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Journal of The Korean Society of Physical Medicine, 2013; 8(2): 153-161 http://dx.doi.org/10.13066/kspm.2013.8.2.153 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 4 주간복합운동치료가유방암림프부종중년여성의통증, 견관절가동범위에미치는영향 이병기 1 이재섭 2 김태수 1 대원대학교물리치료과, 2 가톨릭대학교인천성모병원물리치료실, 고려대학교 The Influence of 4 wks Complex Therapeutic Exercises on Visual Analog Scale of Pain and Range of Motion for Middle-Aged Women with Breast Cancer-Related Lymphedema Byung-ki Lee, PT, MD 1, Jae-sub Lee, PT, MS 2, Tae-soo Kim, PhD 1 Department of Physical Therapy, Daewon University College, 2 Department of Physical Therapy, Incheon St. Mary s Hospital, Korea University Received: October 8, 2012 / Revised: January 9, 2013 / Accepted: April 9, 2013 c 2013 Journal of the Korean Society of Physical Medicine Abstract PURPOSE: This study aimed to investigate the effect of complex theraputic exercise on visual analog scale of pain, shoulder range of motion for middle-aged women with breast cancer related lymphedema. METHODS: The 14 middle-aged women involved voluntary in this study and then they were divided into two groups(n =7 per group). The complex exercise program was implemented over 4 weeks, 60 minutes per day, with 3 types of exercise for stimulation whereas the control group was performed a classical decongestive physiotherapy in a same day. For data analysis, the mean and standard deviation were estimated; 2 way repeated measures ANOVA was carried out. RESULTS: First, The level of VAS was significantly reduced on time, interaction effect in the group. Second, most factors of ROM were significantly increased on time, interaction effect whereas extension was not significantly increased. Corresponding Author : lion9902@hanmail.net CONCLUSION: In conclusion, Our results showed that complex therapeutic exercise could improve or maintain VAS and ROM of shoulder joint for middle-aged women with breast cancer related lymphedema. Key Words: Breast Cancer-related lymphedema, Classical decongestive physiotherapy, Complex therapeutic exercises, Pain, Range of motion on shoulder Ⅰ. 서론세계보건기구에서유방암은여성암의최고흔한형태로세계각지에서매년 1,050,000명이상의유방암이발생되는것으로추정하고있다 (Pereira de Godoy과 Guerreiro Godoy, 2012). GLOBAN 2008년자료에의하면전세계의유방암발병률은 23% 이며, 그중 14% 는사망하는것으로나타났다 (Ferlay 등, 2010). 국내의경우, 유방암은우리나라여성암발생률 1위를차지하고있다 (National Cancer Information Center, 2010). 또한지난 10년간유방암으로인한사망률은지속적으로증가

154 대한물리의학회지제 8 권제 2 호 하고있는것으로밝혀졌다 (Statistics Korea, 2011). 특히주목해야할점은발병연령대에서 60% 이상이 50세로이하로선진국에비해연령이낮다는점과 5년생존률이 83.5% 로높다는점이다 (Lee 등, 2009). 발병연령대별로는 40대가 37.6% 로가장많고, 50대가 27.4% 인것으로나타나중년여성층에게취약한것으로나타났다 (National Cancer Information Center, 2012). 유방암장기생존자의수가증가함에, 유방암림프부종과같은만성유독성들 (chronic toxicities) 이주목을받고있다 (Shah 등, 2012). 림프계는조직으로부터림프를받아정맥을통하여심장으로환류시키는기능을하는순환계의일부이다. 림프순환의붕괴로인한조직액이비정상적으로축적된림프계의상태를림프부종이라한다. 이러한교란 (perturbation) 은단백질함유량이높은체액의축적으로유도되어환측피하조직의부종을야기한다 (Korpan 등, 2011). 림프부종은유방암치료후에흔하게발생되는합병증으로, 유방암환자의 50% 가이에해당된다 (Jemal 등, 2010). 유방암림프부종 (breast cancer-related lymphedema) 의경증정도는유방수술의진행, 감시림프절 (Sentinel lymph node) 생검과액와절절개와같은액와수술, 방사선보조치료의정도, 화학보조와같은공격적인치료의예후로결정된다 (Shah 등, 2012). 유방암림프부종은팔긴장도 (tightness), 통증 (Gautam 등, 2011), 움직임의크기와관절움직임의감소를포함한제한, 상지무게의증가 (Pereira de Godoy과 Guerreiro Godoy, 2012), 일일업무수행의곤란 (Stanton 등, 2009), 일상에서의기능적인활동과건강-관련삶의질에영향을미친다 (Kilbreath 등, 2012). 유방암림프부종관리는체액축적과증상의중증도 (severity), 급성과만성을기초로하여적절한치료방법을선택하게된다 (Shah 등, 2012). 유방암림프부종에대한치료는거상, 압박법, 붕대법, 마사지, 고전 복합부종감소물리치료, 약물치료등과같이다양한방법으로발전되고있다. 최근연구에서는주목할만한운동의사후처치효과를보여주는데, 신체활동은암생존자들을위한특별하고적절한중재가될수있다고보고하였다 (Brown 등, 2011). 이러한연구들은운동이암환자들에게안전할뿐만아니라 건강과근력, 피로감소, 삶의질과신체상 (body image) 을향상시킬수있다는것을보여주고있다 (Laino, 2010). 외국의선행연구에서는저항과유산소의복합운동형태로재택과체육관운동이장애정도의개선과관절가동범위의개선 (Portela 등, 2008), 유방암환자를대상으로유산소운동이삶의질에서신체기능과신체적인웰빙요소의증가 (Campbell 등, 2005) 9개월간저항운동이부종관련증상과상지근력의개선과부종악화발생률의감소 (Schmitz 등, 2009) 등이보고되었다. 국내의선행연구에서는, 상지운동기기를이용한 4주간의운동이부종과관절가동범위의개선 (Lim과 Han, 2011), 재활운동이신체구성과좌전굴, 혈중지질변인에서유의한향상 (Kim, 2010), 수중운동이관절가동범위, 근력, 신체자각증상, 삶의질의호전 (Yoo, 1999) 등이보고되는것으로밝혀졌다. Laino(2010) 는전통적인방법으로암환자에게적절한휴식을취하고활동을피하라고권고하고있다. 또한국내의경우에도대다수의림프부종환자들이병원에내원하지않는경우에는특별한운동을하고있지않은현실이다. 따라서본연구에서는유방암으로유발된상지림프부종환자를대상으로복합부종감소물리치료를포함한복합운동치료가림프부종중년여성에게통증, 관절가동범위에어떠한영향을미치는지규명하여, 다양한림프부종치료프로그램개발에대한논리적근거와지식을제공하는데기여하고자한다. Ⅱ. 연구방법 1. 연구대상본연구는인천광역시 C 대학병원에입원환자중에상지림프부종으로진단받은여성환자를대상으로하였다. 연구에동의한환자 20명을선발하여고전적부종감소물리치료만을실시한 10명을대조군으로, 고전적부종감소물리치료와복합운동치료를실시한실험군 10명으로무선할당 (random allocation) 하였다. 대조군과실험군에서건강상의문제로자의적인탈락이각각 3명발생되어 14명만이최종적으로연구에참여하였다.

4 주간복합운동치료가유방암림프부종중년여성의통증, 견관절가동범위에미치는영향 155 연구대상자의세부선정기준은다음과같다. 첫째, 유방암수술후 3년이내상지림프부종으로진단받은환자, 둘째, 유방절제술을시행하고한쪽팔에만림프부종이발병한환자, 셋째, 이뇨제를사용하지않는림프부종환자, 넷째, 이학적및신경학적검사상특별한이상소견이없는사람으로한정하였다. 최종적으로연구를참여한대상자의신체적특성은 Table 1과같다. 앞으로올라간각도를측정하였고, 벌림은똑바로선자세에서상체는움직이지않은채바닥면이신체에닿게하는자세에서팔을바깥쪽으로들어올리게하여들린각도를측정하였다. 외회전은침상에바로누운자세에서상체를고정시킨후팔을 90 외전시키고주관절을 90 로굴곡시킨자세에서팔을머리쪽으로회전시킬수있는정도를측정하였다. Table 1. Participant characteristics Group Age (yrs) Weight (kg) Height (cm) BMI CDP 53.71±9.37 154.14±4.88 60.24±3.22 25.25±.10 CECDP 56.14±7.01 156.43±4.27 62.35±6.70 25.77±2.63 CDP, classical decongestive physiotherapy; CEDPE, complex exercise and classical decongestive physical therapy. Mean ± SD 2. 실험방법 1) 시각적통증상사척도 (Visual Analog Scale, VAS) 통증척도는 Cole 등 (1994) 의시각적통증상사척도를사용하였다. 시각적통증상사척도는 100mm길이의직선으로이루어져있는데직선의왼쪽끝은통증이전혀없는상태, 오른쪽끝은최대의통증상태로정의한다. 만성요통환자를대상으로한 Micheal 등 (1996) 의시각적통증상사척도신뢰도연구에서는통증과시각적통증상사척도의높은상관관계를입증하였다. 본연구에서는환자가현재느껴지는통증이어느정도인지를직접선위에표시하도록한후에왼쪽끝부분에서부터표시된지점까지의거리를측정하여통증정도를표시하였다. 2) 견관절가동범위 (ROM) 측정어깨관절기능측정은미국의사협회의지침에따라관절각도기 (Goniometer) 로어깨관절의굴곡, 신전, 외전, 내전등의가동범위를측정하였다 (American Medical Association, 1993). 이방법은중립 0 위치를선정하고선정한지점으로부터이탈의각도를측정하는것으로모두 2번씩측정하여평균값으로산출하였다. 굴곡은 3. 고전부종감소물리치료모든군에실시된고전적부종감소물리치료는 Szolnoky 등 (2009) 에의한선행연구방법과동일하게공기압박펌프치료 (Pneumatic Compression), 림프흡수마사지 (Manual Lymph Drainage), 피부관리 (Skin care), 저탄력붕대법 (Low-Stretch Bandages) 의순으로진행되었다. 공기압박펌프치료는환부를공기주머니에넣고원위부부터근위부의순서로부종이발생된부위에 30mmHg의압력으로압박치료를실시하였다. 림프흡수마사지는부종이없는체간쪽부터마사지를적용하여부종부위의림프액이흡수될수있는환경을만들어준다음부종이있는손쪽으로이동하고다시몸통쪽으로실시하였다. 피부관리는보습제를림프액이흐르는방향으로바르도록하여피부의건조함을막아주었다. 저탄력붕대법은부종이있는부위의손가락에서하얀거즈형태의붕대를감는것으로시작하였다. 붕대는직접적으로피부에닿지않도록솜붕대등과패딩을대고붕대를부위별로감게되는데가능한부종의있는모든부위가감겨질수있도록하였다. 감은붕대는부종부위의혈액이잘통하는지를피부의색으로확인하였으며가급적활동을하는낮과잠을자는밤에도착용할것을환자에게당부하였다. 감은붕대의상태점검은하루두번오전시간과오후시간에실시하였으며매일공기압박펌프치료, 림프흡수마사지그리고피부관리후적용하였다. 본연구에서는 1주는치료사가직접감아주었으며, 1주가지난후부터는환자가직접감을수있도록교육을실시하여진행하였다. 이러한고전적부종감소물리치료는공기압박마사지 30분과림프흡수마사지 30분으로일일 1시간, 주 5일, 4주간진행하였다.

156 대한물리의학회지제 8 권제 2 호 Table 2. Complex exercise protocol Type Frequency Content Duration Morning Noon Afternoon Arm ergometer Complex exercise Treadmill 5 time a week until 4 weeks Train to arm ergometer at 20 RPM till 2 weeks and raise 30 RPM till 4 weeks 1. Stretching triceps brachii 2. Curl biceps 3. Paddling in sitting position 4. Paddling in sitting with forward lean position 5. Fluttering with both arms 6. Put your hands above your head in a V shape Train to ROM exercise at 1 kg till 2 weeks and raise 1.5 kg till 4 weeks Train to treadmill at 1 km/h till 2 weeks and raise 2 km/h till 4 weeks 20 min 20 min 20 min 4. 복합운동치료복합운동치료군은위의고전부종감소물리치료를동일하게수행하는동시에운동프로토콜에따라운동치료를시행하였다. 세부적으로는 Kaelin (2007) 의운동방법에기초하여일일 1시간, 주 5회, 총 4주간유산소운동과근력운동을포함한복합운동치료를실시하였다. 암에대한 ACSM(American College of Sports Medicine) 운동지침에따르면암의예방과회복을위하여주 3-5 일, 30-60 분, 중등도이상의운동을권장하고있다. 그러나암환자의전반적인건강상태, 진단, 다른요인들이환자의안전에영향을미칠수있다는점에서신중하게고려되어야한다. 환자인점을감안하여운동의질과양을적절하게조절해야필요가있어서노인을위한 ACSM 운동지침에따라운동자각도를이용하여중등도운동을하루중운동시간을아침, 점심, 저녁각 20분으로배분하여실시하였다. 붕대로인한활동성제약으로인하여 1kg의아령과빨강색의탄력밴드를이용하여 6가지의운동프로그램을 10회씩 3세트실시하였다. 복합운동치료에대한자세한사항은 <Table 2> 와같다. 5. 통계처리본연구에서측정된자료는 SPSS-PC (ver 12.0 SPSS ICC, Chicago, 미국 ) 을이용하여평균 (M) 과표준편차 (SD) 로나타내었다. 측정시점에따른집단내 간의차이를알아보기위하여 2 2 repeated measured ANOVA를실시하였다. 모든통계적유의수준은 α=.05 로설정하였다. 1. VAS 의변화 Ⅲ. 연구결과 유방암림프부종중년여성의 4주간복합운동치료전 후통증척도의변화는 <Table 3> 과같다. <Table 3> 에서제시한바와같이 4주간복합운동치료적용으로인하여통증척도에서는시기에대한주효과와상호작용에서유의한차이가있는것으로나타났다. Table 3. The change of VAS scale after 4wks Variable Group Pre-test Post-test F-value p Visual Analog Scale CDP G 52.14 ±14.67 52.29 ± 11.46 1.18 G T 15.02 CECDP G 51.14 ± 16.65 37.14 ± 13.91 G T 15.65.30 CDP, classical decongestive physiotherapy; CEDPE, complex exercise and classical decongestive physiotherapy. Mean ± SD

4 주간복합운동치료가유방암림프부종중년여성의통증, 견관절가동범위에미치는영향 157 Table 4. The change of shoulder ROM after 4wks Variable Group Pre-test Post-test F-value p Flexion Extension Abduction Adduction External rotation Internal rotation CDP group 156.43 ± 10.29 160.71 ± 9.32 Group CECDP group 147.86 ± 5.37 157.86 ± 4.88 Group CDP group 25 ± 4.08 27.14 ± 2.67 Group CECDP group 31.43 ± 12.15 37.86 ± 3.93 Group CDP group 147.14 ± 14.68 153.57 ± 14.35 Group CECDP group 155 ± 6.45 165.74 ± 3.45 Group CDP group 27.14 ± 4.88 32.14 ± 6.99 Group CECDP group 25.71 ± 3.45 38.57 ± 4.56 Group CDP group 46.43 ± 7.48 47.86 ± 7.56 Group CECDP group 52.14 ± 12.54 57.14 ± 12.86 Group CDP group 25.71 ± 3.45 28.57 ± 4.76 Group CECDP group 47.86 ± 7.56 62.86 ± 11.13 Group CDP, classical decongestive physiotherapy; CEDPE, complex exercise and classical decongestive physiotherapy. 2.02 31.58 5.05 8.73 3.72 0.93 3.12 40.19 2.51 1.11 39.06 7.56 1.93 5.17 1.60 57.08 55.15 25.50.18.04.01.08.35.10.14.31.02.19.04.23 Mean ± SD 2. 견관절 ROM의변화유방암림프부종중년여성의 4주간복합운동치료전 후견관절 ROM 관련변인의변화는 <Table 4> 과같다. <Table 4> 에서제시한바와같이 4주간복합운동치료적용으로인하여굴곡에서는집단에대한주효과와상호작용에서, 신전에서는집단에대한주효과에서만, 외전에서는시기에대한주효과에서, 내전에서는시기에대한주효과와상호작용에서, 외회전에서도시기에대한주효과에서만, 내회전에서도시기와집단에대한주효과와상호작용에서유의한차이가있는것으로나타났다. 결과적으로고전적물리치료군에비하여복합운동치료군에서복합운동치료의효과는신전을제외한굴곡, 외전, 내전, 외회전, 내회전에서유의한차이를나타났다. Ⅳ. 고찰질병에관한중요한위험인자는인종 / 민족, 성, 노화 이며, 이중에서도유방암발생률과사망률은노화에따라증가하는데특히, 45세이상중년여성의경우에는유방암발생률과사망률이최고조에이른다 (Chopra과 Kamal, 2012). 이는국내에서의유방암발병률과도일치하는것으로나타나서우리나라의중년여성의유방암관리에적신호로보여진다. 유방암림프부종은유방암수술또는치료에의한부작용으로신체적, 정신적, 경제적, 사회적인문제를유발시킬수있다. 일단림프부종이발생하게되면완치되는것이아니므로더이상악화를방지하고부종의상태를극소화하는것이필수적이다 (Roh, 2002). 따라서본연구에서는본연구에서는유방암림프부종중년여성을대상으로고전물리치료를포함한복합운동치료가통증, ROM에어떠한영향을미치는지알아보고자하였다. 유방암림프부종으로인하여발생되는일반적인팔의감각은조이는느낌, 무거움, 통증, 딱딱함, 따가움, 불편함, 뜨거움, 약함, 붓기, 따끔거림, 무감각이야기된다 (Tsauo 등, 2011). 통증은유방암림프부종과관련된중요한문제로 (Martín 등, 2011), 유방암림프부종으로

158 대한물리의학회지제 8 권제 2 호 인한상지의주요증상중하나로보고되고있다 (King 등, 2012). 선행연구에서는유방암으로유발된상지부종을지닌여성이일반여성보다높은통증지수 (Velanovich과 Szymanski, 1999) 를, 상지부종이있는사람들이상지부종이없는사람들에비하여유의하게높은통증지수와빈도를보고하였다 (Smoot 등, 2010). 본연구에서는시각적통증상사척도의검사결과로복합운동치료를통하여통증점수가유의하게감소하는것으로나타났다. 반면에고전부종감소물리치료군은통증점수의변화가없는것으로나타났다. 선행연구에따르면부종치료제인벤조피론 (benzopyrones) 을투여한경우 (Shah 등, 2012), 도수림프배수를병행한압박붕대방법군과공기압박을병행한자가림프배수방법군 (Gurdal 등, 2012) 에서통증이유의하게감소되는것으로보고되었다. 운동과관련된선행연구에서는수술후조기운동프로그램을 1개월적용후에통증이감소되는것으로나타났다 (Lee 등, 2001). 또한수술후조기운동프로그램을 1회 30분, 일일 4회, 15분간적용한후에도통증이유의하게감소하는것으로나타났다 (Kim 등, 2005). 운동의효과측면에서림프계의적응 (adaption) 에관해서는매우제한적으로알려져있지만 (Schmitz 등, 2010a), 운동은골격근의수축작용으로정맥배수 (venous drainage) 를위한기초적인펌프기전을제공하며 (Witte과 Witte, 1987), 인체의단백질재흡수와림프순환을증가시키는것으로알려졌다 (Ahmed 등, 2006). 상지운동과관련한선행연구에서는상지운동은교감신경계흥분을이완시키고 (McKenzie 과 Kalda, 2003) 림프계를조절하여림프부종의장기적인관리에보조적인역할을수행한다고보고하였다 (Bicego 등, 2006). 림프부종환자의경우, 통증이원인이되어기능손실이유발될수도있다 (Korpan 등, 2011). 기능손실을평가하는방법중의하나로임상에서는 ROM을측정한다. 선행연구에서상지부종이없는사람들에비하여상지부종이있는사람들의경우에유의하게낮은 ROM(Smoot 등, 2010) 과견관절경직 (Ashikaga 등, 2010) 이보고되었다. 결과적으로유방암림프부종으로인하여감소된관절범위는상지기능에영향을미친다 (Korpan 등, 2011). 유방암치료후 ROM 제한은수술후흉터조직형성, 방사선유발섬유증, 견관절을앞으로하거나움직이지않는방어적인자세와통증으로인하여유발된다 (Smoot 등, 2010). 본연구에서는복합운동치료가유방암림프부종군의폄변인을제외한나머지변인의 ROM을유의하게증가시키고있는것으로나타났다. 선행연구에서는저항과유산소의복합운동형태로재택과체육관운동을통하여견관절의 ROM의개선 (Portela 등, 2008), 배수운동과상지운동을통하여폄, 벌림, 외회전관절가동범위의증가 (Lim과 Han, 2011), 수술후조기운동프로그램이복합치료군의폄, 벌림, 외회전의유의한향상 (Lee 등, 2001) 이보고되었다. 이는운동이유방암으로유발된상지림프부종중년여성의상지기능을강화시키는것으로생각된다. 선행연구에서는암치료중의운동은생리학적이고심리학적인장점을제공한다고결론을도출하고있다 (Young-McCaughan과 Arzola, 2007). 운동은근량, 조직의대사요구량, 미세순환의변화 (Schmitz 등, 2010a), 근골격계펌핑기전을작용시켜정맥과림프환류의증가 (Sander, 2008), 유연성증가와근력증가 (Schmitz 등, 2010b) 등의긍정적인효과를가지고있는것으로나타났다. 본연구의복합운동치료를통하여견갑대 (shoulder girdle) 의하위구성요소인근육, 건, 인대의생리적인변화로유연성이향상되었을것으로생각된다. 또한, 복합운동의구성에있어견관절주변근육의체인으로형성하고있는원위부와근위부의근수축을통해견관절의안정성과운동성의효과를증대시켜견관절의움직임을증가시키는것으로추정된다 (Oliver 등, 2012). 암예방과조절을위한운동의중요성이대두된지는 20년이조금넘었다 (Kwan 등, 2011). 그중에서도유방암림프부종의운동중재에대한연구는알려진지얼마되지않았다 (Smoot 등, 2010). ACSM의암에대한운동지침은일반적으로중등도, 30분, 주당 5회, 걷기와같은신체활동의종류를권장하고있다. 그러나이지침은널리적용할수있도록만든처방에서는개인차가고려되어야하며, 안정성을고려할때전반적인건강상태, 진단과다른요소들이고려되어야한다 (Laino,

4 주간복합운동치료가유방암림프부종중년여성의통증, 견관절가동범위에미치는영향 159 2010). 이런과정을거쳐, 증가된활동과운동치료는유방암과관련된림프부종이있는여성들에게유익하고안전할것으로제안되고있다 (Smoot 등, 2010). 또한암과같은만성적인상태를가진사람을위하여, 그들의능력이허용하는한도내에서신체적으로활동적이며무활동 (inactivity) 을피하도록권고하고있다 (Kwan 등, 2011). 유방암치료후에예견되어지는손상에대하여, 초기평가와치료적중재활동을통하여통증, 유연성과근력, 활동제약의감소를최소화시킬수있다 (Smoot 등, 2010). 본연구에서는고전적부종감소물리치료외에유산소운동과근력운동을복합적으로구성하여운동에대한림프부종환자의견관절 ROM 증가와통증감소의효과를알아보았다. 이는기존에실시하고있는고전적림프부종치료와함께복합운동을환자에게적용했을때통증의감소와 ROM의증가효과를기대할수있는것으로판단되며아직림프부종에대한운동치료관련연구의역사가시작단계에있다는것을주목해야할필요가있다. 복합운동치료효과적인면에서연구해야할부분이산적해있다. 향후연구의방향으로부종인팔이우세한팔인지여부, 수술방법에따른분류, 급성과만성의효과, 운동프로토콜의다양성, 일상생활수행능력과의상관연구등을수행할수있다. 또한림프부종환자를위한지속적인프로그램개발과환자의증상완화, 삶의질증대를위한연구가필요하다고판단된다. Ⅴ. 결론본연구에서는유방암림프부종중년여성을대상으로고전적부종감소물리치료를포함한복합운동치료가상지림프부종중년여성의통증, 견관절가동범위에어떠한영향을미치는지알아보고자하였다. 결론은다음과같다. 첫째, 4주간의복합운동치료적용후유방암림프부종중년여성의통증이유의하게감소하는것으로나타났다. 둘째, 4주간의복합운동치료적용후유방암림프부종중년여성의관절가동범위가유의하게증가되는것으로나타났다. 이상의결과들로볼때, 4주간의복합운동치료는통증과관절가동범위를유지하거나향상시키는데적합한프로그램으로판단된다. References Ahmed RL, Thomas W, Yee D et al. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol. 2006;24(18):2765-72. American Medical Association. Guides to the Evaluation Of Permanent Impairment. 4th ed. Chicago. American Medical Association. 1993. Ashikaga T, Krag DN, Land SR et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102(2):111-8. Bicego D, Brown K, Ruddick M et al. Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther. 2006;86(10):1398-405. Brown JC, Huedo-Medina TB, Pescatello LS et al. Efficacy of exercise interventions in modulating cancer-related fatigue among adult cancer survivors: a metaanalysis. Cancer Epidemiol Biomarkers Prev. 2011;20(1):123-33. Campbell A, Mutrie N, White F et al. A pilot study of a supervised group exercise program as a rehabilitation treatment for women with breast cancer receiving adjuvant treatment. Eur J Oncol Nurs. 2005;9(1):56-63. Chopra I, Kamal KM. A systematic review of quality of life instruments in long-term breast cancer survivors. Health Qual Life Outcomes. 2012;10:14. Cole B, Finch E, Gowalnd C et al. Physical Rehabilitation Outcome Measures. Toronto : Canadian Physiotherapy Association. 1994. Didem K, Ufuk YS, Serdar S, Zumer A. The comparison

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