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The Hertel model of chronic ankle instability (CAI) is commonly used in research but may not be sufficiently comprehensive. Mechanical instability and functional instability are considered part of a continuum, and recurrent sprain occurs when both conditions are present. A modification of the Hertel model is proposed whereby these 3 components can exist independently or in combination. To examine the fit of data from people with CAI to 2 CAI models and to explore whether the different subgroups display impairments when compared with a control group. Cross-sectional study. Community-dwelling adults and adolescent dancers were recruited: 137 ankles with ankle sprain for objective 1 and 81 with CAI and 43 controls for objective 2. Two balance tasks and time to recover from an inversion perturbation were assessed to determine if the subgroups demonstrated impairments when compared with a control group (objective 2). For objective 1 (fit to the 2 models), outcomes were Cumberland Ankle Instability Tool score, anterior drawer test results, and number of sprains. For objective 2, outcomes were 2 balance tasks (number of foot lifts in 30 seconds, ability to balance on the ball of the foot) and time to recover from an inversion perturbation. The Cohen d was calculated to compare each subgroup with the control group. A total of 56.5% of ankles (n = 61) fit the Hertel model, whereas all ankles (n = 108) fit the proposed model. In the proposed model, 42.6% of ankles were classified as perceived instability, 30.5% as recurrent sprain and perceived instability, and 26.9% as among the remaining groups. All CAI subgroups performed more poorly on the balance and inversion-perturbation tasks than the control group. Subgroups with perceived instability had greater impairment in single-leg stance, whereas participants with recurrent sprain performed more poorly than the other subgroups when balancing on the ball of the foot. Only individuals with hypomobility appeared unimpaired when recovering from an inversion perturbation. The new model of CAI is supported by the available data. Perceived instability alone and in combination characterized the majority of participants. Several impairments distinguished the sprain groups from the control group.

The purpose of this study was to assess the safety and efficacy of progressive resistance training (PRT) in breast cancer. Randomized controlled trials (RCTs) published to November 2013 that reported on the effects of PRT (>6 weeks) on breast cancer-related lymphedema (BCRL) (incidence/exacerbation, arm volume, and symptom severity), physical functioning (upper and lower body muscular strength), and health-related quality of life (HRQoL) in breast cancer patients were included. Of 446 citations retrieved, 15 RCTs in 1,652 patients were included and yielded five studies on BCRL incidence/exacerbation ( N  = 647), four studies on arm volume ( N  = 384) and BCRL symptom severity ( N  = 479), 11 studies on upper body muscular strength ( N  = 1,252), nine studies on lower body muscular strength ( N  = 1,079), and seven studies on HRQoL ( N  = 823). PRT reduced the risk of BCRL versus control conditions [OR = 0.53 (95 % CI 0.31–0.90); I 2  = 0 %] and did not worsen arm volume or symptom severity (both SMD = −0.07). PRT significantly improved upper [SMD = 0.57 (95 % CI 0.37–0.76); I 2  = 58.4 %] and lower body muscular strength [SMD = 0.48 (95 % CI 0.30–0.67); I 2  = 46.7 %] but not HRQoL [SMD = 0.17 (95 % CI −0.03 to 0.38); I 2  = 47.0 %]. The effect of PRT on HRQoL became significant in our sensitivity analysis when two studies conducted during adjuvant chemotherapy [SMD = 0.30 (95 % CI 0.04–0.55), I 2  = 37.0 %] were excluded. These data indicate that PRT improves physical functioning and reduces the risk of BCRL. Clinical practice guidelines should be updated to inform clinicians on the benefits of PRT in this cohort.

Shoulder movement impairment is a commonly reported consequence of surgery for breast cancer. The aim of this study was to determine whether shoulder girdle kinematics, including those of the scapula, spine, and upper limb, in women who have undergone a unilateral mastectomy for breast cancer are different from those demonstrated by an age-matched control group. An observational study using 3-dimensional kinematic analysis was performed. Women who had a unilateral mastectomy on their dominant-arm side (n=29, mean [+/-SD] age=62.4+/-8.9 years) or nondominant-arm side (n=24, mean [+/-SD] age=59.8+/-9.9 years), as well as a control group of age-matched women without upper-limb, shoulder, or spinal problems (n=22, mean [+/-SD] age=58.1+/-11.5 years), were measured while performing bilateral arm movements in the sagittal, scapular, and coronal planes. All of the women were free of shoulder pain at the time of testing. Data were collected from the glenohumeral joint, the scapulothoracic articulation, and the spine (upper and lower thoracic and lumbar regions) using an electromagnetic tracking system. Women following mastectomy displayed altered patterns of scapular rotation compared with controls in all planes of movement. In particular, the scapula on the mastectomy side rotated upward to a markedly greater extent than that on the nonmastectomy side, and women following mastectomy displayed greater scapular excursion than controls. The findings suggest that altered motor patterns of the scapula are associated with mastectomy on the same side. Whether these changes are harmful or not is unclear. Investigation of interventions designed to restore normal scapulohumeral relationships on the affected side following unilateral mastectomy for breast cancer is warranted.

PurposePhysical activity is a well-established strategy to alleviate breast cancer-related adverse outcomes. To optimise health benefits, behaviour change theories provide frameworks to support women in improving their physical activity. This review aimed to evaluate (i) the effects of behaviour change theory-based physical activity interventions for women with breast cancer and (ii) the application of these theories.MethodsSeven online databases were searched. Trials were included if randomised and controlled, involved physical activity interventions ≥ 12 weeks duration, used a behaviour change theory, and participants were < 3 years post-cancer treatment. Risk of bias and theory use were assessed. Data were synthesised narratively and meta-analysed.ResultsForty articles describing 19 trials were included. Overall risk of bias was moderately high. Post-intervention pooled effect estimates were medium for self-reported (SMD = 0.57) and objectively measured physical activity (SMD = 0.52). Most trials cited the social cognitive theory (n = 10) and transtheoretical model (n = 9). Trials rarely applied theories in their entirety, expounded on behavioural mechanisms, or tailored interventions according to behavioural constructs. The most commonly used types of behavioural techniques were goals and planning (n = 18), shaping of knowledge (n = 18), feedback and monitoring (n = 17), and comparisons of outcomes (n = 17).ConclusionsThe included trials were effective for increasing physical activity in women with breast cancer. Theories were applied using a wide range of approaches and levels of rigour, although shared the use of common behavioural techniques.Implications for Cancer SurvivorsFuture research may benefit breast cancer survivors by more comprehensively applying behaviour change theories, emphasising individual patient needs and goals.

Purpose The purpose of this study was to evaluate the efficacy of exercise, either alone or in combination with other interventions, compared to a control, for the preservation of bone mineral density (BMD) in early breast cancer (BC) patients. Methods A systematic search was conducted to identify randomized or quasi-randomized trials which met inclusion criteria including prescribed exercise for ≥12 months. Ten publications from seven randomized controlled trials (RCTs), involving 1199 participants, were identified. Data on primary and secondary outcome measures related to BMD at the lumbar spine, total hip, femoral neck and greater trochanter were analysed. Meta-analyses were limited to subgroups by menopausal status as other data could not be pooled. Results Based on mean differences or mean percentage differences between groups at 1 year, exercise did not preserve BMD or bone mineral content at any site in post-menopausal women. In contrast, evidence from one RCT ( n  = 498) found that exercise reduced bone loss in pre-menopausal women at the femoral neck [% MD = 1.20 (95% CI 0.22–2.18); P  = 0.02] but not at the lumbar spine. Conclusions Although this review indicated that exercise may result in a clinically important preservation of bone health among pre-menopausal but not post-menopausal women, further studies are needed to confirm whether or not exercise is important in preservation of bone health in women diagnosed with early BC. Implications for cancer survivors Exercise alone may not be sufficient to prevent bone loss in post-menopausal women at high risk of osteoporosis. Further evidence is required to determine if it provides any benefit to pharmacological therapy.

The aim of this study was to determine whether an exercise program, commencing 4–6 weeks post-operatively, reduces upper limb impairments in women treated for early breast cancer. Women ( n  = 160) were randomized to either an 8-week exercise program ( n  = 81) or to a control group ( n  = 79) following stratification for axillary surgery. The exercise program comprised a weekly session and home program of passive stretching and progressive resistance training for shoulder muscles. The control group attended fortnightly assessments but no exercises were provided. The primary outcome was self-reported arm symptoms derived from the EORTC breast cancer-specific questionnaire (BR23), scored out of 100 with a low score indicative of fewer symptoms. The secondary outcomes included physical measures of shoulder range of motion, strength, and swelling (i.e., lymphedema). Women were assessed immediately following the intervention and at 6 months post-intervention. The change in symptoms from baseline was not significantly different between groups immediately following the intervention or at 6 m post-intervention. The between group difference immediately following the intervention was 4 (95% CI −1 to 9) and 6 months post-intervention was 4 (−2 to 10). However, the change in range of motion for flexion and abduction was significantly greater in the exercise group immediately following the intervention, as was change in shoulder abductor strength. In conclusion, a supervised exercise program provided some, albeit small, additional benefit at 6 months post-intervention to women who had been provided with written information and reminders to use their arm. Both the groups reported few impairments including swelling immediately following the intervention and 6 months post-intervention. Notably, resistance training in the post-operative period did not precipitate lymphedema.

Introduction In the absence of monitoring programs, those at risk of developing breast cancer–related lymphoedema (BCRL) must detect its development. However, the efficacy of self-assessment for BCRL has not been widely investigated. This study will determine if symptoms and signs of BCRL are associated with lymphoedema detected by bioimpedance spectroscopy (BIS) and whether those with and without BCRL can accurately assess the signs of its presence. Methods and results Participants with a history of breast cancer ( n  = 100) reported the presence/absence of symptoms associated with upper limb BCRL and underwent assessment for pitting oedema and differences in tissue texture between their arms (pinch). BIS detected BCRL in 48 women. Women were more likely to have BIS-detected BCRL if they reported swelling (odds ratio (OR), 58.8; 95% CI, 4.9 to 709.4; p  = 0.001) or had inter-limb tissue texture differences in their forearm (OR, 73.5; 95% CI, 7.3 to 736.9; p  = < 0.001) or upper arm (OR, 23.9; 95% CI, 2.8 to 201.7; p  = 0.003). Agreement between therapist and self-assessment of signs of BCRL was almost perfect (kappa, 0.819 to 0.940). A combination of self-reported swelling and/or self-assessed forearm tissue texture difference identified all cases of BIS-detected BCRL. Conclusion Participants accurately identified the presence or absence of physical signs of BCRL in their arm. Perceived swelling and differences in tissue texture in the affected arm were associated with, and sensitive to, BIS-detected BCRL. These findings support the use of self-assessment to determine if BCRL is developing, indicating the need for professional assessment.

Background The current study assessed the level of reliability of ultrasound to assess dermal thickness, a clinical feature of breast lymphedema. Additionally, the relationship of dermal thickness to patient‐reported outcomes was investigated. Methods Women (n = 82) with unilateral breast edema secondary to treatment of breast cancer were randomized to an exercise or control group. Ultrasound measurements of the unaffected and affected breasts were taken at baseline and 12 weeks later at 3–4 cm superior, medial, inferior, and lateral to the nipple. Additionally, women completed breast‐related questions from the European Organization Research and Treatment Committee Quality of Life breast cancer module (EORTC‐BR23) and Lymphedema Symptom Intensity and Distress Questionnaire (LSIDS). Reliability of ultrasound measurements was determined on the unaffected breast. Results Intraclass correlation coefficients (2,1) ranged from 0.66 (95% CI: 0.52–0.77) for the lateral location to 0.84 (0.77–0.90) for the superior location. Percent close agreement (80%) on the unaffected breast ranged from 0.20 to 0.27 mm compared to 0.57 to 0.93 mm on the affected breast. The standard error of measurement (%) on the unaffected breast varied from 9% to 13% with smallest real difference 0.34–0.41 mm. Dermal thickness of the affected breast was not‐to‐poorly associated with EORTC BR23 and LSIDS scores. Conclusion Reliability of dermal thickness measurements of the breast was excellent for the superior, medial, and inferior locations, and fair to good for the lateral location. However, these measurements were not related to the symptom's women perceive and measured with the EORTC BR23 or LSIDS.

The aim of this systematic review was to identify the prevalence and severity of upper limb problems following surgery and radiation for early breast cancer. Additionally, the independent prognostic contribution of radiation, type of breast surgery, type of axillary surgery, age and body mass index (BMI) was evaluated. Searches of electronic databases were conducted to identify articles that reported upper limb and quality of life outcomes after breast cancer surgery and external radiation. Eligible studies for prognosis were longitudinal in design, with ≥95% of patients treated by surgery and radiation that excluded the axilla. Cross-sectional studies were also included for identification of prognostic factors. Where possible, the contribution of independent prognostic factors was analyzed. The review identified 32 relevant studies. Shoulder restriction was reported in between <1% and 67% of participants, lymphedema was reported in between 0 and 34% of participants, shoulder/arm pain was reported in between 9 and 68% of participants and arm weakness was reported in between 9 and 28% of participants. Quality of life was high across studies. Irradiated patients had slightly increased odds of lymphedema (OR = 1.46, 95% CI 1.16–1.84) and shoulder restriction (OR = 1.67, 95% CI 0.98–2.86) compared with non-irradiated patients. For patients undergoing surgery and radiation for breast cancer, the prognosis is good in terms of the upper limb and quality of life. Radiation that excludes the axilla does not appear to be a strong prognostic indicator of adverse upper limb outcomes.

Purpose This study aimed to explore differences in physical activity and fitness between women with metastatic breast cancer compared to healthy controls and factors associated with their physical activity levels. Methods Seventy-one women with metastatic breast cancer, aged (mean (SD)) 57.7 (9.5) and 2.9 (3.1) years after the onset of metastatic disease, and 71 healthy controls aged 55.0 (9.4) years participated. Of those with metastatic disease, 27 % had bone-only metastases, 35 % visceral-only metastases and 38 % bone and visceral metastases. Patient-reported outcomes and physical measures of muscle strength and aerobic fitness assessments were obtained. Participants wore a SenseWear® physical activity monitor over 7 days, and the average steps/day and the time spent in moderate-to-vigorous intensity physical activity were determined. Results Women with metastases were significantly (i) less aerobically fit than the control group (25.3 (5.4) vs. 31.9 (6.1) mL • kg −1  • min −1 ; P  < 0.001); (ii) weaker (e.g. lower limb strength for the metastatic and control groups was 53.5 (23.7) vs. 76.0 (27.4) kg, respectively; P  < 0.001); (iii) less active, with the metastatic group attaining only 56 % of the mean daily step counts of the healthy women; and (iv) more symptomatic, reporting higher levels of fatigue and dyspnoea ( P  < 0.001). Conclusion Women living in the community with metastatic breast cancer possessed lower aerobic fitness, reduced muscular strength and less daily physical activity compared to healthy counterparts. They also experienced poorer functioning and higher symptom burden. Implications for Cancer Survivors Women living with metastatic breast cancer may benefit from a physical activity programme to address their physical impairments.