: 1st postop w

Frequency: 3 times/day

Shoulder mobility (abduction and anteflexion)

Volume of seroma aspirations and number of aspirations

Siedentopf [30] (2013)

Germany

RCT

N = 93

Intervention group; n = 48

Age, mean ± SD: 55.82 ± 10.72

Sx type, n (%):

BCS: 29 (62)/RM: 18 (38)

SND: 37 (71)/ALND: 15 (29)

Systemic treatment, n (%):

Ch: 17 (53)/RT: 23 (70)

Control group; n = 41

Age, mean ± SD: 58.41 ± 9.91

Sx type, n (%):

BCS: 24 (60)/RM: 16 (40)

SND: 32 (78)/ALND: 9 (22)

Systemic treatment, n (%):

Ch: 7 (30)/RT: 16 (64)

Intervention group

Yoga classes

Initiation: Immediately after Sx

Duration: 5 w

Frequency: 2 times/w

Class duration: 75 min

10 classes over 5 w

Control group

Yoga classes

Initiation: 5 weeks after surgery

Duration: 5 w

Frequency: 2 times/w, 10 classes over 5 w

Class duration: 75 min

Yoga classes: started with lying postures and the gradual mobilization of arms and legs + breathing exercises + dynamic exercises

Quality of life

(German version of the European Organization of Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ-C30) and its breast-cancer-specific module EORTC QLQ-BR23)

Temur [31]

(2019)

Turkey

RCT

N = 72

Intervention group; n = 36

Age, mean ± SD: 46.7 ± 9.96

Stage, n (%):

I: 2 (7)/II: 16 (53)/III: 12 (40)

Sx type, n (%):

MRM: 22 (73)/BCS: 8 (27)

Control group; n = 36

Age, mean ± SD: 45.6 ± 9.03

Stage, n (%):

I: 2 (7)/II: 16 (52)/III: 13 (12)

Sx type, n (%):

MRM: 17 (55)/BCS: 14 (45)

Intervention group

Self-management of LE program (SMLP) + exercising program + simple LD

SMLP program: Training booklet containing information about mechanisms and risk factors of LE and about prevention interventions”

Exercising program: Hand squeezing exercises, active and passive arm exercises

Frequency: 3–6 times/day at first and gradually increased to 10

Exercise sessions duration: 30–60 min

Duration: 6 months

Simple lymphatic drainage: Deep diaphragmatic breathing exercises, neck drainage, axillary drainage and UE drainage

Frequency of breathing exercises: 3 times a day

Frequency of self-massage: 2 times a day

Control group

Usual post-op care

Upper extremity function

(DASH)

Presence of LE-upper extremity CIRC

(measuring tape)

Quality of life

(EORTC QLQ-30 and EORTC QLQ-BR23)

Teodózio [32]

(2020)

Brazil

RCT

N = 572

Free ROM group, n = 254

Age, mean ± SD: 52.54 ± 12.03

Sx type, n (%):

Segmentectomy: 107 (42)

MX: 147 (58)

Restricted ROM group, n = 211

Age, mean ± SD: 54.53 ± 10.95

Sx type, n (%):

Segmentectomy: 94 (45)

MX: 117 (56)

Free ROM group

Active UL movements with ROM over 90° (leaflet + home guide)

Restricted ROM group

Active UL movements with ROM restricted to 90° from 1st pod until removal of all surgical stitches (leaflet + home guide)

Initiation: 1st postop day

Frequency: 3 times/day (at least once a day)

Presence of seroma

Necrosis

Dehiscence

Hematoma

Infection

Bruise

Testa [33]

(2014)

Italy

RCT

N = 70

Treated group, n = 35

Age, mean ± SD: 54.3 ± 8.02

Stage: N/A

Sx type, n (%):

Maddens’ MRM: 19 (54)

Segmental MX + ALDN: 16 (45)

Systemic treatment, n (%):

Ch: 24 (69)/RT: 30 (86)

Control group, n = 35

Age, mean ± SD: 55.3 ± 8.5

Stage: N/A

Sx type, n (%):

Maddens’ MRM: 21 (60)

Segmental MX + ALDN: 14 (40)

Systemic treatment, n (%):

Ch: 25 (71)/RT: 27 (77)

Treated group

Early physical rehabilitation program from latest guidelines for rehabilitation in BC

Initiation: 2nd postop day

Program duration: 40 min

Frequency: 5 times/w during all the duration of axillary drainage

Once drainage removed (approximatively postoperative day 7): 20 PT sessions

Frequency: 5 times/w

Duration: 60 min/session

Control group:

No early physical rehabilitation program with no instructions of a PT. Rehabilitation program from the old rehabilitation guidelines

Mobility of the glenohumeral joint (goniometer)

Grade of pain perceived (VAS)

Quality of life

(EORTC QLQ30 and QLQ-BR23)

Todd [34]

(2008)

UK

RCT

N = 116

Delayed shoulder mobs; n = 58

Age, mean ± SD: 56.5 ± 12.4

Stage, n (%):

I: 8 (14)/II: 24 (41)/III: 26 (45)

Sx type, n (%):

WLE: 36 (57)/MX: 24 (43)

Systemic treatment, n (%):

RT: 39 (67)/Ch: 30(52)/HT: 34 (59)

Early full shoulder mobs; n = 58

Age, mean ± SD: 57 ± 14

Stage, n (%):

I: 8 (14)/II: 27 (48)/III: 23 (38)

Sx type, n (%):

WLE: 29 (50)/MX: 29 (50)

Systemic treatment, n (%):

RT: 41 (71)/Ch: 26(45)/HT: 41(71)

Delayed shoulder mobs

Exercise program that limited arm movements < 90° in all planes, followed by a full shoulder ROM program

Early full shoulder mobs

Full shoulder mobilization (i.e., movement > 90°) and shoulder ROM exercises

Initiation:

Limited ROM program: 2nd pod

Full ROM program: 2nd post op w

Exercise sessions duration: 10 min

Frequency: 4 times/day until full shoulder ROM was restored and then once/day for the 1st postop year

Incidence of LE-limb VOL difference

(Water displacement)

Shoulder ROM

(Manual goniometer)

Grip strength

(hand-held dynamometer)

Health-related QoL

(FACT-B + 4 and SDQ)

Torres [35]

(2010)

Spain

RCT

N = 120

Early physiotherapy group; n = 60

Age, mean ± SD: 52.9 ± 10.7

Stage: N/A

Sx type, n (%): QT: 24 (40)/Modified MX: 23 (38)/LUMP:13 (22)

Systemic treatment, n (%):

RT: 44 (75)/Ch: 50(85)/HT: 39 (66)

ED strategy group; n = 60

Age, mean ± SD: 52.9 ± 12.5

Stage: N/A

Sx type, n (%): QT: 26 (43)/Modified MX: 20 (34)/LUMP:14(23)

Systemic treatment, n (%):

RT: 49 (86)/Ch: 45(79)/HT: 33 (58)

Early physiotherapy group

MLD + progressive massage of the scar, stretching exercises and progressive active and action assisted shoulder exercises, combined with functional activities and proprioceptive neuromuscular exercises + ED strategy

ED strategy only group

Instruction with printed materials about the lymphatic system, concepts of normal load vs overload, source of 2ndary LE, precipitating factors and 4 preventive interventions

Initiation: 3 to 5 days after hospital discharge

Duration of both programs: 3 w

Frequency of both programs: 3 times/w

Incidence of secondary LE

(Arm CIRC)

Wingate [36]

(1989)

USA

RCT

N = 115

Treated group, n = 61

Age, mean: 56.26

Control group, n = 54

Age, mean: 58.27

Treated group:

Physical therapy: active hand, wrist, elbow and postural exercises, active and active assisted shoulder exercises, functional activities and PNF

After drain removal: HB program with progressive restrictive exercises and PNF

Initiation: 1st postop day

Duration: 8 w minimum

Frequency: 2 session/day

Exercise sessions duration: 30 min

Control group

Untreated group with no physical therapy

Psychopathologic self-report inventory (SCL-90-R)

Shoulder ROM for flexion and abduction (goniometer)

Functional evaluation of the ipsilateral shoulder

(Scale of difficulty)

Upper extremity CIRC measurement

Zhang [37]

(2016)

China

RCT

N = 1000

Physical exercise group; n = 500

Age group, n (%):

 < 50: 272 (54)/ ≥ 50: 228 (46)

Stage, n (%):

I/II: 211 (42)/III: 289 (58)

Sx type, n (%): MRM: 500 (100)

MLD group; n = 500

Age group, n (%):

 < 50: 266 (53)/ ≥ 50: 234 (47)

Stage, n (%):

I/II: 197 (39)/III: 303 (61)

Sx type, n (%): MRM: 500 (100)

Physical exercise group

Physical exercise alone

Initiation: 24 h before surgery with patient ED

Frequency: pod 1, 2, 3 and day of discharge

Session duration: 20–30 min

Postop day1-7: Passive exercises

Frequency: 3 times/day

Session duration: 15 min

Postop day7-30: (after drain removal to sutures removal): Exercises progressed to localized exercises on the affected UL

After removal sutures to 6 months: Extensive active exercises involving affected shoulder

Frequency: 3 times/day

MLD group

Physical exercises + Self MLD

Initiation: after sutures removal

Frequency: 3 sessions/day

Session duration: 30 min

Stage of upper limb LE

(Observation and tape-measuring)

Scar formation

(Vancouver Scare Scale)

Shoulder function

(max. shoulder abduction)

Zhou [38]

(2019)

China

RCT

N = 92

Intervention group; n = 46

Age, mean ± SD: 49.94 ± 8.88

Stage, n (%):

I: 18 (35)/II: 27 (53)/III: 6 (12)

Sx type, n (%):

MX + SND: 24 (47)/MX + ALND: 15 (29)

BCS + SND:10(20)/BCS + ALND:2(4)

Systemic treatment, n (%): Ch: 41 (80)

Control group; n = 46

Age, mean ± SD: 49.40 ± 9.88

Stage, n (%):

I: 14 (28)/II: 29 (57)/III: 8 (16)

Sx type, n (%):

MX + SND: 25 (49)/MX + ALND: 17 (33)

BCS + SND: 6(12)/BCS + ALND: 3(6)

Systemic treatment, n (%): Ch: 43 (84)

Intervention group

Progressive UL exercises and muscle relaxation training by nurses

Initiation: before surgery

Duration: 6 months

Frequency: 1 session/day at hospital and 1 session/week at home after discharge

Control group

Routine nursing care (surgery district nursing, drainage tube nursing, routine health ED, physical exercises, vital sign monitoring and post-surgery complications)

Quality of function

(Constant-Murley Score)

HRQOL

(FACT-Bv4.0)

Zimmermann [39]

(2012)

Germany

RCT

N = 67

MLD group; n = 33

Age, mean ± SD: 60.3 ± 8.2

Stage, n (%):

I: 12 (36)/II: 15 (46)/III: 6 (18)

Sx type, n (%):

BCS: 20 (61)/MRM: 13 (39)

SND:14 (42)/ALND: 19 (58)

Systemic treatment, n (%):

Ch: 13 (39)/RT: 22 (67)

Control group; n = 34

Age, mean ± SD: 58.6 ± 12.2

Stage, n (%):

I: 11 (32)/II: 16 (47)/III: 7 (21)

Sx type, n (%):

BCS: 20 (59)/MRM: 14 (41)

SND: 18 (53)/ALND: 16 (47)

Systemic treatment, n (%):

Ch: 15 (44)/RT: 25 (74)

Both groups

Exercises of limb and chest physiotherapy

Initiation: 2nd postop day

MLD group

Manual lymph drainage

Initiation: 14th postop day

Duration: 6 months

Frequency: 5 sessions/week

Control group

Applied self-drainage from modification of the method described by Földi and Strönbenreuher

VOL of both arms (water displacement

With glass cylinder with water)

VOL of LE

de Oliveira [40]

(2014)

Brazil

Controlled non-randomized clinical trial

N = 96

Exercise group; n = 48

Age, mean ± SD: 56.7 ± 15.1

Stage, n (%):

I: 1 (2)/II: 17 (37)/III/IV: 28 (61)

Sx type, n (%): MRM: 48 (100)

Systemic treatment, n (%):

Neoadj Ch: 22 (48)

MLD group; n = 48

Age, mean ± SD: 55.6 ± 11.9

Stage, n (%):

I: 0 (0)/II: 9 (20)/III/IV: 34 (79)

Sx type, n (%):

MRM: 42 (62)/Halsted RM: 1 (2)

Systemic treatment, n (%):

Neoadj Ch: 29 (67)

Both groups

ED strategy: Information leaflets about proper care for the OA and lectures delivered by a multi-D team

Initiation: 1st post-op day

Exercise group

19-exercise supervised program including neck and rotator cuff muscles stretching and active assisted and free AROM exercises

Initiation: 3rd post-op day

Duration: 2 days/w for 30 days

Exercise sessions duration: 40 min

MLD group

MLD applied by 3 experienced PT

Initiation: 3rd post-op day

Duration: 2 days/w for 30 days

MLD sessions duration: 40 min

Upper limb CIRC

(Measuring tape)

Shoulder ROM

(Goniometer)

Scarring complications

(Signs of wound dehiscence, infection, seroma and puncture)

Huo(⁴¹

(2021)

China

Controlled non-randomized clinical trial

N = 93

Observation group; n = 47

Age, mean ± SD: 48.5 ± 7.0

Stage, n (%): I: 7 (14.9)/II: 22 (46.8)/III: 18 (38.3)

Sx type, n (%): MRM: 47 (100)

Control group; n = 46

Age, mean ± SD: 47.8 ± 6.4

Stage, n (%): I: 5 (10.9)/II: 27 (58.7)/III: 14 (30.4)

Sx type, n (%): MRM: 47 (100)

Observation group

Routine nursing care + personalized rehabilitation EX intervention

Initiation: 24 h post-Sx

Duration: up to 6 m post-Sx

Control group

Routine nursing care

Immune function (Blood sample)

UL edema (arm CIRC)

Presence of subcutaneous fluid

(Teiler’s approach)

Shoulder ROM (Goniometer)

UL function (DASH questionnaire, ADL score)

QoL (FACT-B)

Na [42]

(1999)

South Korea

Controlled non-randomized clinical trial

N = 33

Rehabilitation group; n = 20

Age, mean ± SD: 43.8 ± 2.1

Stage: N/A

Sx type, n (%):

MRM: 15 (75)/Partial MX: 5 (25)

Control group; n = 13

Age, mean ± SD: 46.9 ± 9.8

Stage: N/A

Sx type, n (%):

MRM: 7 (54)/Partial MX: 6 (46)

Rehabilitation group

Early postmastectomy rehabilitation program

Initiation: 1st post-op day

Duration: 4w (40 min of PT and 30 min of exercises)

Frequency: 4 times/day

1st postop day: Postural exercises, AROM of the shoulder, elbow, wrist, and hands with active use of the involved arm

From the 3rd postop day: Physical modalities for pain relief and therapeutic exercises

After drains removal: Progressive resistance exercises with an increase in functional activities

Control group

Instructions alone for ROM exercises pertaining to the affected shoulder and postural exercises

Symptoms Checklist

(SCL-90-R)

Shoulder ROM

(Goniometer)

Shoulder function

(10 items provided by Wingate)

Upper limb circumference

(Tape measurement)

Oliveira [43]

(2018)

Brazil

Controlled non-randomized clinical trial

N = 116

Active exercise group; n = 58

Age group, n (%): < 55: 22 (42)/ ≥ 55: 31(59)

Stage, n (%):

I: 1 (20)/II: 17 (34)/III/IV: 32 (64)

Sx type, n (%):

MRM Patey: 29 (55)/MRM Madden: 24 (45)

RM Halsted: 0 (0)

Systemic treatment, n (%):

Neoadj Ch: 24 (45)/Adj Ch: 8 (36)

RT: 16 (73)/HT: 14 (64)/IT: 3(14)

MLD group; n = 58

Age group, n (%): < 55: 24 (45)/ ≥ 55: 29 (55)

Stage, n (%):

I: 0 (0)/II: 9 (18)/III/IV: 43 (82)

Sx type, n (%):

MRM Patey: 19 (36)/MRM Madden: 33 (62)

RM Halsted: 1 (2)

Systemic treatment, n (%):

Neoadj Ch: 36 (68)/Adj Ch: 18 (62)

RT: 26 (87)/HT:18 (60)/IT: 5 (17)

Both groups

Educational strategy: Information leaflets about proper care for the OA and daily active exercises to do at home) + lectures delivered by the multidisciplinary team during the first month after surgery

Initiation: 1st postop day

Active exercise group

Initiation: 48 h after surgery

Duration: 30 days

Frequency: 40 min group session, 2/w

MLD group

Manual lymphatic drainage

Initiation: 48 h after surgery

Duration: 30 days

Frequency: 40 min individual session, 2/w

Velocity visualization of axillary lymph nodes and degree uptake in axillary lymph nodes

(Lymphoscintigraphy)

ROM

Upper limb CIRC

Tirolli Rett [44]

(2022)

Brazil

Controlled non randomized clinical trial

N = 65

Age, mean ± SD: 50.61 ± 11.14

Sx type, n (%): MRM: 40 (81.6); QT: 9 (18.4)

Systemic treatment, n (%):

Ch: 29 (59.1)/RT: 23 (46.9)

PT protocol

Initiation: Between 4-8w after Sx

Freq: 3 times/w

Sets/Reps: 3/8–12

Consultation duration: 60 min

Duration: 20 sessions, 7w

Shoulder ROM (Goniometer)

Pain intensity and experience

(VAS and McGill Pain Questionnaire)

Kim [45]

(2019)

South Korea

Retrospective case–control study

N = 115

Early rehabilitation group; n = 49

Age (age range): 43 (34–61)

Stage: N/A

Sx type: Skin-sparing total MX and immediate Brecons with tissue expander

Type of node dissection, n (%):

SNB: 41 (84)/ALND: 8 (16)

Systemic treatment, n (%):Neoadj Ch: 3 (6)

Conventional protocol; n = 66

Age (age range): 42 (24–61)

Stage: N/A

Sx type: Skin-sparing total MX and immediate Brecons with tissue expander

Type of node dissection, n (%):

SNB: 46 (70)/ALND: 20 (30)

Systemic treatment, n (%):Neoadj Ch:7 (11)

Both groups

Self-exercise ED

Initiation: 1st post-op w

Early rehabilitation group

Short term immobilization period (2w) followed by a self-exercise program including progressive shoulder stretch exercises and strengthening exercises

Initiation: 3rd post-op w

Frequency: 4 times a day/7 days per w

Conventional protocol

Were asked to immobilize the OA for more than 4w and engaged themselves in the same self-exercise program after the immobilization period

Initiation: From the 5th post-op w

Frequency: 4 times a day/7 days per w

Shoulder ROM

(goniometer)

Pain (NRS-11)

QoL (SF-36)

Upper limb function (DASH)

Postoperative complications

(Plastic surgeon assessment)

Lu [46]

(2015)

Taiwan

Retrospective cohort study

N = 1217

Group A; n = 415

Age, mean ± SD: 51.79 ± 11.97

Stage, n (%):0–2: 326 (79)/3: 89 (21)

Sx type, n (%):

BCS: 123 (30)/Simple MX: 25 (6)

MRM: 267 (64)

Systemic treatment, n (%):

RT: 182 (44)/Ch: 342 (82)

Group B; n = 672

Age, mean ± SD: 52.67 ± 11.01

Stage, n (%):0–2: 503 (75)/3: 169 (25)

Sx type, n (%): BCS: 152(23)/

Simple MX:11(2)/MRM: 509(76)

Systemic treatment, n (%):

RT: 297 (44)/Ch: 549 (82)

Group C; n = 130

Age, mean ± SD: 51.88 ± 10.08

Stage, n (%): 0–2: 92 (71)/3: 38 (29)

Sx type, n (%): BCS: 303(25)

Simple MX: 41(3)/MRM: 873(72)

Systemic treatment, n (%):

RT: 66 (51)/Ch: 111 (85)

Group A

No ED or PT provided

Group B

ED only which provided information on the lymphatic system, the symptoms and signs of LE, suggestions for preventing LE

Group C

ED + PT sessions which included the following treatments: breathing exercise, postsurgical positioning, massaging of scar tissue, mobs of the shoulders and UE exercises, passive and active stretching of the major and minor pectoral muscles

Initiation: 1st postop w in the hospital and was continued at outpatient clinics post discharge

Frequency: 2 times/w

PT sessions duration: 30 min

Occurrence of LE

(Limb-to-limb CIRC difference)

LE severity

(Criteria defined by the International Society of Lymphology)

Manfuku [47]

(2021)

Japan

Retrospective case–control study

N = 153

BME + PT group; n = 78

Age, mean ± SD: 54.2 ± 9.8

Stage, n (%): 0-I: 28 (48.3)/II-III: 30 (51.7)

Sx type, n (%) MX: 28(48.3); BCS:30(51.7)

Type of node dissection, n (%): SNB: 39 (67.3)/ALND: 19 (32.8) Systemic treatment, n (%):

Ch: 23 (39.7)/RT: 37 (63.8)/HT: 42 (72.4)

PNE + PT group; n = 75

Age, mean ± SD: 52.3 ± 11.3 < Stage, n (%): 0-I: 35 (58.3)/II-III: 25 (41.7)

Sx type, n (%):MX: 37(61.7); BCS:23(38.3)

Type of node dissection, n (%): SNB: 42 (70.0)/ALND: 18 (30.0) Systemic treatment, n (%):

Ch: 17 (28.8)/RT: 32 (53.3)/HT: 43 (71.7)

BME + PT group

PT program that comprised shoulder joint EX and mobs + educational sessions on breast anatomy and surgical procedures

Initiation: 1w before Sx

Duration: 3 m

PNE + PT group

PT program + educational sessions on pain mechanisms (purpose was to change the patient’s knowledge of their pain states)

Initiation: 1w before Sx

Duration: 3 m

Follow-up: 1 year after Sx

Pain intensity and pain interference (BPI)

Shoulder ROM (Goniometer)

Handgrip strength (Dynamometer)

CS-related symptoms (CSI)

Pain-related catastrophizing (PCS)

Presence of LE (arm CIRC)

Morimoto [48]

(2003)

Japan

Prospective observational study

N = 72

BC women stage I or II

PCM group; n = 33

Age, mean ± SD: 50.0 ± 11.0

Stage: N/A

Sx type: PCM

BCS group; n = 38

Age, mean ± SD: 50.8 ± 8.8

Stage: N/A

Sx type: BCS

Both groups

Initiation: postoperative day 1

Duration: After hospital discharge, was entrusted to the patient’s own initiative

Postoperative day 1:

Prevention of development of rigidity of shoulder joint on the OA: Lateral and forward arm raising on the affected side in the dorsal sitting positions

Postoperative day 2:

Training for force releasing through exercise of shoulder joint

Postoperative day 3:

Exercise to approximate preoperative life

Postoperative day 4:

Exercise to reduce functional differences between the normal and affected sides

Shoulder joint ROM (goniometer)

Grip strength

Pain after surgery

Movement associated chest pain

Operative wound pain

ADL (Ability to sleep on the affected side, ability to tie an apron, ability to air the futon in the sun)

Paolucci [49]

(2021)

Italy

Prospective cohort study

N = 38

Age, mean ± SD: 57.40 ± 1.24

Sx type, n (%): Total MX + breast prostheses or tissue expanders: 38 (100)

Rehabilitative treatment group

Relaxation and breathing exercises, stretching, GH joint ROM EX, cervical pumping, isometric strengthening EX

Initiation: unclear

Freq: 2 times/w

Rehabilitation sessions duration: 1 h

Duration: 5w + 2 m at home

Follow-up: 1 year

Pain intensity (VAS)

QoL (EORTCQLQ-C30)

Personality Traits (MMPI-2)

Scaffidi [50]

(2012)

Italy

Prospective observational study

N = 83

Group A; n = 25

Age, mean ± SD: 49.6 ± 8.8

Sx type, n:

LUMP: 10 with 7 SND and 3 ALND

RM: 15 with 2 SND and 13 ALND

Group B; n = 58

Age, mean ± SD: 52.1 ± 11.9

Sx type, n:

LUMP: 35 with 26 SND and 9 ALND

RM: 23 with 6 SND and 17 ALND

Group A

Preoperative information orally + home rehabilitation program

Group B

Preoperative information orally + information materials + PT treatment at hospital + home rehabilitation program

PT at hospital: 1 per day, 30–40 min

Home rehab program: 3 times/day

Shoulder arm mobility

(goniometer)

Upper limb function

(Constant and Murley Score)

Presence of LE

(Universal level meter)

Springer [51]

(2010)

USA

Prospective observational study

N = 94

Age, mean ± SD: 53.39 ± 11.80

Stage, n (%):

0: 11 (12)/I: 40 (43)/II: 30 (32)/III: 13 (14)

Sx type, n (%):

BCT: 41(44)/MRM: 50(53)/Simple MX: 3(3)

Lymph nodes dissection, n (%):

None: 8 (9)/SND: 20 (21)/ALND: 66 (70)

Systemic treatment, n (%):

Ch: 57 (61)/RT: 64 (66)/HT: 67 (7)

Upper Limb ROM program

Flexion, abduction, internal and external rotation

Pre-operative examination: subjects were instructed in a post-operative UL ROM exercise program, and were educated regarding UL LE precautions and physical exercise initiation and progression

Initiation: post-surgery

Reviewed at 1 month

Pain (NRS)

Bilateral shoulder ROM

(Goniometer)

Bilateral shoulder strength

(Break testing of upper limbs)

Volume and girth measurements for both upper limbs in standard position

(Optoelectronic volumeter, Perometer®)

Upper limb function and disability (Upper Limb Disability Questionnaire)

Hsieh [52]

(2008)

USA

Pretest and post-test quasi-experimental study

N = 96

Women referred by local oncologists for rehabilitative exercises

Sx type: N/A

Stage: N/A

Surgery alone; n = 22

Age, mean ± SD: 55.6 ± 11.3

Surgery and Ch; n = 30

Age, mean ± SD: 55.6 ± 11.0

Surgery and RT; n = 17

Age, mean ± SD: 57.2 ± 9.4

Surgery, Ch and RT; n = 27

Age, mean ± SD: 63.1 ± 9.8

All groups

Individualized exercise intervention based on the results of the medical and cancer history, physical examination, and the initial physiologic and psychological assessments

Initiation: immediately following treatment for BC

Exercise sessions duration 10-min warm-up, 40-min of aerobic exercises, resistance training and stretching and concluded with a 10-min cooldown

Intensity: 40–65% of HR reserve (based on the treadmill assessment results)

Cardiovascular endurance

(Bruce Treadmill Protocol; HR, BP, predicted VO_2max, time on treadmill and oxygen saturation)

Pulmonary function-FVC, FEV₁

(Flowmate™ spirometer)

Cancer-related fatigue

(Piper Fatigue Scale)

Petito [53]

(2012)

Brazil

Quasi-experimental, before and after study

N = 64

Mastectomy group; n = 43

Age, mean ± SD: 52.2 ± 9.6

Sx type, n (%): MRM: 37(86)/

Simple MX:4 (9)/RMX:2 (5)

QT group; n = 21

Age, mean ± SD: 63.4 ± 9.0

Exercise program

Initiation: 1st post-op day

Duration: 105 post-op days

Frequency: daily

Phase 1 (until drain removal):

Two stretches for the cervical region, two exercises for movement of the scapular girdle, one for shoulder flexion and one for extension beyond the midline

Phase 2 (after drain removal)

Three additional exercises: one exercise for flexion and two for abduction of the shoulder

Shoulder ROM: flexion, extension, abduction

(goniometer)

Singh [54]

(2013)

Canada

Quasi-experimental pretest post-test study

N = 73

Experimental group; n = 42

Age, mean ± SD: 55.1 ± 14.8

Stage, n (%):0 or I: 2 (5)/II: 14 (34)

III: 19 (46)/N/A: 6 (15)

Sx type, n (%):

MRM: 22 (54)/Simple MX: 7 (17)

BCS: 12 (29)/B recons: 22 (54)

Systemic treatment, n (%):

RT: 22 (54)/Ch: 16 (39)

Comparison group; n = 31

Age, mean ± SD: 62.8 ± 14.1

Stage, n (%): 0 or I: 2 (7)/II: 10 (32)

III: 13 (42)/N/A: 6 (19)

Sx type, n (%):

MRM: 7 (23)/Simple MX: 9 (29)

BCS: 15 (48)/Brecons: 3 (10)

Systemic treatment, n (%):

RT: 14 (45)/Ch: 16 (32)

Experimental group

Standardized preoperative ED + PT treatment if needed focusing on teaching self-management strategies, scar tissue massage and AROM and assisted shoulder exercises

Standardized preoperative ED program:

General postop mobility exercises

AROM exercises

ED on LE

Scar management

Comparison group

Standardized preoperative ED alone

Arm mobility-Shoulder ROM

(goniometer)

Presence of LE

(Arm CIRC, tape measure)

UE strength

(Manual muscle testing)

UE function (DASH)

Quality of life (FACT-B + 4)

Postoperative pain (VAS)

Rekha [55]

(2020)

India

Quasi-experimental study

N = 20

Age range: 40–60

Sx type: Unilateral BSx (MX or BCS) within a month

Group A; n = 10

Swiss ball exercises + diaphragmatic breathing exercises (10 repetitions)

Duration: 4w; 5 days/w

Group B; n = 10:

Stretching exercises + diaphragmatic breathing exercises (10 repetitions)

Duration: 4 w; 5 days/w

Chest expansion (inch tape)

FEV₁ (computerized spirometer)

Shoulder ROM (goniometer)

Kilgour [56]

(2008)

Canada

Pilot study

N = 40

Home-based exercise (HBE) group; n = 20

Age, mean ± SD: 50.6 ± 9.3

Stage, n (%): N/A

Sx type: MRM + ALDN

Usual care (UC) group; n = 20

Age, mean ± SD: 49.1 ± 5.7

Stage, n (%): N/A

Sx type: MRM + ALDN

HBE group

HB exercise video program that incorporated the exercises and guidelines described in a brochure from CCS

Initiation: 3rd postop day

Phase 1 (Day3-9): Self-adm shoulder ROM and flexibility exercises

Frequency: 3 set/day

Sets duration: 5–7 min

Phase 2 (Day 10–14): Same exercises as Phase 1

Frequency: 2 sets/day

Sets duration: 10–15 min

UC group

Received information on diet and skin scare and a 9-page brochure containing stretching and ROM shoulder exercises printed by the CCS, without further instructions

Shoulder ROM (goniometer)

Shoulder strength

(Manual muscle testing techniques)

Grip strength

(Hand-grip dynamometer)

Forearm CIRC

(Tape measurement)

Frequency of medication intake, VOL of fluid from the axillary drains and self-perceived pain level (CR-10 Pain Scale) and exertion (Borg Scale)

Baima [57]

(2017)

USA

Feasibility study

N = 60

Age, mean, stage and systemic treatment: N/A

Sx type: MX or lumpectomy

Group 1-in person teaching; n = 36

Group 2-video-only teaching; n = 24

Both groups

Prehabilitation exercise program and postsurgery shoulder ROM exercises restrictions > 90° until drains were removed

Initiation 1-4w prior to surgery

Frequency: once daily, suspended postsurgery

Group 1-in person teaching

Physical demonstration and instructions of supervised shoulder ROM exercises

Group 2-video-only teaching

Instruction’s sheet of shoulder ROM exercises and optional exercises video without additional supervision

Pain (NRS-11)

Shoulder abduction ROM

(Goniometer)

Postoperative seroma formation