Developing an Evidence-Based Exercise Guideline on Improving Shoulder Motion and Lessening the Severity of Lymphedema for Breast Cancer Patients after Axillary Lymph-Node Dissection

Dorothy N. S. CHAN; Winnie K. W. SO

doi:10.1007/s11805-010-0513-0

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Table 1.

Interventions used by selected studies.

Selected studies	Interventions
Selected studies	Assessment method	Type of exercise (examples)	Commencement day	Frequency	Duration	Follow-up assessment
Ahmed et al. (2006)	Arm circumference	Weight training Stretching	4 months to 3 years post-operatively	Twice a week, repeat each set of exercises 8-10 times	6 months	6 months 2 weeks
Bendz & Olsen (2002)	Arm volume Range of motion	Range of motion	Post-operative day 1	3 times per day, repeat each set of exercise 5 times	Not mentioned	1 month 6 months 2 years
Beurskens et al. (2007)	Arm volume Range of motion	Range of motion Stretching Coordination Muscle strengthening exercise	Post-operative day 14	1-2 times per week, exercise for 10 minutes each time	3 months	3months 6 months
Cinar et al. (2008)	Arm circumference Range of motion	Range of motion Isometric Stretching	Post-operative day 1	Not mentioned	At least 8 weeks	day 5 1 month 3 months 6 months
Kilgour et al. (2008)	Arm circumference Range of motion	Range of motion Stretching	Post-operative day 3	Twice per day, exercise 5-7 minutes for each set	Not mentioned	day 14
Box et al. (2002)	Arm circumference Arm volume Range of motion	Not mentioned	Post-operative day 2	Not mentioned	Not mentioned	day 5 1 month 3 months 6 months 1 year 2 years

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Table 2.

SIGN grading system: levels of evidence and grades of recommendation.

Levels of evidence
1++	High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-	Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case control or cohort studies High-quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+	Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-	Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3	Non-analytic studies, e.g. case reports, case series
4	Expert opinion

Grades of recommendation
A	At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B	A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+
C	A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++
D	Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

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Table 3.

Measurements of range of shoulder motion.

Types of range of motion	Measurement method	Normal range
Flexion	With subject in sitting position, align the stationary arm of the goniometer along the side of trunk (sagittal plane) with the axis close to the acromion process The movable arm of the goniometer is parallel to the arm, using the lateral epicondyle of the humerus as reference The movable arm of the goniometer aligns with the arm as it moves in flexion Angle between the stationary and movable arms of the goniometer is the shoulder flexion angle	180°
Abduction	With subject in sitting position, align the stationary arm of the goniometer vertically with the side of trunk in the frontal plane with the axis close to the acromion process The movable arm of the goniometer is parallel to the arm, using the lateral epicondyle of the humerus as reference The movable arm of the goniometer moves along with the arm in abduction Angle between the stationary and movable arms of goniometer is the shoulder abduction angle	180°
Internal rotation	With subject in supine position, place arm in 90° abduction, elbow in 90° flexion with forearm perpendicular to table Stationary arm of goniometer aligned parallel to forearm with the axis over the oleranon process Movable arm of goniometer moves along with the forearm, using the styloid process of the ulna as reference Ensure there is no compensation by the shoulder girdle during movement Angle between stationary and movable arms of the goniometer is the shoulder internal rotation angle	70°
External rotation	Similar to that of internal rotation but shoulder and arm move in opposite direction	90°