In this study, improvements were found in scapulothoracic muscle strength and endurance, scapular dyskinesia, thoracic kyphosis, and balance in the CDP + SSE group. It was determined in the CDP + SSE group, compared to the CDP group, that there was a greater improvement in middle trapezius muscle strength and posture after the TP, and a greater improvement in scapulothoracic muscle strength, endurance and posture after the MP.
In patients with upper extremity lymphedema, along with changes in shoulder biomechanics, changes in scapular kinematics and muscle strength have been also observed [2, 3]. However, to the best of our knowledge, there was no study investigating the effect of CDP applied in patients with upper extremity lymphedema on scapular functions. We applied CDP in patients who developed lymphedema after mastectomy and evaluated their scapular functions. There was an increase in the lower trapezius muscle strength of the affected side in the CDP group, but there was no change in the scapular endurance and the amount of scapular shift. This change in muscle strength may be due to the decrease in extremity volume and improvement in function. However, it was concluded that only CDP was insufficient in patients with upper extremity lymphedema to increase muscular endurance or scapular position.
Different exercise approaches applied alone or in addition to CDP or CDP components in patients who develop BCRL can also be applied to increase lymphatic flow, protein resorption, and soft tissue flexibility [4, 27–33]. In a randomized controlled study examining the effects of resistant exercises in a patient group with MLD, the patients were divided into 2 groups and MLD treatment was applied in the first group for 1 or 2 weeks. In the second group, in addition to MLD treatment, 8 weeks of resistance exercise training for the upper extremity was applied. A significant increase was observed in the upper extremity muscle strength of the group in which the resistive exercise was applied compared to the other group [33]. In the study of Buchan et al., the effectiveness of whole body strengthening exercises and aerobic exercises were compared in patients with BCRL. At the end of the programs applied for 12 weeks, the upper extremity and grip strength of the group in which whole body strengthening exercise was applied showed a significant increase in the group in which aerobic exercise was applied [32]. In our study, an additional 8 weeks of SSE was applied in addition to CDP in the CDP + SSE group, and it was found that scapular region muscle strength, endurance, and scapular dyskinesia improved in this group at the end of the treatment. In the intergroup comparison, it was seen that scapular muscle strength and endurance improved more in the CDP + SSE group than in the CDP group. Reducing muscle tension around the scapular area, breaking the pain spasm cycle, and increasing the pain threshold and tissue flexibility may have affected these changes. In addition, increased activation of the deep muscles and better stabilization of the scapula may have been achieved.
It has been shown that BCRL can adversely affect not only the upper extremity and shoulder girdle, but also the thoracic region and spine [4–6]. In a case study, CDP was applied 3 days a week for 4 weeks in a case who developed lymphedema after mastectomy. It was observed that the thoracic kyphosis and lateral inclination angles decreased [12]. Unlike the literature, in our study there was no significant change in the postural parameters of the group in which only CDP was applied after the TP and MP. The fact that remedial exercises, which are included in the treatment of CDP, are part of a special exercise program that increases upper extremity muscle activity rather than posture and is prepared to stimulate the lymphatic system, may be the reason why no change was observed in the thoracic and general posture parameters. In this context, there is a need for randomized controlled studies examining the effects of CDP on changing posture in upper extremity lymphedema patients.
To our knowledge, a limited number of studies have examined the effects of exercise practices on posture in patients with BCRL. Loudan et al. examined the effects of yoga on posture in patients with BCRL. The pelvic angle, which was measured as 25º before the treatment, decreased to 15º at the end of 8 weeks, a significant difference, and decreased to 13º at the end of 12 weeks. The thoracic kyphosis angle decreased from 31º to 28º, which was not significant [4]. In our study, it was found that thoracic kyphosis decreased and general posture improved after treatment in the CDP + SSE group. In addition, a decrease in thoracic kyphosis was observed after the TP in this group. In the comparison between the groups, it was determined that the general posture improved in the CDP + SSE group compared to the CDP group. These results may be due to the maintenance of vertical posture and kinesthetic awareness with SSE [14, 34].
The balance problems in BCRL is important and should be treated. However, the number of studies examining the effects of CDP on balance is limited. Yoosefinejad et al. applied CDP in treatment phase for 5 days a week for 2 weeks in patients who developed BCRL. Significant improvement was found in balance scores at the end of the treatment [13]. Celenay et al. applied 12 sessions treatment phase of CDP and it was concluded that the patient’s static and dynamic balance improved [12]. Unlike the literature, in our study, the treatment phase of CDP was 3 weeks, and then the patients were followed up with a 5-week maintenance phase and no improvement was observed. Many factors such as proper posture, anatomical integrity and symmetry of the extremities, adequate muscle strength, endurance and sensory input, and sufficient range of motion are required in maintaining balance [35]. The diversity of factors affecting balance may be a reason why CDP did not have a positive effect on balance in our study. In this context, there is a need for further studies that comprehensively examine the effects of CDP on balance in patients with upper extremity lymphedema.
There were also studies investigating the effects of different exercise approaches on balance in patients with BCRL. In a study conducted in patients who developed BCRL, the patients were divided into 2 groups. While CDP was applied in one group for 6 weeks, the other group was given balance training in addition to CDP applied for 6 weeks. It was found that there was a significant decrease in anteroposterior and mediolateral sways in the group that received balance training at the end of 6 weeks [36]. In our study, a significant improvement was observed in the intuitive, reactive postural control, and dynamic gait balance sub-parameters of the CDP + SSE group after the treatment, and in the total balance scores both before PT and after MP. The reason for the improvement in balance may be due to the SSE given in this group. These exercises contribute to the development of postural smoothness, increase in scapular region muscle strength and muscle endurance, and increase in proprioceptive input to the thoracic region [15–17, 24]. The fact that there was no change in posture and balance parameters of the group in which only CDP was applied, but positive changes in posture and balance were obtained in the group that was administered SSE, shows that the scapulothoracic region is important for posture and balance. There was no significant change in balance parameters between the groups. The lack of difference between the groups in terms of balance parameters may be due to the fact that many parameters were effective on balance [35].
There were some limitations of our study. In our study, the patients were followed for 8 weeks. Further studies investigating the long-term follow-up are needed. In our study, the evaluation of the effect of SSE applied in addition to CDP and CDP on balance was evaluated with the valid and reliable MiniBest scale. However, there is a need for studies in which the balance can be evaluated in more detail and objectively within the scope of this subject.
In this study, it was concluded that SSE applied in addition to CDP in patients who developed unilateral lymphedema after mastectomy was more effective in providing proper posture and improving scapulothoracic muscle function compared to CDP applied alone. Considering that the scapulothoracic region, posture, and balance may also be affected in these patients, it is recommended to integrate SSE into the treatment.