This study aimed to compare the effects of yoga and clinical Pilates exercise methods, combined with compression stockings, on lymphedema, upper extremity muscle strength and functions, and QoL in patients with breast cancer–associated lymphedema. The results revealed that lymphedema reduction was more pronounced in the yoga and clinical Pilates groups compared with the control group. The participants in the clinical Pilates group exhibited a significant increase in IR muscle strength in EwLE compared with the yoga and control groups. Moreover, the improvements in upper extremity function were more significant in the yoga and clinical Pilates groups compared with the control group. Further, the subscale symptom scores of QoL indicated a positive increase in the breast and arm symptoms in the yoga group, and arm symptoms in the clinical Pilates group, compared with the control group.
Pilates exercises are generally considered safe and may contribute to reducing the symptoms of breast cancer–associated lymphedema [26]. Şener et al. reported the effectiveness of clinical Pilates exercises applied with compression stockings in decreasing the severity of lymphedema in various segments, except for the axillary region, compared with that in the control group [14]. Similarly, we observed significant differences in lymphedema severity in the clinical Pilates group at two levels (5 cm above the wrist and 10 cm above the elbow) and in volumetric measurements post-treatment compared with pre-treatment. In addition, in circumference measurements, lymphedema reduction was more pronounced in the clinical Pilates group compared with the control group at one level (10 cm above the elbow). Lymphedema was alleviated the most in the clinical Pilates group in terms of percentage (clinical Pilates: 3.29%, yoga: 1.75%, control: 1.61%). Clinical Pilates exercises may potentially alleviate lymphedema by promoting core stability, a key principle of Pilates. This stability can facilitate lymphatic flow by stimulating the ductus thoracicus and abdominal lymph nodes through the contractions of trunk muscles and the diaphragm. Moreover, Pilates exercises involving extremity movements may further stimulate the lymphatic system through their pumping action.
Previous studies showed that Satyananda yoga exercises did not lead to a decrease in lymphedema severity or arm volume. However, they demonstrated a decrease in the amount of fibrous tissue and enhanced skin tissue elasticity compared with the control group. These findings suggested that the long-term use of Satyananda yoga exercises might reduce EwLE volume [15,27]. Fisher et al. reported that hatha yoga exercises, without additional resistance or repeated muscle contractions, improved lymphatic fluid pumping and flow, thereby reducing lymphedema [17]. Similarly, although the present study did not observe a significant reduction in lymphedema severity in any segment with yoga exercises, a significant reduction of 10 cm above the elbow was observed compared with that in the control group. This reduction in lymphedema in the yoga group compared with the control group suggested that hatha yoga might enhance lymphatic flow. This improvement could be attributed to the activation of lymphatic collecting vessels during yoga postures and breathing techniques, along with stimulation of the ductus thoracicus by lymphatic fluid movement, resulting in increased lymphatic flow due to pressure changes.
Upper extremity muscle strength is affected more in the EwLE compared with that in the extremity without lymphedema in breast cancer survivors [28,29]. Bertoli et al. found that mat Pilates exercises enhanced shoulder abductor and trunk extensor muscle strength in the upper extremity muscles on both the operated and intact upper extremities [30]. Zengin Alpozgen et al. reported that Pilates exercises played a crucial role in increasing muscle strength in breast cancer survivors than in the home exercise group [31]. The present study found that clinical Pilates was more effective than yoga, and yoga was more effective than the control, in increasing IR muscle strength in the affected extremities. The clinical Pilates group demonstrated the greatest increase in IR muscle strength (clinical Pilates: 10.62%, yoga: 6.36%, control: 0.77%). Clinical Pilates exercises (triceps pull and swimming) promoted significant activation of IR muscles compared with yoga exercises. Furthermore, it was noted that the majority of participants exhibited kinesiophobia (fear of movement) leading them to limit their range of shoulder joint motion during exercise in order to prevent injury. The participants reported less fear when engaging in clinical Pilates exercises than with yoga exercises. This could be attributed to the fact that clinical Pilates exercises were similar to those performed by the patients in previous rehabilitation programs. These factors might explain why IR muscle strength improvement was the most pronounced in the clinical Pilates group.
Mazor et al. demonstrated that Ashtanga yoga exercises increased shoulder abductor muscle strength in EwLE and increased elbow flexor muscle strength in EwLE and Ew/oLE [32]. Another study found that yoga exercises applied with compression stockings in patients with lymphedema associated with unilateral breast cancer resulted in an increase in only serratus anterior muscle strength in both EwLE and Ew/oLE and no change in other muscle groups [33]. The present study revealed that yoga exercises increased IR muscle strength compared with that in the control group. This outcome could be attributed to the fact that asana postures aimed at stabilizing the scapula/shoulder complex (amsa bandha), which might regulate the scapulohumeral rhythm and increase the strength of internal rotator muscles commonly affected post-surgery. In addition, the isometric contraction induced by asana postures, along with increased resistance with an increase in body weight during pose transitions, likely contributed to increased IR muscle strength through isotonic contractions in the muscles.
A previous systematic review and meta-analysis examined the effects of exercise on upper extremity functions in breast cancer–associated lymphedema, revealing significant benefits across various exercise modalities including aerobic, resistance training, yoga, and Pilates [34]. Additionally, clinical Pilates exercises positively influenced the functional status compared with that in the control groups [14]. Fisher et al. stated that hatha yoga exercises did not yield statistically significant effects on upper extremity function, but a decrease in DASH scores was observed post-treatment [17]. In our study, significant improvements in DASH scores were observed in the clinical Pilates and yoga exercises groups compared with the control group. Specifically, the clinical Pilates group demonstrated the most significant reduction in DASH total scores (15.82%), followed by the yoga (14.72%) and control groups (4.49%), compared with the pretreatment scores. The results further indicated that the clinical Pilates group experienced a significant increase in physical parameters (increase in IR muscle strength and decreased proximal edema) compared with the yoga group. In this context, the significant improvement in upper extremity functions in the clinical Pilates group could be attributed to the more pronounced reduction in proximal arm lymphedema and the greater increase in upper extremity muscle strength compared with the yoga group.
Lymphedema is a prevalent post-treatment complication negatively affecting QoL in breast cancer survivors [35]. A study investigating QoL in breast cancer survivors with and without lymphedema using the EORTC QLQ-BR23 found that the symptom scores associated with arm and breast issues were higher in patients with lymphedema compared with those without it [36]. Previous studies examining the QoL in patients with breast cancer–associated lymphedema found that Pilates exercises improved QoL [14,37,38]. Similarly, studies on the effects of yoga demonstrated positive increases in QoL and significant decreases in breast and arm symptom scores after yoga exercises [39,40]. In the present study, the symptom scores of QoL decreased in the Pilates group post-treatment compared with the control group, and a decrease in arm and breast symptoms was observed in the yoga group compared with the control group. In addition, the arm symptom scores (yoga: 43.37%, clinical Pilates: 33.74%, control: 16.59%) and breast symptom scores (yoga: 57.80%, clinical Pilates: 42.20%, control: 19.53%) decreased more in the yoga group compared with the clinical Pilates group. Breathing techniques, focusing methods, and meditation practiced during yoga exercises contribute to the clearing of blockages, balancing of the body’s energy channels, and mental healing, thereby reducing symptoms. This explained why yoga exercises resulted in more improvement in symptom subscales compared with clinical Pilates exercises. In the present study, despite differences observed in symptom subscales between the groups, no differences were found in functional subscales such as future perspective and sexual enjoyment. This could be because the questions in these subscales were more emotionally oriented and the patients might have been suffering from breast cancer for many years. Consequently, the aforementioned issues remained unnoticed compared with physical functions.
Implications for Practice
Considering that patients with breast cancer–associated lymphedema may experience significant challenges in EwLE compared with Ew/oLE, exploring the severity of edema, upper extremity muscle strength, upper extremity functions, and QoL in this population in terms of exercise protocols may offer valuable insights. The research findings indicated that the clinical Pilates group experienced greater improvements in physical parameters, including lymphedema, muscle strength, and upper extremity functions. However, it is worth noting that yoga activities possess the capacity to enhance emotional well-being and overall quality of life. Hence, the findings of this study might be crucial for encouraging the adoption of appropriate exercise methods among patients with breast cancer–associated lymphedema.
Strength and Potential Limitations
This study investigated the effectiveness of yoga and clinical Pilates exercises in reducing lymphedema severity, improving muscle strength, and enhancing upper extremity functions and QoL. These two exercise methods were not compared in previous studies, making our results promising and potentially pioneering.
In this study, all participants were instructed to use compression stockings daily for 8 h. However, the feedback received post-treatment showed that some participants might not have adhered to this recommendation inadequately. Therefore, the lack of a systematic follow-up method to monitor the use of compression stockings, including a daily or weekly usage log, could be considered a significant limitation of the study.
Kinesiophobia due to potential injury or pain, was not evaluated in our study. However, individuals avoided certain exercises in the initial weeks due to fear of movement, leading to incomplete performance of exercises within the full range of motion. Therefore, the absence of kinesiophobia assessment was another limitation, highlighting the importance of evaluating this physiological factor in future studies.