Does Lymphedema Affect the Postural Stability in Women After Breast Cancer?

Topics in Geriatric Rehabilitation • Volume 28, Number 4, 1–8 • Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

DOI: 10.1097/TGR.0b013e318270c89b

Does Lymphedema Affect the Postural Stability in Women After Breast Cancer?

Selda Basar , PhD, PT , Yesim Bakar , PhD, PT , I·lke Keser , PhD, PT , Hande Kaba , MSc, PT ,

Nevin Atalay Güzel , PhD, PT , Özlem Çinar Özdemir , MSc, PT , and I·rem Düzgün , PhD, PT

Author Affi liations: Faculty of Health Science, Department of

Physiotherapy and Rehabilitation, Gazi University, Ankara, Turkey (Drs

Basar, Keser, Güzel, and Düzgün); and School of Physical Therapy and

Rehabilitation, Abant Izzet Baysal University, Bolu, Turkey (Dr Bakar,

Mr Kaba, and Mr Özdemir).

The authors declared that there is no confl ict of interest.

Correspondence: Yesim Bakar, PT, PhD, School of Physical Therapy and

Rehabilitation, Abant Izzet Baysal University, Bolu, Turkey ( ptyesim@

yahoo.de ).

[AQ1]

Aim: The aim of this study was to evaluate the static postural

stability and fall risk of preelderly women with unilateral

secondary lymphedema after breast cancer.

Methods: This study was conducted on 46 preelderly

women (24 with unilateral secondary lymphedema and 22

healthy) aged from 52 to 69 years. The Biodex Balance

System was used to measure the parameters of postural

stability and fall risk. The data acquisition involved 3 trials of

20 seconds to test the postural stability test. It was made in 3

directions (overall, anterior-posterior, and mediolateral) and 2

conditions (once with open eyes, once with eyes closed). The

fall-risk test was performed under the following conditions:

(1) eyes open, fi rm surface; (2) eyes closed, fi rm surface;

(3) eyes open, foam surface; and (4) eyes closed, foam

surface.

Results: For the postural stability, signifi cant differences

( P � .000) were observed in overall, anterior-posterior, and

mediolateral displacement parameters in eyes closed condi-

tion between the lymphedema and healthy groups. There were

no statistically signifi cant differences in the fall-risk test results

among the lymphedema and healthy group ( P � 0.05).

Conclusion: Preelderly women with unilateral lymphedema

exhibited a lower postural stability compared with health

women. These results lead to think us that asymmetric fl uid

distribution in the upper body parts increases postural sway

and leaving them more vulnerable to falls.

Key words: balance , breast cancer , lymphedema , postural

stability , preelderly .

breast cancer, with an estimated 6% to 35% developing it sometime after breast cancer treatment. 4 - 6 It can range from mild to severe and can be a chronic condition that affects patients’ quality of life for years after cancer sur-gery. 7 , 8 Breast cancer–related lymphedema is associated with chronic or recurring swelling of the affected area. While the arm is the most common site, the chest and the upper back are also often involved. 9 , 10 Women commonly report symptoms such as pain, loss of sensation, stiff-ness, and impairment in the range of motion due to the swelling and limb changes of their affected arm. 11 - 13 These symptoms affected the upper body functions. In addition, biomechanics of the thoracic-shoulder area can be com-promised, 14 , 15 which can induce further upper body impair-ment. 16 The impairment of upper body function can lead to postural instability and imbalance. 17

The decline in postural control systems has been shown related to age. Elderly subjects often experience deteriora-tion in the integrity of many of the physiological systems, which participate in the control of postural stability. 18 - 20 Pos-tural balance requires the integrity of the central nervous system (CNS) for the recognition of the position and move-ment of the head relative to the body and the environment. In addition, to maintain body stability, the CNS depends on the afferent information of the vestibular, visual, proprio-ceptive, and interoceptive systems, which promote the interaction of the body in space. 21 , 22 It is known that aging promotes a decrease in the sensory systems responsible for postural balance, identifi ed as multisensory defi cit, making it diffi cult for the elderly subjects to maintain their balance. 23 Impaired balance in the elderly subjects has been shown to be an important factor that increases the risk of falls. 24 , 25

Few studies have analyzed balance in obese elderly people. 26 , 27 Being overweight or obese is modifying body geometry, increase the mass in different areas of the body, 28 , 29 and, therefore, impose functional limitations in the biomechanics associated with postural balance con-trol and daily living activities. 30 , 31 As overweight and obe-sity, BRCL also comprise asymmetric weight distribution, which may change postural stability. Until now, no study has analyzed the postural stability of elderly people with arm lymphedema. Thus, the aim of this study was to evalu-ate the static postural stability and fall risk of preelderly women with unilateral secondary arm lymphedema using the Biodex Balance System.

[AQ2]

Breast cancer–related lymphedema is the most com-mon chronic impairment following breast cancer surgery and/or radiotherapy. Lymphedema is the

accumulation of protein-rich fl uid due to damage and/or obstruction in lymphatic vessels and fl ow caused by lymph node dissection, surgery, or radiation therapy. 1 - 3 Lymph-edema is a common problem for patients diagnosed with

TGR200173.indd 1TGR200173.indd 1 14/09/12 5:17 PM14/09/12 5:17 PM

2 www.topicsingeriatricrehabilitation.com October–December 2012


METHOD Twenty-four women clinically diagnosed with second-ary lymphedema resulting from the surgical treatment of breast cancer and subsequent radiotherapy, and 22 healthy women were enrolled into the study. Lymphedema was defi ned as a difference in circumference of the arm more than 2 cm compared to the contralateral arm. The ages of the patients varied between 52 and 69 years.

All subjects provided informed written consent, and the investigation was carried out in accordance with the Decla-ration of Helsinki. All tests were implemented by the same physiotherapist, offering standardized verbal encourage-ment during each test. The research was approved by the Scientifi c Research Ethics Committee at the University of Gazi, Ankara.

The inclusion criteria were the following:

• Underwent unilateral radically mastectomy sur-gery

• Diagnosed with secondary arm lymphedema after breast cancer therapy

• Evaluated a 2- to 5-cm difference in the circum-ference measurements between right and left arm

• Had mild- to moderate-degreed lymphedema (A difference in circumference of up to 2 cm indi-cated mild lymphedema; a difference of 2 to 5 cm shows moderate lymphedema)

• Conserved lymphedema with a duration of at least 6 months.

• Age more than 50 years

Patients were excluded from the study according to following criteria:

• Having visual impairment, any orthopedic prob-lem, or venous insuffi cient of the lower extremity

• Having vestibular impairment • Having a previous diagnosis of coronary heart

disease, diabetes, or stroke • Undergoing lumpectomy or spinal surgery • Bilateral mastectomy

Static postural stability and fall risk were evaluated by the Biodex Balance System.

BIODEX BALANCE SYSTEM The Biodex Balance System (Biodex Medical Systems, Shirley, New York) was designed to evaluate problems relating to balance, proprioception, and neuromuscu-lar control. This testing machine consists of a multiaxial standing platform, which can be adjusted to provide vary-ing degrees of platform instability. A static platform surface can be selected. With this surface, a static situation is cre-ated. The ability of the patient to maintain static postural balance on this stable platform is assessed. The patient

[AQ3]

[AQ4]

stands on the platform and is instructed to try to balance or hold the platform in static position. Static platform is tested for a selected period of time. The patient’s ability to control the static stability of the platform is quantifi ed as a variance from the neutral position. In a static platform sys-tem, the center of gravity (CoG) moves laterally, and the vertical ground reaction force and center of pressure must follow. Patients must move their CoG (sway) to maintain balance, and this shift is measured in by the static platform systems.

Three indices are electronically generated: (1) anterior/posterior (AP) index (before and after movement in the sagittal plane), (2) medial/lateral (ML) index (side-to-side movement in the frontal plane), and (3) overall index (dis-persive index of balance performance). The overall index is known to be the best indicator of the overall ability of the patient to balance the platform. The output of this machine is such that the larger the numerical value of the balance index and the greater the degree of diffi culty in balancing the platform. 32

THE POSTURAL STABILITY TEST The Postural Stability Test emphasizes a patient’s ability to maintain center of balance. The patient’s score on this test represents deviations from center, thus a lower score is more desirable than a higher score.

Tests were performed while each patient stood on both legs for 20 seconds with the platform in its most

[AQ5]

Figure 1.




]

Figure 2.

stable position. The foot position on the platform was recorded and remained constant throughout each test. After the patient had acclimated to the platform, 3 trial repetitions should be performed before testing in static position. A 1-minute test period was given between trials. During the test, arms were placed at their sides ( Figure 1 ). The patient’s performance is noted as a stability index. It was made in 3 directions (overall, anterior-posterior, and mediolateral) and 2 conditions (once with open eyes, once with eyes closed). The stability index represents the vari-ance of platform displacement in degrees from level. At the completion of the test, a postural stability assessment report can be printed ( Figure 2 ). A high number indicates a lot of motion, which means the patient had diffi culty to maintain his/her balance. 33

MODIFIED CLINICAL TEST OF SENSORY INTEGRATION AND BALANCE The fall-risk test allows identifi cation of potential fall can-didates. The m-CTSIB test protocol conducted of 4 condi-tions for fall-risk assessment: condition 1—standing on a fi rm surface with eyes open, condition 2—standing with eyes closed on a fi rm surface, condition 3—standing on a foam surface with eyes open, and condition 4—stand-ing on a foam surface with eyes closed. Total test time was approximately 10 minutes for each subject. Although each subject was offered to have rest as needed, all subjects completed the 4 test conditions without rests. The subjects were tested in a quiet room with a linoleum fl oor. High-density viscoelastic foam (60 � 45 � 18 cm 3 ) was used. All subjects were tested by an investigator and were asked




to stand for 30 seconds timed in each condition. The trial was discontinued if the subjects opened their eyes during an eyes-closed trial, fell down, and moved their hands off their chest or their feet from the starting position. No talk-ing was allowed during the trials. Subjects were considered

to have an abnormal score if the average of the 3 trials was less than 30 seconds. The scores over the 3 trials were averaged automatically. In this protocol, stability index and sway index measured by Biodex Balance System. The Biodex Balance System tracks the subjects’ sway angle and

Figure 3. [AQ10]




among the lymphedema group and the control group ( P � 0.05) ( Tables 3 and 4).

DISCUSSION The static postural stability and fall risk in preelderly women with unilateral secondary lymphedema after breast can-cer and healthy controls was compared in this study. The primary fi ndings revealed that individuals with unilateral secondary lymphedema group demonstrated a worse bal-ance performance, and that postural activity was negatively affected in bilateral stance. The fi ndings also indicated that there is a trend in lymphedema group to deteriorate postural stability in anteroposterior (AP) and mediolateral (ML) directions when compared with the control group.

It is known that postural asymmetry can be affected fi rst in measures of the body weight applied to both feet among specifi c patients as a result of some diseases, 34 - 37 or in measures of the center of pressure and consequently the CoG mean positions especially on the ML direction. 38 - 40 Postural balance is fundamental in allowing us to perform tasks and maintain daily life. In other words, postural sta-bility has been defi ned as the ability to maintain an upright posture within the base of support 41 and is considered to be an important indicator of musculoskeletal health and physical performance. Balance can be defi ned as the ability to return the center of mass within the base of support to maintain body stability against perturbation. 42 Upper limb amputations cause in correlation to weight loss a shift of the trunk to the side of the amputation, an elevation of the shoulder on the amputation side and a torsion of the trunk. Muscular asymmetries induces shift of the CoG. To get the CoG over the legs, the amputee compensates the loss of weight by shifting the upper trunk to the side of the amputation. 43 As differences in postural activities were demonstrated in different patient groups in the previous studies, it is important to investigate the changes in sec-ondary lymphedema group.

Similarly, there was a remarkable difference between involved and uninvolved body part, which causes differ-ences in weight distribution in lymphedema patients. Signifi cant changes occur in body posture and function of

[AQ6]

direction from center. This measure is called as stability index . The stability index is the average position from cen-ter. The sway of the person was measured by the standard deviation of the stability index. This value is called the sway index . Poor balance described a risk factor for fall. At the completion of the test, a fall-risk assessment report can be printed with a score compared to normative data ( Figure 3 ). The direction of the sway is important with regard to the predisposition of a falls direction. 33

Statistical analysis All data were analyzed using the Statistical Package for the Social Sciences (version 11.5: SPSS, Chicago, Illinois). Demographic data of Lymphedema patients and controls were compared using Independent-Samples T Test. � � 0.05 was selected as the bias level for all analysis.

RESULTS The subject’s characteristics are summarized in Table 1 . No signifi cant differences were detected in age, height, weight, and BMI (body mass index) between the lymphedema and control groups ( P � 0.05). The results of the static test of postural stability are presented in Table 2 . Overall, anterior-posterior and mediolateral stability indexes with closed eyes increased in the lymphedema group compared with the control group ( P � 0.05). There were no statistically signifi cant differences in the fall-risk m-CTSIB test results

TABLE 1 Demographic Characteristics of the Subjects.

Lymphedema Group (n � 24),

X SD

Control Group (n � 22), X SD P

Age (y) 57.37 7.21 55.09 6.58 .26

Height (cm) 158.75 6.51 160.00 5.84 .49

Weight (kg) 70.08 7.75 72.18 10.55 .44

BMI (kg/m 2 ) 28.00 3.88 28.25 4.44 .83

Abbreviation: BMI, body mass index ( P � .05).

TABLE 2 Results of Postural Stability in Static Condition

Lymphedema Group (n � 24), X SD


Overall stability index eyes open 0.47 0.32 0.51 0.32 .66

Anterior-posterior stability index eyes open 0.37 0.30 0.40 0.2734 .69

Mediolateral stability index eyes open 0.19 0.15 0.21 01726 .71

Overall stability index eyes closed 2.64 0.93 1.29 0.53 .00

Anterior-posterior stability index eyes closed 2.07 0.79 1.00 0.51 .00

Mediolateral stability index eyes closed 1.27 0.46 0.60 0.40 .00




TABLE 3 Sway Index of Fall-Risk m-CTSIB Test


X SD


Eyes open fi rm surface

0.50 0.181 0.57 0.27 0.27

Eyes closed fi rm surface

0.92 0.57 0.87 0.29 0.68

Eyes open foam surface

1.19 0.58 1.08 0.37 0.46

Eyes closed foam surface

2.66 0.56 2.54 0.75 0.53

TABLE 4 Stability Index of Fall-Risk m-CTSIB Test


X SD


Eyes open fi rm surface

1.65 1.25 1.82 0.98 0.61

Eyes closed fi rm surface

1.87 1.18 1.98 1.03 0.75

Eyes open foam surface

3.32 1.70 2.68 1.40 0.19

Eyes closed foam surface

3.95 1.60 3.91 1.50 0.94

the spine in women who underwent mastectomy. Asym-metrical body weight distribution following surgery, which is not always compensated by the prosthesis weight, and changes in the loads of the shoulder girdle on the side of surgery, induces impairment of statics and dynamics of the chest and spine. Ku et al reported that the individuals with high BMI had a greater postural sway for bilateral and uni-lateral stance. They stated that weight distribution might relate to the increase of postural sway. 44 Menegoni et al indi-cated that only AP stability is correlated with body weight. In addition, weight gain in the BMI group induced a simi-lar effect on AP and ML stabilities in both gender groups. 45 Center of gravity horizontal motions are controlled by both feet with 2 different strategies along 2 directions: an ankle strategy in the AP direction and a hip strategy (involving load/unload mechanisms on both feet) in the ML one. 17 , 46 Generally, balance control in ML direction occurs at the hip and trunk of the body while the pelvis generates ML motion in the lateral direction. 23 In current study, the data showed that there was signifi cant deterioration in overall, anteroposterior, and mediolateral stability index of lymph-edema group. This situation may be due to different fl uid distribution of the upper body parts. The static control balance results for lymphedema group are more revealing with regard to their ability to maintain postural control. Asymmetric weight distribution may relate to the increase of postural sway. These results revealed that the lymph-edema group could not generate suffi cient muscle force to control the displacement of CoG.

An improved understanding of factors related to fall risk in preelderly women with unilateral secondary lymph-edema after breast cancer is important, given the high occurrence of falls in elderly population. 24 , 25 Rubenstein et al 47 stated that the risk of falls increases beyond 60 years of age, Era et al 48 assessed the postural balance of 7979 subjects who were 30 years old and over using a force platform and found that deterioration in balance function

started at a relatively young age and was accelerated from about 60 years onward. Falls are serious healthy problem for elderly people. 49 The association between postural sta-bility and risk of falls received attention in the literature. 50 Deterioration in postural control in elderly populations can be explained by impaired cognitive function 51 ; decline in sensory input such as visual, vestibular, and somatosen-sory input; decline in motor responses; and deterioration in sensory integration systems and other musculoskel-etal and neuromuscular systems, resulting in decreased muscle strength, impaired knee or plantar refl exes, slow reaction time, and decreased effi cacy of protective movement. 18 , 51 - 54

In the present study, it was found out that fall-risk m-CTSIB test results of lymphedema group were similar to that of control group. Since this research proved that postural stability deteriorated in preelderly women with unilateral secondary lymphedema, these results must not be interpreted that lymphedema group does not have fall risk. Therefore, preelderly women having unilateral secondary lymphedema seem to have high fall risk con-sidering the relationship between postural stability and fall risk.

As a result, it was found that signifi cant deterioration in overall, anteroposterior, and mediolateral stability index of preelderly women with unilateral lymphedema com-pared with healthy women. These results lead to think us that asymmetric fl uid distribution in the upper body parts increases postural sway and leaving them more vulnerable to falls. Reduction of lymphedema could be effective in decrease postural sway and also prevent falls. In literature, we could not fi nd any article about lymphedema and pos-tural stability. It is the fi rst study that shows how lymph-edema affected the postural stability. Follow-up studies should include a larger number of cases and the compari-son of complex decongestive physiotherapy outcomes on postural stability.




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[AQ8]

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AUTHOR QUERIES

TITLE: Does Lymphedema Affect the Postural Stability in Women After Breast Cancer?AUTHORS: Selda Basar, Yesim Bakar, I· lke Keser, Hande Kaba, Nevin Atalay Güzel, Özlem Çinar Özdemir, and I· rem Düzgün

[AQ1]: Please check whether the affi liations as set are OK.[AQ2]: Please expand BRCL.[AQ3]: Is radically OK or should be radical?[AQ4]: Is venous insuffi cient the proper word to be used here?[AQ5]: AP and ML are used both for antero-posterior and mediolateral, respectively and for anterior/posterior and medial/

lateral, respectively. Please abbreviate accordingly throughout.[AQ6]: [The primary fi ndings … in bilateral stance.]: Please check the changes to verify the intended meaning.[AQ7]: Ref 23: The manufacturer’s name has been inserted. Please verify and provide the location.[AQ8]: Ref 38: Updated per the online information. Please verify.[AQ9]: [Control of Posture and Gait]: Please provide the publisher and location for this book.[AQ10]: Please provide captions for all the three fi gures.


Does Lymphedema Affect the Postural Stability in Women After Breast Cancer?

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