Disability and Rehabilitation, 2008; 30(15): 1098 1105

RESEARCH PAPER

Decreased muscle strength following management of breast cancer

C. R. MERCHANT1, T. CHAPMAN1, S. L. KILBREATH1, K. M. REFSHAUGE1 & K. KRUPA2

1
Discipline of Physiotherapy, University of Sydney, and 2Breast and Endocrine Surgery Unit, Concord Hospital, Sydney,
New South Wales, Australia
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14

Accepted May 2007

Abstract
Purpose. To assess whether muscle strength, power and endurance at the affected shoulder were reduced in women
treated for breast cancer. Secondly, we assessed whether muscle performance was explained by management or other
symptoms.
Methods. Participants were 40 women (mean + SD: 56.7 + 11.6 yr) who had completed all treatments for breast cancer at
least 6 m previously. We measured dynamic concentric strength at one repetition maximum (1RM), endurance at 90%1RM,
and power through a range of 40 100% 1RM for shoulder protractors, extensors and retractors. Strength and endurance,
but not power, were measured for shoulder flexors. Additionally, maximal grip strength, passive shoulder range of motion
For personal use only.

and arm circumference were measured. Self-reported symptoms were recorded using a questionnaire.
Results. Shoulder protractors ( p 0.011), retractors ( p 0.007), and extensors (p 0.009), but not flexors, were signi-
ficantly weaker on the affected side compared to the unaffected side. Muscle power and endurance at the shoulder and grip
strength were not impaired. Inter-limb differences in muscle strength were not explained by the surgical and medical
management of the cancer. Self-reported weakness correlated poorly with our measures of muscle strength.
Conclusions. Long-term weakness occurs about the shoulder secondary to treatment for breast cancer. Strategies to prevent
weakness need to be considered.

Keywords: Shoulder, grip, strength, range of motion

see 8;2,9]. The prevalence of these symptoms at

Introduction
In recent years, rates of survival from breast cancer
have increased mainly due to early detection [1];
however, as current management of breast cancer is
invasive, aggressive and liable to leave women with
long-term shoulder morbidity, the number of women
living with the after-effects of breast cancer mana-
gement is increasing. It is not uncommon for
women to report shoulder and upper limb problems
years after surgery, particularly when the surgery in-
cluded axillary node dissection [2 4]. Interestingly,
womens self-reported impairments are often more
severe than the measured changes would infer
[5 7].
The chronic shoulder and arm problems identified
by women after treatment for breast cancer include
weakness, arm and breast swelling (lymphedema),
shoulder stiffness, pain, and numbness [for review,
6 months or later following surgery is high: *25% of
women develop lymphedema; up to 18% have
weakness; 420% have stiffness; and 40% have pain
in the axilla and/or chest wall [3,9,10]. Most of these
problems are present within 3 months of surgery and
have not resolved up to 2 years after surgery [9,11].
These symptoms have generally been attributed to
surgery involving the axilla and to radiotherapy
[10,12 16].
The extent to which muscle strength at the
affected shoulder has been impaired has not been
investigated to date although women report weak-
ness as a long-term problem. Grip strength has been
used as an indication of strength of the upper limb,
even though surgery is in the region of the shoulder
[2,17]. The aim of this descriptive study was,
therefore, to determine the extent to which muscle
strength, power and endurance were impaired in

Correspondence: Dr Sharon L. Kilbreath, School of Physiotherapy, Faculty of Health Science, University of Sydney, PO Box 170, Lidcombe NSW 1825,
Australia. Tel: 61 2 9351 9272. Fax: 61 2 93519601. E-mail: s.kilbreath@usyd.edu.au
ISSN 0963-8288 print/ISSN 1464-5165 online 2008 Informa UK Ltd.
DOI: 10.1080/09638280701478512
 Decreased muscle strength following management of breast cancer 1099

women treated for breast cancer, and whether inter- Table I. Participant characteristics and medical management.
limb strength was explained by the surgical and Mastectomy Wide Local
medical management. As loss of shoulder range and (n 16) Excision (n 24)
swelling are commonly reported and can impact on
shoulder strength, we also assessed range of motion Age (yr; mean + SD) 55.3 + 12.0 57.7 + 11.5
Time since surgery 27.7 + 21.4 29.3 + 21.0
at the shoulder and arm circumference.
(months; mean + SD)
Dominant side affected (n) 11 15

Methods Medical management (n)

Axillary surgery
Participants None 0 3
Sentinel node biopsy 5 3
Forty women who had undergone unilateral surgery Axillary lymph node biopsy 11 18
for breast cancer and whose treatment had been
Adjuvant treatment
completed for at least 6 months volunteered to parti- Radiotherapy 1 16
cipate. Participants responded to recruitment letters
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14

Chemotherapy 4 0
mailed out from either the local breast cancer sur- Both 5 7
geon associated with the study or through the Encore None 6 1
online support program run through the YWCA. To Hormone therapy 10 11
(Tamoxifen)
be included, participants were required to be female,
have undergone surgery for unilateral breast cancer, Symptoms (n)
and had their last intervention at least 6 months Swelling 4 2 cm{ 3 4
previously. Potential participants were excluded from Loss of range* 6 11
the study if they had undergone bilateral surgery, {
2 cm difference present between affected and unaffected limbs
experienced unstable hypertension or had a history of 10 cm above and/or below the elbow; *108 difference present
stroke, cardiac conditions, or had any upper limb between affected and unaffected limbs for forward flexion or
For personal use only.

morbidity of the non-surgical side. abduction range.

Participants were aged between 37 and 81 years
(mean + SD: 57 + 12 yr). All had undergone uni-
lateral surgery for breast cancer and had completed
their treatment for cancer between 9 and 106 months
previously (29 + 21 m). Sixteen women (40%) had
undergone a mastectomy and 24 women (60%) a
wide local excision (WLE). Surgery was performed
to the breast on the same side as hand dominance in
26 women (65%). Treatments and symptoms are
summarized in Table I.
Ethics approval was received from the Human
Research Ethics Committee of The University of
Sydney and all participants gave informed consent
before data collection.
Protocol
Participants attended the research laboratory for one
test session lasting 2 hours. Both the affected and
unaffected sides were tested. Muscle strength was
measured before power and endurance because the
1RM results were used as the basis for testing power
and endurance. A recovery period of 10 15 min
between muscle tests ensured that there was suffi-
cient recovery time before commencing the next test.
The protocols used for strength, power and endur-
ance have been previously reported [18,19] and are
based on the American College of Sports Medicine
Guidelines [20]; protocols for strength and power
are reliable [21]. The order in which the muscle
groups were tested was randomized.
Muscle strength, power and endurance. The unilateral
concentric strength of shoulder protractors, retrac-
tors and extensors was measured as the one repetition
maximum (1RM) using Keiser pneumatic-resistance
machines for biaxial chest press, shoulder retractors
and latisimuss dorsi pull down1. The Hur Push
Up machine2 was used to measure 1RM for the
shoulder flexors.
We used a standardized protocol for determining
1RM which involved familiarization with the equip-
ment, and verbal encouragement. For all tests, parti-
cipants were seated with legs supported. For a lift to
be considered successful, it had to be completed
through full range with no compensatory movement.
To identify 1RM accurately, the examiner pro-
gressively increased the resistance until the partici-
pant was unable to complete more than 1 repetition.
To identify the 1RM required approximately 8
progressions.
Maximal grip strength was measured using a com-
puterized dynamometer3. The participant was seated
with the forearm in neutral and the elbow at 908.
They squeezed the hand grip as hard as they could,
and the best of 3 attempts was used for analysis.
The peak force, velocity and power achievable
during a single explosive contraction for shoulder
extensors, retractors and protractors were deter-
mined on the Keiser pneumatic-resistance training
equipment. The Hur Push Up used for measurement
 1100 C. R. Merchant et al.
of the shoulder flexors did not have the capability to
measure power. Participants were asked to perform a
single repetition as rapidly as possible while main-
taining good form. To identify peak power, which is
the product of the force and the velocity of muscle
shortening [22], it is necessary to assess power across
a range of resistances. The resistance was sequen-
tially increased to 40, 60, 80 and 100% of parti-
cipants previously determined 1RM. If the power at
100% 1RM was higher than at 80% 1RM, the load
was increased by 10% increments until the power
dropped below peak. This would be required if, for
example, the participants maximal effort had acti-
vated less than 100% of the motor units during
testing of 1RM. Peak power in watts (W), the
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14
percentage of 1RM at which it occurred and the
velocity (cm/s) were recorded.
For measurement of muscle endurance, the
position and settings were the same as those used
for 1RM testing. The resistance was set at 90% of
participants previously determined 1RM for each
machine. Participants performed as many repetitions
as possible at this load using a continuous slow pace
until failure. The test was concluded when the lift
could not be completed through the full range and
For personal use only.
without compensatory strategies. The number of
successful repetitions was recorded.
Range of motion
Forward flexion, horizontal extension and external
rotation were measured passively at the shoulder of
both the affected and non-affected sides, and abduc-
tion at the shoulder was measured actively. To
accommodate for preconditioning of soft tissue, each
movement was measured 3 times with each position
held for 3 s and a 10 s rest was given between each
measurement. An inclinometer4 was used to mea-
sure the maximum displacement.
For measurement of passive range of movements,
participants were positioned in supine with their
knees flexed; gravity provided the standardized force.
Active abduction range at the shoulder joint was
measured with participants seated adjacent to the
plinth. The plinth was adjusted in height to ensure
that the arm was held in 908 abduction and the
forearm in neutral. To restrict movement predomi-
nantly to the glenohumeral joint and thereby avoid
compensatory shoulder elevation, movement of the
scapula was resisted by applying a downward
pressure over the clavicle. Participants were in-
structed to lift the arm as high as they could. The
angle between the horizontal and the arm was
recorded. This method is reliable (ICC(2,1) 0.81,
95% CI, 0.67 0.90), determined in our laboratory
with a group of women (n 40) tested one week
apart.
Arm swelling. Participants were seated with the arm
flexed to 908 and resting on a Perspex sheet marked
with a 10610 cm grid. The circumference of the
arm was measured 10 cm above and below the
medial epicondyle using a soft narrow tape mea-
sure [23] and the grid lines to guide the location of
the tape measure. Reliability of measures of arm
circumference has been previously reported [24].
Self-reported arm symptoms. McCredie et al.s [3]
questionnaire regarding long-term arm symptoms
was used. Participants were asked if they had
experienced shoulder stiffness, or pain, numbness,
or swelling in the arm after the first 6 months post
surgery, or if they currently experienced these
symptoms. In addition to the impairments listed
above, we also asked about muscle weakness. They
were then asked whether the severity of their sym-
ptoms affected their activities of daily living (ADL).
They responded with yes/no to indicate the occur-
rence of these symptoms and marked a 4-point
Likert scale (with descriptors not at all, only a
little, quite a lot and a great deal) to assess the
severity of effect on performance of ADL.
Data analysis
Descriptive statistics were used to summarize
participants characteristics and performance on
the measures of strength, power, endurance, range
of motion, arm swelling and self-reported arm
symptoms.
To determine differences between arms, a 2-way
repeated measures analysis of variance (ANOVA)
was performed for each variable of strength, power
and endurance. The within subject factors were
side (affected or unaffected) and muscle group
(shoulder protractors, retractors, extensors). For
measures of strength and endurance, muscle group
also included shoulder flexors. If significant effects
were identified for side, each muscle group was
analysed separately post hoc, using repeated mea-
sures analysis of variance with the within-subject
factor being side (affected, unaffected). The inter-
limb difference in grip strength and arm swelling was
assessed with paired t-tests.
We used Pearsons moment-product correlation
coefficient (r) to correlate our measurement of
strength of the affected arm, as well as the absolute
difference between the affected and unaffected arm,
with perceived severity of weakness, and the extent
to which weakness was perceived to affect ADL.
Stepwise regression was used to determine the con-
tribution of type of surgery and adjuvant therapies
to interlimb differences of muscle strength. The
relationship of related symptoms to change in
muscle strength was also investigated. A difference
 Decreased muscle strength following management of breast cancer 1101

of 2 cm between the affected and unaffected arm

was defined as swelling. A loss of 10 deg in
forward flexion or abduction was determined as a
clinically worthwhile reduction in range [11]. The
significance level was set at p 5 0.05. Data are
presented as mean + SD. All statistical analyses were
performed using a statistical software package
(SPSS, version 11.0, SPSS headquarters, Chicago,
Illinois, USA).

Results
Strength, endurance and power
Overall, the affected side was significantly weaker
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14

than the unaffected side (Side: F 12.378;

p 0.001). Analysis of each muscle test revealed
that the affected side was significantly weaker than
the unaffected side for shoulder extensors (F 7.61,
p 0.009), protractors (F 7.04, p 0.011) and
retractors (F 8.241, p 0.007) but not for shoulder
flexors (F 3.24, p 0.080) or for grip strength
(F 0.003, p 0.957) (Figure 1). The affected
movements were 10% weaker than the unaffected
ones in approximately 25% of participants, and
For personal use only.

20% weaker in 5 11 participants (12.5 27.5%),

with shoulder retractors least affected and flexors the
most affected. The difference in 1RM was
8.8 + 20.0 N for shoulder extensors, 6.4 + 15.3 N
for shoulder protractors, 7.2 + 15.4 N for shoulder
retractors, 9.7 + 33.2 N for shoulder flexors and
0.4 + 43.2 N for grip strength. Absolute values for
strength are shown in Table II.
Unlike measures of muscle strength, the endur-
ance of the affected arm was not consistently poorer
than the unaffected arm (F 2.668; p 0.112).
However, an interaction was identified between
muscle groups tested and the side tested
(F 3.601; p 0.03) indicating that performance
varied across muscle groups and between sides.
Figure 1. Differences in strength and range of motion
Thus, each muscle group was analyzed separately.
(mean + SD) between the unaffected and affected arm. 1RM
No significant difference was identified between the differences are shown for the shoulder extensors, flexors,
number of repetitions performed by the affected and protractors and retractors, and for grip strength. Differences in
unaffected sides for shoulder protractors, retractors shoulder forward flexion, horizontal extension, external rotation
or flexors; however, the participants were able to and abduction range of motion are shown. The dotted lines
indicate that the affected arm is equal to the unaffected arm in
perform significantly more repetitions with the
terms of strength (A) or range (B). *Indicates significant difference
affected side than the unaffected side for shoulder between limbs.
extensors (Table II).
Overall, power was significantly less in the affected
arm (F 5.07, p 0.03) than the unaffected arm. unaffected sides. For example, the velocity at which
Analysis of each muscle group separately revealed peak power was achieved for shoulder protraction
that protractors were significantly less powerful on was 92.9 + 27.1 cm/s for the affected side and
the affected side (F 8.94, p 0.005), but the 93.2 + 27.4 cm/s for the unaffected side and the
extensors (p 0.08) and retractors were not percentage of force at which peak power was
(p 0.834) (Table II). There was no significant achieved for this muscle group was 71 + 12% 1RM
difference in the %1RM or the velocity at which for the affected side and 71 + 13% 1RM for the
maximum power was achieved between affected and unaffected side.
 1102 C. R. Merchant et al.

Table II. Muscle strength, power, and endurance for the Table III. Self-reported symptoms.
affected and unaffected shoulder and muscle strength for grip
(mean + SD). Present in the past Present now

Percentage Yes No Yes No Effect on ADL*

difference
Muscle 19 21 15 25 Not at all: 23
(affected/
weakness Little bit: 12
Affected Unaffected unaffected)
A lot: 5
Strength (n) Muscle 17 23 10 30 Not at all: 24
Extensors* 113.2 + 30.2 122.0 + 27.4 93.2 + 16.3 stiffness Little bit: 10
Protractors* 108.4 + 32.5 115.0 + 28.9 93.3 + 14.0 A lot: 6
Retractors* 145.0 + 39.7 152.1 + 34.4 94.8 + 10.7
Flexors 113.8 + 52.0 123.6 + 49.0 92.2 + 26.9 Pain 26 14 16 24 Not at all: 18
Grip 254.0 + 72.6 254.0 + 60.8 99.6 + 16.5 Little bit: 18
A lot: 4
Power (watts)
Extensors 88.3 + 40.4 97.1 + 38.6 93.0 + 51.6 Swelling 21 19 18 22 Not at all: 23
Little bit: 11
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14

Protractors* 71.2 + 28.4 78.2 + 28.7 98.0 + 42.3

Retractors 117.9 + 51.1 118.7 + 53.9 109.7 + 69.0 A lot: 6

Endurance (repetitions) Numbness 24 16 22 18 Not at all: 25

Extensors* 12 + 5 10 + 5 Little bit: 12
Protractors 10 + 4 11 + 3 A lot: 3
Retractors 12 + 4 12 + 5
*ADL, activities of daily living.
Flexors 5+3 4+4

*Inter limb comparison significant (p 5 0.05).

weakness was poorly correlated with our measure-

ment of shoulder strength (r 0.26 0.41).
For personal use only.

Stepwise regression of medical interventions

Other impairments
Overall, range of motion was impaired on the
affected side (F 10.01; p 0.003). Analysis of each
movement direction separately revealed that forward
flexion (F 20.66, p 0.000), horizontal flexion
(F 12.33, p 0.001), external rotation (F 6.15,
p 0.02) and abduction (F 12.71, p 0.001) were
all significantly restricted on the affected side
(Figure 1). A difference of 108 between limbs for
abduction or forward flexion was experienced by 17
participants, of whom 5 experienced a loss 108 in
both directions (Table I).
Overall, arm circumference was significantly great-
er on the affected side than the unaffected side
(F 5.45, p 0.025). Analysis of each measurement
revealed that the affected arm was significantly bigger
than the unaffected arm 10 cm below the elbow
(F 4.39, p 0.043) but not above the elbow
(F 3.89, p 0.06). A clinical diagnosis of lymphe-
dema is based on a difference of 2 cm between
limbs [6,25,26]; seven women (17.5%) met this
criterion (Table I).
Analysis of self-reported symptoms revealed that
31 (77.5%) women experienced at least one symp-
tom. Nine women reported no current symptoms,
seven reported one symptom, nine reported two
symptoms, seven reported three symptoms, five
reported four symptoms, and three women reported
having all five symptoms (Table III). Of particular
note, 15 women reported that their affected arm was
currently weak. However, self- reported shoulder
(type of primary and axillary surgery, and occurrence
of radiotherapy and chemotherapy) did not explain
the difference in absolute muscle strength between
the two limbs. Stepwise regression of loss of 108
range in forward flexion or abduction and swelling of
the limb was also conducted to determine whether
these other symptoms contributed to the between-
limb differences in shoulder strength. Decreased
forward flexion significantly contributed to de-
creased shoulder flexor strength (p 0.001) whereas
decreased abduction significantly contributed to
decreased shoulder extensor strength ( p 0.045).
Swelling did not contribute to loss of muscle
strength.
Discussion
This study shows that muscle strength about the
shoulder persists even years following surgery for
breast cancer. However, the loss in strength for most
women was minimal. Whilst there was statistically
significant loss of muscle strength, the ability to
activate the muscles, as evidenced by the lack of
significant difference between the affected and un-
affected side in tests of endurance and power, was
not overall significantly impaired. Loss of overhead
range 108, i.e., shoulder flexion and abduction,
significantly contributed to loss of strength of
shoulder flexors and extensors.
Because of our broad selection criteria, i.e.,
surgery for breast cancer, it was not possible to
 Decreased muscle strength following management of breast cancer
determine from the current sample what aspects
of the treatment contributed to the impairment.
Given the relatively small cohort in this study, this
finding is not surprising. Further research, in a
larger sample, is now required to determine
whether particular interventions are associated with
weakness.
Muscle weakness among the women in our study
was not of the same magnitude as that reported by
Nikkanen et al. [27]. They showed a reduction in
strength of 25% in women treated for breast cancer
up to 8 years after surgery [27]. Notably, the surgical
and adjuvant treatment received by their cohort was
more extensive. For example, 66 (87%) women had
undergone a Halsted mastectomy in which the entire
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14
breast, chest muscles and all lymph nodes found in
the axilla were removed, and a further 10 (13%) had
undergone a mastectomy with axillary exploration.
All participants received radiotherapy. Changes in
surgical and medical management may explain, in
part, why women typically present with only mild
muscle weakness. In the current study, only 16
(40%) women had undergone a mastectomy; of
these women, none had their chest muscles removed,
11 underwent axillary dissection, and only one had
For personal use only.
received radiotherapy. Lane et al. [28] found no
difference in strength between the affected and
unaffected upper limb in women (n 16) months
following surgery for breast cancer.
The relationship between the tests of muscle
strength and power raises an interesting issue. The
shoulder protractors on the affected side were
reduced in strength and power, and there was a
trend for shoulder extensors to be similarly impaired;
however, whilst shoulder retractors were weak
compared to the unaffected side, power was not
impaired. Other factors may have contributed to the
weakness of the shoulder retractors, in particular,
with no consequent reduction in power. Protocols
such as the one used in this study rely on voluntary
effort. We do not know to what extent the muscles
were activated. Many factors can impact on effort,
including pain and the intent to protect the limb
from maximal exertion. Shoulder retraction stretches
the muscles and tissue across the anterior chest wall.
To assess whether women were protecting their chest
and arm and, in fact, exerting less than maximal
effort, requires neurophysiological studies in which
their effort is compared to that elicited from an
evoked contraction [29 31].
The finding that endurance was not impaired on
the affected side indicates that while there may
weakness as a consequence of loss in cross-sectional
area of the muscle, the ability to activate the muscle
was not impaired. As the majority of women were
affected on their dominant side, it was not surprising
that they could perform the same or even slightly
1103
better than the unaffected side, albeit at an absolute
lower torque.
Shoulder strength may not be addressed after
breast cancer surgery out of concern that measure-
ment of strength and performance of resistance
exercises may cause lymphedema [11,32]. However,
there is preliminary evidence to challenge the belief
that resistance training early following surgery for
breast cancer leads to lymphedema [33]. In our pilot
randomized controlled trial, 22 women who had
undergone surgery for breast cancer, including
axillary surgery, were randomized to either usual
care or to an exercise intervention group. The
exercise comprised resistance training using thera-
band plus prolonged stretching commencing 4 weeks
following surgery. No swelling, measured by arm
circumference, occurred within the 8 weeks of
training [33]. Furthermore, recent studies of
moderate to high intensity resistance training in
women months to years following surgery for breast
cancer has shown that resistance training neither
caused nor exacerbated lymphoedema [28,34 36].
Thus, as shoulder weakness is a persisting problem
years following surgery, consideration should be
given to prescribing resistance training exercises for
these women.
We hypothesized that measurement of 1RM for
various shoulder movements would lead to good
correlations between measured and self-reported
strength. However, only weak relationships were
found for strength. Comparison of the affected arm
to the intact arm, rather than to an age-matched
control group, may have biased the results. The
majority of activities of daily living are bimanual [33],
and therefore if the women had decreased the use of
both arms, there may have been a consequent
reduction in the strength of both arms. Another
explanation for the lack of correlation may be that we
measured the wrong impairment. In the current
study, we examined participants ability to perform
brief maximal contractions for assessment of 1RM,
the power with which they could activate their
muscles, and the number of repetitions they could
perform. We did not examine the quality with
which they performed the task. It may be that the
participants interpreted poor motor control as
weakness.
Grip strength has been measured in previous
studies [17,26,37] as an indicator of upper limb
strength. We found no difference in grip strength
between the affected and unaffected limb. As we did
not have a control group, it is not known whether
the grip strength of both the affected and un-
affected sides was within normal limits or both were
weaker.
The women in this study used a standardised,
rigorous protocol based on one repetition maximum
 1104 C. R. Merchant et al.
(1RM) to determine the extent of shoulder weak-
ness. There were no reports of increased arm
swelling and, anecdotally, one woman spontaneously
reported that following the testing her arm swelling
had decreased. Testing was terminated in one
instance because the woman developed increasing
pins and needles in a median nerve distribution
towards the end of the testing protocol; however
there was no prolonged adverse reaction.
Our findings show that shoulder weakness is a
long-term consequence of treatment for breast
cancer, and is particularly associated with loss of
overhead range. The next step is to identify which
aspects of the medical and surgical management of
the breast cancer contribute to the weakness. As
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14
there is compelling evidence that resistance training
does not exacerbate or cause lymphedema and is
likely to be beneficial, resistance training should be
included in the rehabilitation of women following
treatment for breast cancer.
Acknowledgements
We would like to thank Dr Hugh Carmalt and NSW
Encore Support Group for referral of participants to
For personal use only.
our study.
Notes
1. Keiser Ports Health Equipment Inc., Freson CA.
2. Ab Hur Oy, Kokkola Finland.
3. Biometrics Limited, Upper Limb Exerciser, United Kingdom
Version 1.0.
4. Baseline Digital Inclinometer Fabrication Enterprises Incorpo-
rated, Irvington, New York, USA.
References
1. National BCA. Breast Cancer Incidence from 1982 to 1997 and
Mortality to 1999 in Australian Women. National Breast Cancer
Centre. http://www.nbcc.org.au/pages/info/stats/incidence/index.
htm; 2001.
2. Rietman JS, Dijkstra PU, Hoekstra HJ, Eisma WH,
Szabo BG, Groothoff JW, Geertzen JH. Late morbidity after
treatment of breast cancer in relation to daily activities and
quality of life: A systematic review. Eur J Surg Oncol 2003;
29:229 238.
3. McCredie MRE, Dite GS, Porter L, Maskiell J, Giles GG,
Phillips KA, Redman S, Hopper JL. Prevalence of self-
reported arm morbidity following treatment for breast cancer
in the Australian Breast Cancer Family Study. Breast 2001;
10:515 522.
4. Ronka R, von SK, Tasmuth T, Leidenius M. One-year mor-
bidity after sentinel node biopsy and breast surgery. Breast
2005;14:28 36.
5. Haid A, Koberle-Wuhrer R, Knauer M, Burtscher J,
Fritzsche H, Peschina W, Jasarevic Z, Ammann M,
Hergan K, Sturn H, et al. Morbidity of breast cancer patients
following complete axillary dissection or sentinel node biopsy
only: A comparative evaluation. Breast Cancer Res Treatment
2002;73:31 36.
6. Voogd AC, Ververs JM, Vingerhoets AJ, Roumen RM,
Coebergh JW, Crommelin MA. Lymphoedema and reduced
shoulder function as indicators of quality of life after axillary
lymph node dissection for invasive breast cancer. Br J Surg
2003;90:76 81.
7. Hayes S, Battistutta D, Newman B, Hayes S, Battistutta D,
Newman B. Objective and subjective upper body function
six months following diagnosis of breast cancer. Breast Cancer
Res Treatment 2005;94:1 10.
8. Harris SR, Campbell KL, McNeely ML. Upper extremity
rehabilitation for women who have been treated for breast
cancer. Physiother Can 2004;56:202 214.
9. Karki A, Simonen R, Malkia E, Selfe J. Impairments,
activity limitations and participation restrictions 6 and
12 months after breast cancer operation. J Rehabil Med
2005;37:180 188.
10. Ernst MF, Voogd AC, Balder W, Klinkenbijl JH, Roukema JA.
Early and late morbidity associated with axillary levels I III
dissection in breast cancer. J Surg Oncol 2002;(Suppl.)79:
151 155;discussion p 156.
11. Johansson K, Ingvar C, Albertsson M, Ekdahl C. Arm lymp-
hoedema, shoulder mobility and muscle strength after breast
cancer treatment a prospective 2-year study. Adv Physiother
2001;3:55 66.
12. Ivens D, Hoe AL, Podd TJ, Hamilton CR, Taylor I,
Royle GT. Assessment of morbidity from complete axillary
dissection. Br J Cancer 1992;66:136 138.
13. Yap KP, McCready DR, Narod S, Manchul LA, Trudeau M,
Fyles A. Factors influencing arm and axillary symptoms after
treatment for node negative breast carcinoma. Cancer
2003;97:1369 1375.
14. Kakuda JT, Stuntz M, Trivedi V, Klein SR, Vargas HI.
Objective assessment of axillary morbidity in breast cancer
treatment. Am Surgeon 1999;65:995 998.
15. Aitken RJ, Gaze MN, Rodger A, Chetty U, Forrest AP. Arm
morbidity within a trial of mastectomy and either nodal
sample with selective radiotherapy or axillary clearance. Br J
Surg 1989;76:568 571.
16. Duff M, Hill AD, McGreal G, Walsh S, McDermott EW,
OHiggins NJ. Prospective evaluation of the morbidity of
axillary clearance for breast cancer. Br J Surg 2001;88:
114 117.
17. Bendz I, Olsen MF. Evaluation of immediate versus delayed
shoulder exercises after breast cancer surgery including lymph
node dissection: A randomised controlled trial. Breast 2002;
11:241 248.
18. Foldvari M, Clark M, Laviolette LC, Bernstein MA,
Kaliton D, Castaneda C, Pu CT, Hausdorff JM,
Fielding RA, Singh MA. Association of muscle power
with functional status in community-dwelling elderly
women. J Gerontol. Ser A, Biolog Sci Med Sci 2000;55:
M192 199.
19. Capodaglio P, Strada MR, Lodola E, Grilli C, Panigazzi M,
Bazzini G, Bernardo G. Work capacity of the upper limbs after
mastectomy. Giornale Italiano di Medicina del Lavoro Ed
Ergonomia 1997;19:172 176.
20. American College of Sports Medicine. ACSMs Guidelines
for Exercise Testing and Prescription. Philadelphia: Lippin-
cott Williams & Wilkins; 2005.
21. Fielding RA, LeBrasseur NK, Cuoco A, Bean J, Mizer K,
Fiatarone Singh MA. High-velocity resistance training in-
creases skeletal muscle peak power in older women. J Am
Geriat Soc 2002;50:655 662.
22. Knuttgen H, Kraemer W. Terminology and measurement in
exercise performance. J Appl Sports Sci 1987;1:1 10.
23. Na YM, Lee JS, Park JS, Kang SW, Lee HD, Koo JY. Early
rehabilitation program in postmastectomy patients: A pro-
spective clinical trial. Yonsei Med J 1999;40:1 8.
 Decreased muscle strength following management of breast cancer
24. Megens AM, Harris SR, Kim-Sing C, McKenzie DC.
Measurement of upper extremity volume in women after
axillary dissection for breast cancer. Arch Phys Med Rehabil
1639;82:1639 1644.
25. Mondry TE, Riffenburgh RH, Johnstone PA. Prospective trial
of complete decongestive therapy for upper extremity lymphe-
dema after breast cancer therapy. Cancer J 2004;10:42 48.
26. Tasmuth T, von Smitten K, Kalso E. Pain and other sym-
ptoms during the first year after radical and conservative
surgery for breast cancer. Br J Cancer 1996;74:2024 2031.
27. Nikkanen TA, Vanharanta H, Helenius-Reunanen H. Swel-
ling of the upper extremity, function and muscle strength of
shoulder joint following mastectomy combined with radio-
therapy. Ann Clin Res 1978;10:273 279.
28. Lane K, Jespersen D, McKenzie DC. The effect of a whole
body exercise programme and dragon boat training on arm
volume and arm circumference in women treated for breast
cancer. Eur J Cancer Care 2005;14:353 358.
Disabil Rehabil Downloaded from informahealthcare.com by Northwestern University on 09/09/14
29. Allen GM, Gandevia SC, Neering IR, Hickie I, Jones R,
Middleton J. Muscle performance, voluntary activation and
perceived effort in normal subjects and patients with prior
poliomyelitis. Brain 1994;117(Pt 4):661 670.
30. Lloyd AR, Gandevia SC, Hales JP. Muscle performance,
voluntary activation, twitch properties and perceived effort in
normal subjects and patients with the chronic fatigue syn-
drome. Brain 1991;114(Pt 1A):85 98.
For personal use only.
1105
31. Todd G, Taylor JL, Butler JE, Martin PG, Gorman RB,
Gandevia S. Use of motor cortex stimulation to measure
simultaneously the changes in dynamic muscle properties
and voluntary activation in human muscles. J Appl Physiol
2007;102:1756 1766.
32. Harris SR, Hugi MR, Olivotto IA, Levine M. Clinical
practice guidelines for the care and treatment of breast
cancer: 11. Lymphedema. CMAJ: Can Med Assoc J 2001;
164:191 199.
33. Kilbreath S, Refshauge K, Beith J, Lee M. Resistance and
stretching shoulder exercises early following axillary surgery
for breast cancer. Rehabil Oncol 2006;24:9 14.
34. Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized
controlled trial of weight training and lymphedema in breast
cancer survivors. J Clin Oncol 2006;24:2765 2772.
35. Cheema BS, Gaul CA. Full-body exercise training improves
fitness and quality of life in survivors of breast cancer.
J Strength Conditioning Res 2006;20:14 21.
36. Johansson K, Tibe K, Weibull A, Newton RC. Low intensity
resistance exercise for breast cancer patients with arm lym-
phedema with or without compression sleeve. Lymphology
2005;38:167 180.
37. Hladiuk M, Huchcroft S, Temple W, Schnurr BE. Arm
function after axillary dissection for breast cancer: A pilot
study to provide parameter estimates. J Surg Oncol 1992;
50(Suppl.):47 52.