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Systematic Review
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Effects of aquatic exercises in woman who have undergone surgery after breast cancer: a systematic review with meta-analysis
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Carla T. Silvaa, Claudia K. Silvaa, Juliano Casonattob, Aline C. Carrascoa,c, Joseph G. McVeighd, Jefferson R. Cardosoa,
Corresponding author
jeffcar@uel.br

Corresponding author. Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group and Aquatic Physical Therapy Center ‘‘Prof. Paulo A. Seibert”, Associated Graduate Program in Rehabilitation Science UEL-Unopar, Universidade Estadual de Londrina, Av. Robert Kock, 60, Londrina PR, Brazil.
a Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Associated Graduate Program in Physcial Education UEL-UEM, Universidade Estadual de Londrina, Londrina, PR, Brazil.
b Universidade Norte do Paraná, Research Group in Physiology and Physical Activity, Londrina, PR, Brazil
c Universidade Estadual do Centro-Oeste, Guarapuava, PR, Brazil
d College of Medicine and Health, University College Cork, Cork, Ireland
Highlights

  • Breast cancer treatments can cause numerous deleterious effects for survivors

  • Aquatic exercises may help reduce complaints arising from cancer treatments

  • Aquatic exercises may improve quality of life in patients with breast cancer compared to usual care.

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Abstract
Background

Breast cancer (BC) is the most common cancer among women, with an incidence of 310,720 new cases for the year 2024. In addition to survival, quality of life has become an important outcome measure in BC clinical investigations.

Objective

To evaluate the effects of aquatic exercises (AE) on quality of life (QoL), lymphedema, pain, fatigue, and range of motion in breast cancer survivors compared to land exercise and a control group.

Design

Systematic review. Ten databases were searched from inception until February 2024. Risk of bias and certainty of evidence were assessed using the Risk of Bias 2 tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Pooled effects were calculated using standardized mean difference (SMD) and 95 % confidence interval (CI).

Results

A total of 1873 studies were identified, 10 were included in the review and four were included in a meta-analyses. Only 30 % (n = 3) of the studies were classified as having a low risk of bias. The effect of AE on the emotional subdomains of the QoL was superior to usual care (SMD=0.58; 95 % CI: 0.1, 0.9; =0 %) but the certainty of evidence was rated as very low. When AE was compared with land exercise, no significant differences were found for pain (SMD=1.1; 95 % CI: 1.5, 3.7; =97 %) with the certainty of evidence graded as low.

Conclusions

Although further studies of high methodological quality are needed to provide more robust conclusions, AE may improve QoL outcome and emotional subdomain compared to usual care, but the evidence is very uncertain.

Keywords:
Aquatic exercise
Breast cancer
Hydrotherapy
Lymphedema
Meta-analysis
Systematic review
Full Text
Introduction

The number of cancer survivors in the United States has reached 15.5 million, and it is estimated that this number will double by 2040.1 Breast cancer (BC) is the most common cancer among women, with an incidence of 310,720 new cases for the year 2024.2 In addition to survival, quality of life (QoL) is an important outcome measure in BC clinical investigations, often reflecting quality health care and highlighting issues related to the deleterious effects of treatments.

Physical exercise is important during the recovery process in BC,3 with guidelines recommending 150 min of moderate-intensity aerobic exercise or 75 min of high-intensity exercise per week, plus muscle-strengthening exercise at least twice a week.4,5 Aquatic exercise (AE) is a safe, non-pharmacological intervention for those recovering from BC. The benefits of AE are obtained, through a combination of fluid mechanics and the characteristics of the environment itself (temperature). For example, shoulder range of motion (ROM), often restricted due to the healing process and/or radiotherapy, can be improved with simple AE and exercises performed with less pain when compared to land exercise. Water temperature (which can improve lymphatic clearance) combined with hydrostatic pressure can reduce lymphedema by approximately 21.4 %, (95 % CI`: 14.9, 29.8) in individuals three months to 20 years after BC diagnosis.6

Five systematic reviews7-11 investigated the effects of AE compared to usual care for the outcomes: lymphedema,8,11 fatigue,7,10,11 pain,10,11 shoulder ROM,10 cardiorespiratory fitness,10 muscle strength,10 body composition,10 pulmonary function,10 and quality of life10,11 in BC survivors. Two meta-analyses were performed on lymphedema and physical function (QoL) outcomes9 and no differences were found between the groups. Notwithstanding the literature to date there remains some controversy on the effectiveness of AE in the management of BC. The results in the literature are inconclusive because primary studies are lacking in methodological quality and previous systematic reviews were unable to extract results while taking into account the risks of bias.

Furthermore, a literature review identified approximately 40 studies that were not located in the cited reviews, clearly identifying the need for an updated review. This review aims to answer the following clinical question: In people with breast cancer, what are the effects of AE on QoL, lymphedema, pain, fatigue, and ROM, compared with land exercises and usual care, after at least eight weeks of treatment?

Methods

This systematic review and meta-analyses of randomized controlled trials was performed adhering to the guidelines of the Cochrane Collaboration,12 the PRISMA 2020 Statement,13 and AMSTAR 2.14 It was registered with PROSPERO (CRD42024506498).

Data sources and searches

A total of 10 databases were searched from inception until February 2024: Web of Science (1945), EMBASE (Excerpta Medical Database, 1947), PUBMED (U.S. National Library of Medicine, 1950), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982), LILACS (Latin American and Caribbean Health Science, 1982), SPORTDiscus (1985), Cochrane Library (1988), Scopus (1996), SciELO (Scientific Electronic Library Online, 1998), and PEDro (Physiotherapy Evidence Database, 1999). The keywords used were combined with Boolean operators and are available in the appendix (Supplementary material A).

The search strategy was formulated independently by two researchers for each database, to ensure reliability and reproducibility. Any disagreements were resolved by discussion. Studies were included if they met the following criteria according to the methodology: Population, Intervention, Comparison, Outcome, and Time (PICOT).

(P) Population: women undergoing unilateral surgical treatment after BC;

(I) Intervention: studies were eligible if they included an arm of the treatment dedicated to AE;

(C) Comparison: land exercise and/or usual care;

(O) Outcomes: QoL, lymphedema, fatigue, pain, and ROM;

(T) Time: greater than eight weeks intervention.

Study selection

After the preliminary searches were completed, each article was examined for relevance and citations checked for additional papers not found in the original search. BC experts were also consulted about additional studies of interest. There were no language restrictions on searches.

Studies that performed AE in the management of women who had undergone surgical treatment for BC were included. AE were defined as: an individual or group intervention where participants were immersed in water in all treatment sessions proposed by the study. Initially the studies were pooled, according to treatment time, into short-term (8–12 weeks), medium-term (13–24 weeks), and long-term (>24 weeks) and/or comparison.

Outcomes

The primary outcomes of interest were QoL, lymphedema, and fatigue, secondary outcomes were ROM and pain.

Data extraction and quality assessment

Two reviewers independently assessed each included study for risk of bias with the Cochrane Risk of Bias 2 tool for clinical trials (RoB-2),15 any disagreements were resolved through discussions. The RoB-2 tool examines five main sources of bias: 1) Randomization; 2) Deviations from intended interventions; 3) Missing outcome data; 4) Outcome measurement; 5) Selection of the reported outcome. Bias is classified as “high risk of bias”, “some concerns”, and “low risk of bias”.

To assess the overall certainty of evidence, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used.16 The GRADE tool classifies the certainty of evidence for each result in the following domains: limitations of the studies (risk of bias, according to the recommendations of the Cochrane Collaboration Handbook), inconsistency of results (heterogeneity or variability of results), imprecision (small sample and wide confidence intervals), indirect evidence (comparison of two different treatments with the usual care and not tested face-to-face), and publication bias (small number of studies and funding sources). The certainty of evidence is classified as follows17:

  • High: all GRADE domains have been met, indicating high degree of confidence in the findings.

  • Moderate: one of the GRADE domains was not met, suggesting a need for more studies to improve the certainty of evidence.

  • Low: two GRADE domains were not met, indicating a need for more research.

  • Very low: three or more GRADE domains were not met, suggesting that the results of the studies are uncertain

Data synthesis and analysis

Information from the included studies was extracted and presented descriptively. The standardized mean difference (SMD) was used for analysis of continuous data, with 95 % confidence interval [95 % CI]. Study authors were contacted when more information was needed for effect size and risk of bias calculations.

All analyses were conducted using the random-effects inverse variance approach proposed by Hartung and Knapp and by Sidik and Jonkman.18 To assess heterogeneity, the chi-square test was used to verify the studies included in the meta-analysis. Inconsistencies were estimated using the I² statistic, where 25, 50, and 75 % were low, moderate, and high heterogeneity thresholds, respectively. Sensitivity analyses were performed by removing the study with the highest “weight” for each cluster, the random effect model was adopted. Statistical analyses were performed using the Comprehensive Meta-analyses v3. Statistical significance was set at 5 %.

Results

Supplementary material B provides an overview of the research selection process until inclusion in the meta-analyses (PRISMA Flow Diagram). Database searches identified 1813 studies, of which 41 met the inclusion criteria and 34 were excluded.19-52

Therefore, 10 studies53-62 were considered in this review and, four were included in the meta-analyses.5356 The year of publication ranged from 2010 to 2024. The characteristics of the included studies are shown in the Supplementary material C. The descriptive analysis of the results was presented according to the guidelines of the synthesis in systematic reviews63 and the criterion adopted was the classification of risk of bias.

Characteristics of BC survivors

A total of 505 BC survivors were included, with ages ranging from 44 to 63 years. The stage of cancer diagnosis was reported by 20 % (n = 2) of the studies and ranged from I to IIIa. The surgical techniques used were: tumorectomy, lumpectomy, quadrantectomy, mastectomy, or mastectomy associated with breast reconstruction. All survivors had completed chemotherapy or radiation treatments, and many remained on hormone treatment.

The AE group consisted of 235 women, the land exercise group of 147 women, and the usual care of 123 women. The treatment time after mastectomy was reported by 70 % (n = 7) of the studies and ranged from six months to six years. Treatment time ranged from eight to 48 weeks. The weekly frequency of the intervention ranged from one to three times a week and the duration of the sessions ranged from 30 to 60 min. None of the included studies performed the comparison AE vs. land exercise vs. usual care. All studies performed short-term treatments (between 8–12 weeks). It was not possible to carry out a meta-analysis for medium (13–24 weeks) or long-term treatments, as only one included study used this treatment time (>24 weeks).

Due to the heterogeneity of the studies, subgroup analyses were not possible. Two studies were not included in the meta-analyses due to heterogeneity of treatment and outcomes, and also due to their high risk of bias, which could compromise clinical applicability (external validity). The pilot study by Letellier et al.58 did not blind the allocation during randomization, as a consequence there were differences in important prognostic variables at baseline. In addition, there were missing data at the end of treatment, which were not corrected by the intention-to-treat analysis principle. Johansson et al. ,59 also a pilot study, did not carry out the allocation concealment process, however, this did not lead to problems at baseline, additionally the principle of analysis by intention-to-treat, was not carried out. At the end of the treatment, there was 6 % attrition in the AE group and 21 % in the usual care.

Characteristics of the interventions

The characteristics of the interventions are presented in the Supplementary material D.

Adverse effects

One study found a transient increase in lymphedema in three participants and four participants reported fatigue immediately after AE sessions.58 In another study,54 three participants reported discomfort or low-intensity pain/stiffness after an AE session.

Risk of bias assessment

The assessment of the risk of bias using the RoB-2 tool is presented in Figs. 1 and 2. For the classification of overall bias, 30 % (n = 3) of the studies were classified as having low risk of bias, 30 % (n = 3) as having some concerns, and 40 % (n = 4) as having a high risk of bias. The domain with the most alterations in bias was the randomization process, where 40 % of the studies did not perform this process correctly and in domain two, 50 % of the studies did not perform an intention to treat analysis. Although none of the studies had significant attrition, as with all trials there were some dropouts, and with the existing biases as outlined may have had an effect on outcome, the results therefore, must be interpreted with this in light.

Fig. 1.

Risk of bias assessment of included studies.

(0.16MB).
Fig. 2.

Percentage of bias by domains (n = 10).

(0.11MB).

Four studies compared AE with usual care, with 235 participants in the AE group and 123 in the usual care group.53,54,57,59 Five studies compared AE with land exercise with 235 participants in the AE group and 147 in the land exercise group.55,56,58,60–62

QoL

Meta-analysis for QoL showed very low certainty of evidence that AE may improve QoL emotional domain (SMD=0.58; 95 % CI: 0.1, 0.9; =0 %) compared with usual care (Fig. 3). (Supplementary material E)

Fig. 3.

Outcome meta-analysis quality of life - emotional subdomain (aquatic exercise vs. usual care).

(0.11MB).

Due to the heterogeneity of the QoL questionnaires (generic, specific, and outcome measures by domain or general), it was not feasible to perform a meta-analyses to compare AE vs. land exercises. Letellier et al.58 and Odynets et al.55 investigated QoL through questionnaires such as Functional Assessment of Cancer Therapy Breast Cancer (FACIT-B) and European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life questionnaire (EORTC QLQ-BR23). Odynets et al.55 found significant differences for the subdomains: body image (P < 0.01), breast symptoms (P < 0.05), and arm symptoms (P < 0.05). Due to the high risk of bias, the results from Letellier et al.58 will not be discussed.

Lymphedema

Thidar and Katz-Leurer53 found no statistically significant differences in the measurement of lymphedema by % Relative Lymphedema Volume ( % RVL) (SMD = 0.12; 95 % CI: −0.4, 0.7; P = 0.08) in the AE vs. usual care comparison. Ali et al.56 included women two years after breast surgery and found statistically significant differences in lymphedema in favor of AE when compared with land exercise (P < 0.001).

Fatigue

Only one study investigated the effect of AE on fatigue compared to usual care. Cantarero-Villanueva et al.54 found a statistically significant difference in favor of AE after mastectomy or lumpectomy surgery (P < 0.001).

Pain

One study investigated the effect of AE on pain compared to usual care. Cantarero-Villanueva et al57 reported a statistically significant difference in neck pain (P < 0.001) and shoulder pain (P = 0.04)57 in favor of AE. For the comparison between AE and land exercise, two studies were included in the meta-analysis.55,56 The evidence is very uncertain about the effect of AE on pain (SMD= 1.10; 95 % CI: −1.54, 3.74; =97 %) compared to land exercise (Fig. 4). (Supplementary material E).

Fig. 4.

Pain outcome meta-analysis (aquatic exercises vs. land exercises).

(0.1MB).
ROM

Only studies with a high risk of bias investigated this effect with Ali et al.56 finding statistically significant differences for shoulder flexion (P < 0.001) and abduction movements (P < 0.001).

Discussion

The aim of this review was to determine if AE, of a minimum of eight weeks duration were effective in improving QoL, lymphedema, fatigue, pain, and ROM in BC survivors, when compared with land exercise and usual care. Overall, there is very low certainty evidence regarding the effect of AE. Meta-analyses revealed that AE may improve QoL outcomes compared to usual care but the effect of AE on pain compared to land exercise is still uncertain. Only single studies investigated the effect of AE on fatigue, lymphedema, and ROM.

Meta-analyses were pooled by treatment time and short-term results only. For the comparison between AE and usual care, we found very low certainty of evidence that AE may improve QoL emotional domain (SMD= 0.58; 95 % CI: 0.19, 0.98; I²=0). In contrast, when AE was compared with land exercise, we found very low certainty of evidence that AE and land exercise have similar effects on pain.

Women with BC experience physical symptoms and psychosocial distress that negatively affect their QoL.63 Quality of life consists of several domains, including emotional and physical components. The psychological impact of BC can present in the form of anxiety and depression64 and a multitude of physical aspects of BC such as distortion of body image due to lack of breast, presence of scars, hair loss, persistent fatigue, functional disability, and post-lymphedema arm care can all impact on QoL.65

We found that AE may improve the emotional component of QoL in BC survivors after AE. Cantarero-Villanueva et al.54 included two important items that may be related to these findings, aerobic activity, which corroborates the findings of a review of reviews published in 202,066 and group treatment of 10/12 participants. The aquatic environment requires appropriate clothing that challenges and exposes the body and femininity; being in contact with women with the same condition, with or without breast reconstruction, associated or not with lymphedema, can stimulate dialogue, the exchange of experiences, and improve self-acceptance. However, these results should be evaluated with caution, due to the low quality of the evidence.

Lymphedema often presents as a long-term problem post breast reconstruction or breast surgery in BC.67 Interventions for lymphedema are required at various points along the clinical trajectory and guidelines recommend AE combined with resistance exercise in all phases of treatment, associated with complete decongestive therapy.68

Therefore, BC survivors should be encouraged to continue their care at home, with compression bandage, lymphatic drainage, skin care, and water treatment combined with aerobic and resistance exercises added individually for each condition.69 The study by Thidar and Katz-Leurer53 proposed aqua lymphatic therapy which had minimal impact on lymphedema. These findings may be explained by the low weekly frequency of sessions (1x per week) and the chronic characteristics of lymphedema (survivors with surgery time of six years), and low exercise intensity. Two of the included studies55,56 which found statistically significant differences in lymphedema, had an intervention frequency of three times a week.

Fatigue is one of the most common and distressing side symptoms of cancer and its treatment and can persist for years after treatment is complete. Fatigue prevalence estimates range from 25 to 99 %, depending on the population, type of treatment, and method of assessment.70 Exercise-based interventions can reduce inflammatory activity or disrupt pro-inflammatory circuits, thought to contribute to fatigue. Additionally, interventions that increase physical activity could potentially reduce body mass index and increase cardiorespiratory fitness and thereby may improve fatigue.71 Only one study evaluated fatigue in BC survivors and more studies are needed to determine the effect of AE on fatigue.

Three studies evaluated pain in BC survivors.54–56 Only Odynets et al.55 found no significant differences. Cantarero-Villanueva et al.57 was the only study that included BC survivors without the presence of lymphedema. All studies performed the aquatic treatment at a thermoneutral temperature (31–33 °C) and the treatment time was eight weeks. The evaluation method used by two studies was the VAS,56,57 one used the McGill Pain Questionnaire Short Form,58 and Odynets et al.55 used the symptoms subdomain of the European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life questionnaire.

The meta-analysis of the pain outcomes did not find differences between AE and land exercise. This result could be related to the high heterogeneity of the studies, such as populations with different pain symptoms, the presence or absence of lymphedema, and risk of bias in the studies. The findings of Letellier et al.58 should be considered with caution due to the high risk of bias and therefore was not included in the meta-analysis.

The shoulder joint can often present with problems post-breast reconstruction,65 consequently shoulder ROM is one of the outcomes to consider when treating the patient in the aquatic environment. The aquatic environment can reduce shoulder and cervical joint stress and facilitate movements that are difficult to perform on the ground. Ali et al.56 found statistically significant improvement in shoulder ROM and reported earlier time to start treatment after surgery (six months).

In general, the sequence of exercises performed by the studies using AE included: warm-up, strength, and mobility exercises, and cool-down/relaxation, following a progression of intensity according to specific guidelines, monitored by the Borg scale. For studies with lymphedema, the proposed treatment was based on the aqua lymphatic therapy proposed by Tidhar and Drouin21 and consisted of axillary lymph node activation, lymphatic self-drainage, and lymphokinetic exercises. Not all studies recorded the temperature and dimensions of the pool, which is unfortunate as this information is necessary to reproduce the intervention.

Previous literature reviews in this area are replete with methodological weaknesses, the current review included only randomized controlled trials and studies with potential biases in the randomization process were not included in the quantitative analysis due to validity concerns and underestimation or overestimation of results/effect sizes.

Future studies should take into account the recommendations of the current American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care guidelines regarding the prescription of exercises, with a weekly frequency of at least twice a week. In addition, strength training and aerobic exercises should be included in the treatment and directed to the specific audience. Women with a low risk factor for lymphedema should be treated to reduce pain, limited ROM, and fatigue. Women at a high risk of developing lymphedema (axillary chain resection) should be counseled on the gold standard management of lymphedema, compression therapy, skin care, and lymphatic drainage. Exercises should be offered in an adjuvant way and long-term effects encouraged. It is important to emphasize that specific interventions, such as Bad Ragaz Concept, which has specific movement patterns for the trunk and upper limbs that can help in the treatment of BC survivors should be stimulated. Standardized measurement instruments should be used, such as specific questionnaires for BC and lymphedema.

Finally, methodological rigor must be followed when conducting research, which will lead to better decision making. Quality information is essential so that it can be extracted and assist in the indication, treatment, and improvement in the QoL of BC survivors, for example, following the rules of the CONSORT Statement.

This review was limited by the high variability of the assessment instruments for each outcome, which impacted the meta-analysis (performed with a limited number of studies), precluding sensitivity and subgroup analyses. The low response rate of the authors to the requested information about the studies, such as results in mean and SD, were also responsible for the low number of studies included in the meta-analysis. It is also necessary to interpret meta-analyses with less than five studies and unequal sizes with caution. The certainty of the evidence assessed by GRADE was limited, due to the low inclusion of studies in the meta-analyses, this is not only due to the heterogeneity of the studies in relation to the treatment time combined with the weekly frequency, but also due to the classification of the risk of bias.

Publication bias was not analyzed by funnel plot due to the inclusion of only two studies in the meta-analysis. In addition, two pilot studies were included, with numerous methodological limitations (power, for example). The lymphedema outcome data from the Thidar and Katz-Leurer53 study were obtained through the study by Yeung and Semciw.9 Our results refer to the short-term effect, as few studies performed follow-up, making long-term analysis unfeasible.

Conclusion

AE improved the emotional subdomain of QoL when compared with the usual care group. When compared with land exercises, no differences were found for pain. However, there are important concerns in classifying the risk of bias of the included studies and the certainty of the evidence was very low. Results should be interpreted with caution. No relevant adverse effects that contraindicate AE were reported.

Acknowledgments

The last author wishes to thank the Productivity Scholarship received by CNPq (#315,240/2021–0) and the Aquatic Physical Therapy Center ‘‘Prof. Paulo A. Seibert” coordination and staff support. The funders played no role in the design, conduct, or reporting of this study. All studies included in this review denied study funding.

References
[1]
American cancer society. Cancer treatment & survivorship facts & figures 2019–2021. Atlanta: American Cancer Society. 2021.
[2]
R.L. Siegel, A.N. Giaquinto, A. Jemal.
Cancer statistics, 2024. CA.
Cancer J Clin, 74 (2024), pp. 12-49
[3]
F.T. Baumann, A. Reike, V. Reimer, et al.
Effects of physical exercise on breast cancer-related secondary lymphedema: a systematic review.
Breast Cancer Res Treat, 170 (2018), pp. 1-13
[4]
C.D. Runowicz, C.R. Leach, N.L. Henry, et al.
American cancer society/American society of clinical oncology breast cancer survivorship care guideline.
CA Cancer J Clin, 66 (2016), pp. 43-73
[5]
C.L. Rock, C. Doyle, W. Demark-Wahnefried, et al.
Nutrition and physical activity guidelines for cancer survivors.
CA Cancer J Clin, 62 (2012), pp. 243-274
[6]
T. DiSipio, S. Rye, B. Newman, S. Hayes.
Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis.
Lancet Oncol, 14 (2013), pp. 500-515
[7]
K. Barbagelata, J. Eadi, M. McNamara, et al.
Aquatic therapy reduces pain and fatigue in breast cancer survivors: a systematic review.
Rehab Oncol, 39 (2021), pp. E35-E41
[8]
E. Bills, M. Delsar, S. O’Donnell, et al.
Effectiveness of hydrotherapy as an adjunct treatment for the management of breast cancer related lymphedema in women following breast cancer surgery: a systematic review.
J Allied Health, 15 (2017), pp. 12
[9]
W. Yeung, A.I. Semciw.
Aquatic therapy for people with lymphedema: a systematic review and meta-analysis.
Lymphat Res Biol, 16 (2018), pp. 9-19
[10]
E. Mur-Gimeno, P. Postigo-Martin, I. Cantarero-Villanueva, et al.
Systematic review of the effect of aquatic therapeutic exercise in breast cancer survivors.
Eur J Cancer Care (Engl), 31 (2022),
[11]
E. Muñoz-Gómez, A. Arnal-Gómez, A. López Cascón, et al.
Systematic review of aquatic therapeutic exercise efficacy in breast cancer survivors.
Support Care Cancer, 16 (2022), pp. 44
[12]
Higgins J.P.T., Thomas J., Chandler J., Cumpston M., Li T., Page M.J., Welch V.A. (Eds.). Cochrane handbook for systematic reviews of interventions version 6.5 (updated August 2024). Cochrane, 2024. Available from www.training.cochrane.org/handbook.
[13]
M.J. Page, J.E. McKenzie, P.M. Bossuyt, et al.
The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
BMJ, 29 (2021), pp. 71
[14]
B.J. Shea, B.C. Reeves, G. Wells, et al.
AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions or both.
BMJ, 358 (2017), pp. 4008
[15]
J.A.C. Sterne, J. Savović, M.J. Page, et al.
RoB 2: a revised tool for assessing risk of bias in randomised trials.
BMJ, 366 (2019), pp. 4898
[16]
H. Balshem, M. Helfand, H.J. Schunemann, et al.
GRADE guidelines: 3 rating the quality of evidence.
J Clin epidemiol, 64 (2011), pp. 401-406
[17]
G.H. Guyatt, A.D. Oxman, R. Kunz, et al.
What is "quality of evidence" and why is it important to clinicians?.
[18]
J. IntHout, J.P. Ioannidis, G.F. Borm.
The Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis is straightforward and considerably outperforms the standard DerSimonian-Laird method.
BMC Med Res Methodol, 18 (2014), pp. 25
[19]
A. Dionne, S. Goulet, M. Leone, et al.
Aquatic exercise training outcomes on functional capacity, quality of life, and lower limb lymphedema: pilot study.
J Alterna Complem Med, 24 (2018), pp. 1007-1009
[20]
S.C. Hayes, H. Reul-Hirche, J. Turner.
Exercise and secondary lymphedema: safety, potential benefits, and research issues.
Med Sci Sports Exerc, 41 (2009), pp. 483-489
[21]
D. Tidhar, J. Drouin.
Aqua lymphatic therapy for postsurgical cancer lymphedema.
Rehab Oncol, 22 (2004), pp. 1-9
[22]
C. Ambroza, P.R. Geigle.
Aquatic exercise as a management tool for breast cancer–related lymphedema.
Top Geriatr Rehabil, 26 (2010), pp. 120-127
[23]
R. Deacon, M. de Noronha, L. Shanley, et al.
Does the speed of aquatic therapy exercise alter arm volume in women with breast cancer related lymphedema? A cross-over randomized controlled trial.
Braz J Phys Ther, 23 (2019), pp. 140-147
[24]
A. Enblom, H. Lindquist, K. Bergmark.
Participation in water-exercising long-term after breast cancer surgery: experiences of significant factors for continuing exercising as a part of cancer rehabilitation.
Eur J Cancer Care, 27 (2018),
[25]
R.B.A. Siqueira, R. Freitas-Junior, P.S. Lopes, et al.
Hydrotherapy following breast cancer surgery phase II trial on hydrotherapy in women following breast cancer surgery.
Breast J, 26 (2020), pp. 1107-1110
[26]
V.R. Elsner, R.P. Trentin, C.C. Horn.
Efeito da hidroterapia na qualidade de vida de mulheres mastectomizadas.
Arq Cienc saúde, 16 (2009), pp. 67-71
[27]
E. Czenczek-Lewandowska, E. Szeliga, J. Leszczak.
The effects of aquatic and land exercise on the mental well-being of women following breast cancer surgery-comparative study.
Breast Cancer Res Treat, 202 (2023), pp. 585-593
[28]
S. Cuvelier, C. Goetgheluck-Villaron, M. Cohen, et al.
Aqua polo: preliminary feasibility and efficacy study of a programme of adapted, supervised water polo to reduce fatigue and improve women&apos;s psychological and social recovery after breast cancer treatment: a mixed-methods design.
Contemp Clin Trials Commun, 22 (2023), pp. 101-120
[29]
H. Lindquist, A. Enblom, G. Dunberger, et al.
Water exercise compared to land exercise or standard care in female cancer survivors with secondary lymphedema.
Lymphol, 48 (2015), pp. 64-79
[30]
Ellen Broach, Phillip M. Norrell.
Effect of aquatic exercise on fatigue, fitness, arm edema, levels of distress, and quality of life among breast cancer survivors.
Int J Aquat Res Edu, 12 (2019), pp. 3
[31]
A.I. Cuesta-Vargas, J. Buchan, M. Arroyo-Morales.
A multimodal physiotherapy programme plus deep water running for improving cancer-related fatigue and quality of life in breast cancer survivors.
Eur J Cancer Care, 23 (2013), pp. 15-21
[32]
C. Fernadez-Lao, I. Cantarerro-Villanueva, A. Ariza-Garcia, et al.
Water versus land-based multimodal exercise program effects on body composition in breast cancer survivors: a controlled clinical trial.
Support Care Cancer, 21 (2013), pp. 521-530
[33]
A.H. Mohammed, H.G. Mahran, S.N. Aboelazm.
Does hydrotherapy improve shoulder abduction in post-mastectomy patients?.
Int J of Adv Res, 2 (2014),
[34]
Yang-Sook.
Effects of aquatic exercise program on the shoulder joint function, physical symptom and quality of life in postmastectomy patients.
Asian Nursi Res, 13 (1999), pp. 107-114
[35]
I. Cantarero-Villanueva, C. Fernández-Lao, E. Caro-Morán, et al.
Aquatic exercise in a chest-high pool for hormone therapy-induced arthralgia in breast cancer survivors: a pragmatic controlled trial.
Clin Rehabil, 27 (2012), pp. 123-132
[36]
T. Odynets, Y. Briskin, M. Pityn.
Effect of individualized physical rehabilitation programs on respiratory function in women with post-mastectomy syndrome.
Physiother Theory Pract, 35 (2019), pp. 419-426
[37]
T. Odynets, Y. Briskin, I. Zakharina, et al.
Impact of a 12-week water program on the respiratory function in breast cancer survivors.
Adv Rehab, 33 (2019), pp. 5-11a
[38]
T. Odynets, Y. Briskin, M. Pityn.
Effect of individualized physical rehabilitation programmes on the functional state of the cardiovascular system in women with post-mastectomy syndrome.
Int J Ther Rehabil, 26 (2019), pp. 1-10
[39]
T. Odynets, Y. Briskin.
Influence of a water physical rehabilitation program in the hemodynamic parameters in breast cancer survivors.
Phys Q, 27 (2019), pp. 6-10
[40]
T. Odynets, Y. Briskin, M. Pityn.
Effectiveness of individualized physical rehabilitation programs for upper extremity disorders in women with post-mastectomy syndrome.
Rev Andal Med Deporte, 12 (2019), pp. 372-375
[41]
I. Malicka, J. Matyszczak, B. Vavric, et al.
Trunk muscle function in post-mastectomy women participating in water exercise.
Fizjoterapia Polka, 2 (2003), pp. 153-180
[42]
I. Malicka, K. Pawlowska, M. Stefanska, et al.
The effect of water exercise on muscle functions in women after mastectomy-pilot study.
Fizjoterapia, 14 (2005), pp. 57-63
[43]
F.B. Zohre, D.V. Roshan, A. Ayaz, M. Hoseinzadeh.
The relationship between pro-inflammatory markers and lipid peroxidation after water-based regular exercise and ginger supplementation in patients with breast cancer.
Daneshvar Med, 20 (2013), pp. 61-76
[44]
A.J. Salacinski, E.J. Doyle, R. Damon, et al.
Effects of 12 weeks of water aerobics on body composition in those affected by breast cancer.
Supp Care Cancer, 29 (2021), pp. 1205-1212
[45]
J.M. Hanuszkiewicz, M. Woźniewski, I. Malicka.
The relationship between sagittal spinal curvatures and isokinetic trunk muscle endurance after aquatic exercise training in survivors of breast cancer.
Acta Bioeng Biomech, 22 (2020), pp. 21-30
[46]
N. Karimi, D.V. Roshan, B.Z. Fathi.
Individually and combined water-based exercise with ginger supplement, on systemic inflammation and metabolic syndrome indices, among the obese women with breast neoplasms.
Iran J Cancer Prev, 8 (2015), pp. e3856
[47]
Z Ghorbani Shorkaii, D.V Roshan.
Changes in growth factors and estrogens in course of breast cancer: role of the individual and combined of water-based exercise and ginger supplementation.
Horiz Med Sci, 19 (2014), pp. 198-204
[48]
F. Dalenc, V. Ribet, A.B. Rossi, et al.
Efficacy of a global supportive skin care programme with hydrotherapy after non-metastatic breast cancer treatment: a randomized, controlled study.
Eur J Cancer Care, 27 (2018),
[49]
V. Sibaud, D. Guerrero, V. Georgescu.
Toxicités dermatologiques après prise en charge d’un cancer du sein: intérêt d’une cure thermale en soins oncologiques de support: long lasting cutaneous adverse events after breast cancer and evaluation of hydrotherapy as supportive care.
Ann Dermatol Venereol, 147 (2020),
[50]
A. Ayaz, D.V. Roshan.
Effects of 6-weeks water-based intermittent exercise with and without zingiber officinale on pro-inflammatory markers and blood lipids in overweight women with breast cancer.
J Appl Pharm Sci, 2 (2012), pp. 218-224
[51]
R.O. Gimenes, P.M. Tacani, S.A.G. Junior, et al.
Aquatic and land physiotherapy group in the posture of women with mastectomy.
J Health Sci Inst, 31 (2013), pp. 79-83
[52]
M. Nissim, Y. Rottenberg, N. Karniel, et al.
Effects of aquatic exercise program versus on-land exercise program on cancer-related fatigue, neuropathy, activity and participation, quality of life, and return to work for cancer patients: study protocol for a randomized controlled trial.
BMC Complem Med Ther, 2 (2024), pp. 74
[53]
D. Thidar, M. Katz-Leurer.
Aqua lymphatic therapy in women who suffer from breast cancer treatment-related lymphedema: a randomized controlled study [published correction appears in Support Care Cancer.
Support Care Cancer, 18 (2010), pp. 383-392
[54]
I. Cantarero-Villanueva, C. Fernández-Lao, A.I. Cuesta-Vargas, et al.
The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: a randomized controlled trial.
Arch Phys Med Rehabil, 94 (2013), pp. 221-230
[55]
T. Odynets, Y. Briskin, A. Perederiy, et al.
Effect of water physical therapy on quality of life in breast cancer survivors.
Phys Quart, 26 (2018), pp. 11-16
[56]
K.M. Ali, E.R. El Gammal, H.M Eladl.
Effect of aqua therapy exercises on postmastectomy lymphedema: a prospective randomized controlled trial.
Ann Rehabil Med, 45 (2021), pp. 131-140
[57]
I. Cantarero-Villanueva, C. Fernández-Lao, C. Fernández-de-Las-Peñas, et al.
Effectiveness of water physical therapy on pain, pressure pain sensitivity, and myofascial trigger points in breast cancer survivors: a randomized, controlled clinical trial.
Pain Med, 13 (2012), pp. 1509-1519
[58]
M.E. Letellier, A. Towers, A. Shimony, et al.
Breast cancer-related lymphedema: a randomized controlled pilot and feasibility study.
Am J Phys Med Rehab, 93 (2014), pp. 751-763
[59]
Johansson k, Hayes S, R.M. Speck, et al.
Water-based exercise for patients with chronic arm lymphedema: a randomized controlled pilot trial.
Am J Phys Med Rehab, 92 (2013), pp. 312-319
[60]
Y. Odynets T Briskin, V. Todorova.
Effects of different exercise interventions on quality of life in breast cancer patients: a randomized controlled trial.
Int Cancer Ther, 18 (2019),
[61]
T. Odynets, Y. Briskin, A. Yefremova, et al.
The effectiveness of two individualized physical interventions on the upper limb condition after radical mastectomy.
Phys Quart, 27 (2019), pp. 12-17
[62]
E. Mur-Gimeno, M. Coll, A. Yuguero-Ortiz, et al.
Comparison of water- vs. land-based exercise for improving functional capacity and quality of life in patients living with and beyond breast cancer (the AQUA-FiT study): a randomized controlled trial.
Breast Cancer, 31 (2024), pp. 815-824
[63]
M. Campbell, J.E. McKenzie, A. Sowden, et al.
Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline.
BMJ, 16 (2020), pp. 6890
[64]
M. Thakur, R. Sharma, A.K. Mishra, et al.
Psychological distress and body image disturbances after modified radical mastectomy among breast cancer survivors: a cross-sectional study from a tertiary care centre in North India.
Lancet Reg Health Southeast Asia, 7 (2022),
[65]
X. Wang, N. Wang, L. Zhong, et al.
Prognostic value of depression and anxiety on breast cancer recurrence and mortality: a systematic review and meta-analysis of 282,203 patients.
Mol Psychiatry, 25 (2020), pp. 3186-3197
[66]
N.E. Blackburn, J.G. Mc Veigh, E.M. Mc Caughan, et al.
The musculoskeletal consequences of latissimus dorsi breast reconstruction in women following mastectomy for breast cancer.
PLoS One, 13 (2018),
[67]
P. Mokhatri-Hesari, A. Montazeri.
Health-related quality of life in breast cancer patients: review of reviews from 2008 to 2018.
Health Qual Life Outcomes, 12 (2020), pp. 338
[68]
P. Mortimer.
Arm lymphedema after breast cancer.
Lancet Oncol, 14 (2013), pp. 442-443
[69]
C. Davies, K. Levenhagen, K. Ryans, et al.
Interventions for breast cancer–related lymphedema: clinical practice guideline from the academy of oncologic physical therapy of APTA.
Phys ther, (2020), pp. 1163-1179
[70]
D.P. Lawrence, B. Kupelnick, K. Miller, et al.
Evidence report on the occurrence, assessment, and treatment of fatigue in cancer patients.
J Natl Cancer Inst Monogr, (2004), pp. 40-50
[71]
J.E. Bower.
Cancer-related fatigue mechanisms, risk factors, and treatments.
Nat Rev Clin Oncol, 11 (2014), pp. 597-609

The data for this study are available from the corresponding author upon reasonable request.

Registration (PROSPERO): CRD42024506498

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