Exercise reduces arm and shoulder disability, pain in women recovering after breast cancer surgery

The debilitating arm and shoulder disability and pain that some women who have had breast cancer surgery experience as a side effect of their surgery can be reduced by following a physiotherapy-led exercise programme after their operation, a new study has found.

Researchers led nationally by the University of Warwick with University Hospitals of Coventry and Warwickshire NHS Trust saw an improvement in shoulder and arm mobility and reduction in pain amongst women who were recovering after non-reconstructive breast cancer surgery after taking part in the structured PROSPER rehabilitation programme.

Published in The BMJ, the study authors are calling for wider adoption of the PROSPER programme in cancer services to improve the wellbeing of women recovering from breast cancer surgery. The study was funded by the National Institute for Health Research (NIHR), the research partner of the NHS, public health and social care.

In non-reconstructive breast cancer surgeries, which includes women having mastectomy and surgery to the axilla (armpit), surgeons aim to remove the cancer and often some nodes in the armpit to control the cancer. This targeted treatment can leave patients with shoulder and arm problems, including chronic pain, restricted movement and arm swelling (known as lymphoedema). Past research has shown that as many as one third women recovering from breast cancer surgery can struggle to return to everyday tasks such as lifting bags and driving.

Usual care is to give an advice leaflet explaining exercises to do after breast cancer surgery. As part of the Prevention of Shoulder Problems Trial (PROSPER), researchers led from the University of Warwick worked with physiotherapists and breast cancer patients to design an exercise programme for those at higher risk of developing shoulder problems. The PROSPER exercise programme consists of an assessment with a physiotherapist at one week after their surgery, and followed by a prescribed programme of stretching, range of motion and resistance exercises.

In what is the largest trial in this patient group to date, they recruited 392 women undergoing non-reconstructive breast cancer surgery who were at higher risk of developing shoulder or arm complications. Half were randomly assigned to take part in the PROSPER rehabilitation programme, and half to receive usual care (advice leaflets only). 17 UK National Health Service cancer centers recruited to the trial, including at University Hospitals of Coventry and Warwickshire NHS Trust which was the top recruiter for the trial.

Participants were asked to complete questionnaires on their arm function, pain and overall quality of life over a 12 month period. After 12 months, women in the exercise group reported fewer arm disability symptoms, lower pain intensity, and better physical quality of life than those in the usual care group.

Professor Julie Bruce of Warwick Clinical Trials Unit at the University of Warwick, and principal investigator on the PROSPER trial, said: “We know that some women present to physiotherapy services and pain clinics further down the line with shoulder restriction and pain problems, so we wanted to test a rehabilitation programme to find out if this could help at an early stage."

We hope these results will encourage NHS Trusts to consider offering this service to women having non-reconstructive breast cancer surgery. This would mean training physiotherapists in the PROSPER rehabilitation programme. This is a proven cost-effective programme that we know can help women undergoing certain breast cancer procedures, and it could be offered on the NHS.”

Julie Bruce, Professor, Warwick Clinical Trials Unit, University of Warwick

Breast cancer is the commonest cancer in the UK, with over 50,000 women newly diagnosed with breast cancer each year. Thanks to screening programmes and new treatments that allow doctors to act earlier, women now survive for longer after their cancer treatment. This also means a greater number of women seeking treatment for arm and shoulder problems following their surgery.

Co-author Professor Alastair Thompson, professor and section chief of breast surgery at Baylor College of Medicine’s Dan L Duncan Comprehensive Cancer Center, said: “After breast cancer surgery, arm and shoulder disability impacts the functioning and quality of life for many women. Using a physiotherapy led exercise program introduced a week or so after surgery, led to better upper limb function, less pain and lower costs, up to a year later without any adverse impacts. This randomized trial demonstrates the benefits of early, supported exercise after breast surgery should become standard practice in women treated for breast cancer.”

• ‘Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicenter randomized controlled trial and economic evaluation’ is published in The BMJ, DOI: 10.1136/BMJ-2021-066542 Link: https://www.bmj.com/content/375/bmj-2021-066542
• The institutions involved in this research were: University of Warwick; University Hospitals Coventry and Warwickshire; University of Oxford; Royal Wolverhampton NHS Trust and Baylor College of Medicine, USA.
• Co-authors from University of Oxford led the economic evaluation and also contributed significantly to co-development of the PROSPER programme
• The research has informed a new online, free-to-access Futurelearn course, aimed at health professionals, to teach them how to deliver the PROSPER programme to their patients as part of routine care. Funded by the University of Exeter and led by Professor Sallie Lamb, the course is open to registration, launches on November 29, and aims to swiftly roll out the PROSPER programme to benefit patients.