The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment : a pilot study

This thesis reports the effect of an integrated yoga practice on women diagnosed with secondary arm lymphoedema from breast cancer treatment (n=28). The study design was a blinded Randomised Controlled Trial in Hobart and Launceston (Tasmania) from February to May 2011. The literature suggests that at least 20% of women treated for breast cancer will develop secondary arm lymphoedema, leading to a reduction in upper body function and quality of life. There is evidence to support the use of exercise, based on breathing, gentle movement and relaxation, with progression in the level and adequate warm-up and cool-down, in the management of this chronic and often debilitating condition. An integrated yoga practice, based on these principles, has been investigated for people with lower limb lymphoedema from filariasis and for women during and after breast cancer treatment, with positive outcomes. This suggests that a similar intervention may be helpful for women with breast cancer-related lymphoedema (BCRL). As no published research was located on the topic, this study was undertaken to evaluate the impact yoga may have on women with BCRL. As such, it provided novel findings to support further research, as well as the development of guidelines for use by yoga teachers. The intervention was eight weekly sessions of a teacher-led 90-minute yoga class and a daily home-practice using a DVD (42 minutes). The control group continued with current care. Randomisation occurred after the baseline measurement. Other measurements were at weeks 4 and 8 with a four-week follow-up measurement at week 12. Primary objectives of the study were to determine the effect of yoga on lymphoedema in terms of lymphoedema level, tissue density, the degree of sensations, pain and fatigue and their limiting effects on daily activity and quality of life. Secondary objectives were to determine the effect of yoga on upper body impairment in terms of range of motion of the shoulder and spine and strength of grip, shoulder and the muscles affected by surgery (pectoralis major, pectoralis minor and serratus anterior). Amount of physical activity, demographic and medical information were also obtained from participants. Through interview subjective information was sought from the intervention participants about their perception of the effects of yoga and the effectiveness of the home-practice DVD. Data was collected through bioimpedance spectroscopy, arm and hand circumferential readings, visual analogue scales, tonometry, goniometry, dynamometry, optoelectronics and questionnaires (including the LYMQOL quality of life measure and the International Physical Activity Questionnaire - short form). Descriptive data was analysed by SPSS, version 19. Primary and secondary outcomes were analysed by STATA, version 12. The level of significance was set at p<0.05. Data from the interviews was analysed using an iterative-thematic approach. Results showed that lymphoedema was not exacerbated over the 8-week study period and arm volume of lymphoedema improved significantly (p=0.029) for the intervention group. In comparison to the control group, the intervention group demonstrated reductions in tissue density of the affected upper arm (p=0.050), symptoms (p=0.038), the degree to which pain limited activity (0.035) and also improvement in pelvic stability for lateral flexion of the spine (p=0.023). Whilst the control group improved in comparison to the intervention group in range of motion for the non-affected arm in flexion (p=0.011) and abduction (p=0.049), the intervention group demonstrated improved symmetry in these actions. Most of these improvements were not maintained at week 12. Moreover, in comparison to the control group, the intervention group increased in arm volume of lymphoedema (p=0.032) and in decreased internal rotation for the affected arm (p=0.001) at week 12. During the interviews, participants reported improvements in many aspects of physical function and quality of life which were not measured by instruments. Examples included increased physical and mental awareness, calmness, wellbeing, time for self and improved relationships and various physical functions such as better digestion and elimination, improved posture and ease of movement. In addition, there was positive feedback about the conduct of the class, benefits of group interaction and the effectiveness of the DVD. Nine of the 15 women reflected on a personal change that had occurred in them during the yoga intervention. Participants also talked about the stress of their breast cancer experience, irrespective of how long ago they had been diagnosed. Subjective comments were supported by objective scores for many outcomes such as level of lymphoedema, tissue density, quality of life, shoulder and spinal range of motion. The findings provide a basis for the recommendation of yoga as a complementary therapy for women with BCRL, and for the development of guidelines for yoga teachers. However, further research is warranted to better elucidate the benefits of yoga for this population.