both non - pharmacological and pharmacological treatments of breast cancer have negative side 
 effects ranging from the kinesiological to psychological domain , depending on the 
 interaction of treatment characteristics with the physio - pathological and psychological 
 conditions of each subject1 , 2 .
upper limb lymphedema is a potential negative consequence 
 of breast cancer surgery and radiation therapy that can appear during the months or even 
 years after treatment ends .
a growing body of scientific literature emphasizes the psycho - physical importance of early 
 physical exercise engagement of breast cancer survivors in order to facilitate an early 
 recovery , and to prevent breast cancer recurrence and the onset of all sedentarism - related 
 diseases3 . currently , various forms of 
 exercise are prescribed following breast cancer treatment .
although walking training , as the 
 most accessible and low cost activity , is the most practised activity , proper exercises for 
 breast cancer survivors should principally aim to correct faulty posture , balance muscle 
 chain lengths , elasticity and strength , improve general physical fitness , prevent 
 lymphedema , reduce mental distress , and activate the immune system4,5,6 . in order to achieve all or most of the described aims ,
it is very 
 important to plan the correct training and if possible to choose a complete discipline .
to 
 furnish a wide - ranging healthy intervention , the recently introduced physical fitness 
 discipline of nordic walking appears to be useful for breast cancer survivors .
nordic 
 walking is a form of brisk walking , utilizing a walking pole , which actively engages the 
 trunk and upper limbs during walking , increasing their range of motion and increasing total 
 body muscle endurance7,8,9,10 , and it has positive effects on cardio - metabolic , postural and 
 balance measures in both healthy and pathological conditions11,12,13 . in addition , due to its principal characteristics , it is 
 conceivable to consider nordic walking as an effective discipline against lymphedema14 , 15 .
indeed , during nordic walking practice there is an alternating open 
 and close cycle of the hands , creating a  pumping effect  , theoretically favouring both 
 lymphatic and blood circulation through upper limb muscle contraction , as reported for the 
 pole walking technique7 , 9 , 16 . as nordic 

walking and pole walking are not the same discipline , they use different equipment and have 
 a few but substantially different principal characteristics ( table 1table 1.nordic walking vs. pole walking characteristicsnordic walkingpole walkingequipment : equipment: light - weight poles come in fixed - length , 2 or 3 sections; poles are adjustable in length and divided into 3 sections; releasable hand strap system that attaches to the handle and is 
 fixed to the pole whilst in use ;  baskets are interchangeable and useful for preventing poles from 
 sinking into the ground; specially - designed , removable rubber tips and fixed steel tips 
 are angled to assist with push - off; adjustable , locking straps with a different variety of handle 
 types , enable user to maintain contact with grips without causing hand 
 strain; poles are alternately used beside and behind the body in a 
 pushing action; concave , carbide flex tips are designed for optimal performance 
 on a variety of non - paved surfaces; the body s natural gait pattern  called the reciprocal gait  is 
 accentuated when using nordic walking poles; rubber tips with a flat surface , enable the user to walk indoors 
 or on pavements ;  to some extent , without losing the natural walking pattern , the 
 stride lengthens , and spinal rotation is the key to achieving walking  with 
 attitude  .
this recruits more muscles but actually often lowers perceived exertion 
 because more muscles are being used. pole walkers use the poles to transfer body weight onto the pole 
 which helps to share the load and provide stability with the principal aim to take 
 some weight off the lower body joints and to cope with tough conditions 
 underfoot; in general , pole walkers are not seeking to gain such forward 
 propulsion or increase stride in the way nordic walkers do and they plant the 
 poles in front of them at a much more upright angle.created and adapted from the contents of jayah faye paleys blog . 

http://adventurebuddies.net/blog/2010/09/nordic-walking-poles-vs-trekking-poles-whats-the-difference/ ) , it is very important to verify the effectiveness of the nordic walking 
 technique on the upper limb circumferences of breast cancer survivors .
taking into account 
 that to maintain natural gait , while the hands are performing the nordic walking 
 characteristic open - close cycle in an alternating manner ( fig .
1.hands coordination scheme during nordic walking practice ) , could be too complex a task for novice nordic walkers with little previous 
 experience of physical exercise , with a consequent delayed beneficial effect on upper limb 
 circumferences , we designed a series of exercises , properly tailored for breast cancer 
 survivors ( i.e. the isa method ) , to enhance the pump effect of the upper limbs and 
 contrasting arthralgia .
the aim of this study was to verify the effects of 10 weeks of 
 nordic walking , nordic walking + isa method , walking alone , and walking + isa method on 
 upper limb circumferences and total body water of breast cancer survivors
twenty breast cancer survivors ( bcs ) ( mean age , 50.60  3.60  years ) were recruited by the 
 department of general surgery specialized in senology of the  g. bernabeo  hospital ( ortona , 
 italy ) .
the inclusion criteria were : age>4055  years ; no past or current chemotherapy ; no 
 current radiotherapy ; current hormonal therapy ; cardiovascular and orthopaedic eligibility 
 for nordic walking practice ; no endocrine diseases ; lymphedema lower than class 2 of the 
 ceap - l classification17 ; no dieting or 
 use of nutritional supplements ; no participation in any exercise programme during the six 
 months prior to the study ; and un - employed status .
the ethics committee of the  g. 
 dannunzio  university of chieti - pescara approved this study , and all of the participants 
 gave their written informed consent .
after recruitment , the breast cancer survivors were visited by both cardiology and sports 
 medicine specialists to verify their cardiovascular and orthopaedic eligibility for walking 
 and nordic walking practice through medical examination , echocardiography and the maximal 
 stress test .
after meeting the medical eligibility criteria , the participants were randomly 
 assigned to one of four different workout groups , which performed nordic walking ( nwg ) , 
 nordic walking + isa method ( nw - isag ) , walking ( wg ) or walking + isa method ( w - isag ) 
 workout . before starting 10 weeks of supervised training , both nwg and nw - isag
were 
 introduced to nordic walking , through 10 lessons on the nordic walking technique .
after the 
 10 lessons , two nordic walking instructors of the international nordic walking association 
 ( i.e. inwa ) independently verified the proficiency of each participant .
after nwg and 
 nw - isag had completed the 10 lessons of nordic walking technique ( t0 ) , all the participants 
 underwent anthropometry and body composition analysis , which were repeated at the end of the 
 study ( t1 ) . a resting 12-lead electrocardiogram (
stress ecg hd+ , cardioline , trento , italy ) was 
 recorded after 10  min supine rest . because the majority of participants had never used a 
 treadmill before , the eligibility for aerobic training was assessed through a graded maximal 
 exercise test on a cycle ergometer ( cardioline xr50 , cardioline , trento , italy ) , supervised 
 by a sports medicine specialist medical doctor .
participants performed a graded maximal 
 exercise test , the astrand protocol using 3-minute steps18 , under continuous electrocardiogram monitoring ( stress ecg hd+ , 
 cardioline , trento , italy ) , and blood pressure was measured at the end of each step .
the 
 test lasted until the doctor saw absolute or relative indications for clinical graded 
 exercise test termination , according to the italian federation of sports medicine 
 guidelines19 .
a second level anthropometrist of the international society for the advancement of 
 kinanthropometry , following the society s guidelines20 , measured weight , stretched stature and the following 
 circumferences of the upper limbs : relaxed arm ( the circumference at 
 acromiale - radialemedio point ) , maximal forearm ( the maximal circumference of 
 forearm ) , mid forearm ( the circumference at mid - point between radiale and 
 stylion points ) and wrist ( the wrist circumference at distal region of the 
 stylion point ) .
a stadiometer with a balance - beam scale ( seca 220 , seca , 
 hamburg , germany ) was used to measure weight and stretched stature ; an anthropometric tape 
 ( cescorf , porto alegre , brazil ) was used to measure circumferences and a segmometer 
 ( cescorf , porto alegre , brazil ) was used to locate the acromiale - radiale medio 
 point and mid forearm .
anthropometric measures were reported to the nearest 0.1  kg and 
 0.1  cm .
body extracellular water of the participants was assessed using a hand - to - foot electrical 
 bioimpedance technique , and a 50-khz frequency bioelectric impedance analyzer ( bia 101 , 
 akern , pontassieve , italy ) .
the test was performed 3  h after waking , and immediately after 
 voiding , with the participants undressed in the supine position , the upper limbs separated 
 from the trunk , and the lower limbs separated from each other .
all the training groups followed the same training schedule with different contents 
 according to group membership .
the 70  min of training , including 15  min of warm - up , 45  min 
 of central phase and 10  min of cool down , was performed three time a week for 10 weeks . from 
 the first to the fourth week , the participants trained at 1011 on the borg rating of 
 perceived exertion ( rpe ) scale21 , from 
 the fifth to the eighth week at 1213 rpe , and from the ninth to the tenth week at 1314 
 rpe .
the participants were familiarized with this scale before beginning the training , and 
 also during the first week of training .
the borg scale is particularly useful for 
 prescribing and monitoring exercise intensity in this population , as with the same external 
 load it is possible to have a different internal load due to the side effects of 
 pharmacological treatments ( e.g. fatigue ) .
exercise trainers checked the exercise 
 intensities of the participants through the talk test22 , and checked their compliance with the training sessions .
nwg and nw - isag were conducted 
 and supervised by exercise specialists who were also instructors of the italian nordic 
 walking association , and members of the same international association ( i.e. inwa ) . 

considering the differences between the groups : i ) nwg executed the traditional anwi - inwa 
 suggested exercises for warm - up and cool - down , including whole body mobilization exercises 
 during warm - up , and stretching exercises during cool - down23 , and nordic walking in the central phase of the training session ; 
 ii ) wg executed whole body mobilization exercises during warm - up and stretching exercises 
 during cool - down23 , 24 , and walking in the central phase of the training session ; iii ) 
 nw - isag executed the isa method during warm - up and both the isa method and stretching 
 exercises during cool - down , and nordic walking in the central phase of the training session ; 
 and iv ) w - isag executed the isa method during warm - up and both the isa method and stretching 
 exercises during cool - down , and walking in the central phase of the training . during the 
 training period , participants did not practice other forms of exercise and did not have 
 lymphatic drainage .
the isa method includes a series of dynamic exercises , propaedeutic for nordic walking , 
 lymphedema and arthralgia , properly tailored for breast cancer survivors .
it requires the 
 use of isa balls , foam balls of 6 or 7  cm diameter with different densities , that can be 
 used both alone or with nordic walking poles ( fig . 

this series of exercises has the following objectives : to gently warm - up joints , 
 and to reduce muscular tensions and counteract or prevent upper limb lymphedema .
the scheme 
 of execution is the following : the protocol starts with warm - up exercises for the hand and 
 wrist joints , that are executed using only isa balls , followed by multi - joint exercises , 
 actively involving wrists , elbows and shoulders using both nordic walking poles and isa 
 balls applied to them , and by neck exercises , that are executed using only nordic walking 
 poles .
the main task performed by participants in the workout with isa balls , was to gently 
 squeeze them , during the forward and the returning phases of each exercise , in order to 
 promote the pumping effect in the upper limbs .
after the neck and 
 upper limb exercises , trunk and lower limb exercises were executed using only nordic walking 
 poles .
lower limb exercises were executed following a distal to proximal order , from feet to 
 hip joints .
isa balls applied to nordic walking poles statistical analysis was performed using the sas 9.2 software ( sas institute inc . , cary , 
 usa ) .
although non - parametric tests were performed because of the small sample size , some 
 data are presented as means  standard deviation in order to better comprehend the results . 

considering the whole sample , the kruskall - wallis test was used to verify whether the groups 
 differed in basal characteristics . considering each group separately
, the mann - whitney test 
 was used to verify whether circumferences of the upper limb , homolateral with surgical 
 intervention for breast cancer , significantly differed from those of the opposite side .
the 
 wilcoxon test was used to verify , separately in each group , the significance of changes in 
 the outcome measures at the end of the training period .
table 2table 2.anthropometric and hydration differences of the groupsnwgnw - isagwgw - isagage ( years)52.6  2.148.4  1.549.2  5.752.2  2.5weight ( kg)78.3  12.560.5  7.465.1  10.764.2  5.1tbw ( lt)35.8  4.132.8  432.3  3.133.5  1ecw ( lt)19.1  3.217.1 
1.316.9  1.617.8  2.2ecw / tbw ( % ) 53  5.852.7  4.252.2  1.553.2  5.4relaxed arm circ .
( cm ) 34.6  3.3 * 29.2  2 * 30.6  2.4 * 30.6  1.7*max forearm circ .
( cm) 33.7  3.1 * 28.5  1.8 * 29.9  2.4 * 29.6  1.5*max forearm circ .
 0.516.1  0.7nwg : nordic walking group ; nw - isag : nordic walking + isa method group ; wg : walking 
 group ; w - isag : walking + isa method group ; tbw : total body water ; ecw : extracellular 
 water ; circ . : circumference ; max : maximum ; homolateral to the surgical 
 intervention for breast cancer ; contralateral to the surgical intervention for breast 
 cancer ; * p<0.05 shows the homogeneity of the groups , which had the same starting values , 
 except for the relaxed arm circumferences , which were higher in the nwg . as nwg had higher 
 relaxed arm circumference than the other groups , and not only on the side homolateral to the 
 surgical treatment , the observed difference was not due to a different grade of lymphedema 
 but to a difference in the group s characteristic .
table 3table 3.analysis of upper limb differences of the groupshomolateral upper limbcontralateral upper limbnwgrelaxed arm circ .
( cm)16.1  0.616.1  0.7homolateral upper limb , circumferences taken on the upper limb homolateral to the 
 surgical intervention for breast cancer ; contralateral upper limb , circumferences 
 taken on the upper limb contralateral to the surgical intervention for breast cancer ; 
 max : maximum ; nwg : nordic walking group ; nw - isag : nordic walking + isa method group ; 
 wg : walking group ; w - isag : walking + isa method group ; circ . ,
circumference ; 
 * p<0.05 shows that all the upper limbs homolateral to the surgical intervention for 
 breast cancer had circumferences greater than those of the contralateral upper limb except 
 the wrist circumferences , which showed no significant difference .
the wilcoxon test showed 
 that while wg showed no significant changes in any of the outcome measures , and increased 
 both total body water and mid - forearm circumference , the other groups exhibited significant 
 reductions ( table 4table 4.analysis of variables modifications of the groupsnwgt0nwgt1nw - isagt0nw - isagt1wgt0wgt1w - isagt0w - isagt1weight ( kg)78.3  12.578.8  11.960.5  7.460.2  6.665.1  10.765.2  11.264.2  5.164.4  5.1tbw ( lt)35.8  435.4  3.932.8  4.132.7  3.732.3  3.133.1  3.4 * 33.5  134.3  1.1ecw ( lt)19.1  3.218.5  2.717.1 
1.316.8  1 * 16.9  1.617.2  2.317.8  2.217.4  1.8ecw / tbw ( % ) 53  5.852.1  4.152.7  4.251.7  4.2 * 52.2 
( cm)34.6  3.334  3.1 * 29.2  229.1  2 * 30.6  2.430.6  1.930.6  1.729.7  1.5*max forearm circ .
( cm)*24.3  2.323.8  2.3 * 22.9  2.222.2  2.3 * 23.1  1.922.8  1.923.5  0.622.5  0.8*mid forearm circ .
( cm) 33.7  3.133.8  2.928.5  1.828.2  1.729.9  2.430.1  1.929.6  1.529.5  1.5max forearm circ .
( cm)24  2.224  2.522.4  2.122.3  2.322.7  1.723.6  1.522.4  1.121.9  0.8mid forearm circ .
( cm)23.2  223.2  2.221  2.321  2.321.7  1.121.8  1.220.7  0.720.3  0.7wrist circ .
1.215.5  0.915.9  0.515.8  0.516.1  0.716.3  0.6nwg : nordic walking group ; nw - isag : nordic walking + isa method group ; wg : walking 
 group ; w - isag : walking + isa method group ; tbw : total body water ; ecw : extracellular 
 water ; circ .
: circumference ; max : maximum ; homolateral to the surgical 
 intervention for breast cancer ; contralateral to the surgical intervention for breast 
 cancer ; * p<0.05 ) . both nwg and
nw - isag showed significantly reduced relaxed arm and maximum 
 and mid - forearm circumferences homolateral to the surgical intervention .
nw - isag also showed 
 significant reductions in extracellular water , the extracellular to total body water ratio 
 and the wrist circumference homolateral to the surgical intervention ( table 4 ) .
in contrast to wg , which showed no significant 
 reductions in arm circumferences , w - isag showed a significant reductions in the 
 extracellular to total body water ratio , relaxed arm circumference , and both maximum and 
 mid - forearm circumferences homolateral to the surgical intervention ( table 4 ) .
nwg : nordic walking group ; nw - isag : nordic walking + isa method group ; wg : walking 
 group ; w - isag : walking + isa method group ; tbw : total body water ; ecw : extracellular 
 water ; circ . : circumference ; max : maximum ; homolateral to the surgical 
 intervention for breast cancer ; contralateral to the surgical intervention for breast 
 cancer ; * p<0.05 homolateral upper limb , circumferences taken on the upper limb homolateral to the 
 surgical intervention for breast cancer ; contralateral upper limb , circumferences 
 taken on the upper limb contralateral to the surgical intervention for breast cancer ; 
 max : maximum ; nwg : nordic walking group ; nw - isag : nordic walking + isa method group ; 
 wg : walking group ; w - isag : walking + isa method group ; circ . ,
circumference ; 
 * p<0.05 nwg : nordic walking group ; nw - isag : nordic walking + isa method group ; wg : walking 
 group ; w - isag : walking + isa method group ; tbw : total body water ; ecw : extracellular 
 water ; circ . : circumference ; max : maximum ; homolateral to the surgical 
 intervention for breast cancer ; contralateral to the surgical intervention for breast 
 cancer ; * p<0.05
taking into account that our pilot study was conducted on a restricted sample and that our 
 results need further confirmation , our study provides interesting preliminary results for 
 optimizing recovery from breast cancer treatment .
according to our results , walking training 
 does not seem capable of reducing upper limb circumferences and extracellular body water , so 
 it should not be used alone for the prevention / treatment of upper limb lymphedema .
this 
 result should be explained by the fact that there is a lack of active use of the upper 
 limbs , whereas nordic walking actively uses the upper limbs as a propulsive means , one of 
 its main features .
indeed , pellegrini et al.26 showed that the muscle activities of the triceps brachii , 
 latissimus dorsii , biceps brachii and anterior deltoideus muscles , were respectively 
 16-fold , 40-fold and 3-fold lower in walking than in the nordic walking .
also , each muscle s 
 activation is characterized by a cyclical pattern , with activation of different intensities , 
 according to the phase of walking .
the alternating active use of the upper limb muscles 
 supports lymphatic and blood circulation , benefiting from the gravity effect helping to 
 prevent or reduce upper limb swelling .
an important result of the present preliminary study 
 is that by coupling the isa method with walking training , it is possible to compensate for 
 the lack of the upper limb  pumping effect  , a typical negative characteristic of walking 
 training .
indeed , after 10 weeks of training , while wg showed no significant modifications , 
 w - isag exhibited significant reductions in extracellular to total body water ratio , and arm 
 and forearm circumferences .
this result could be particularly useful for breast cancer 
 survivors favoring walking training but not nordic walking , and also for those who have to 
 train indoors , using a treadmill , for any reason . in the present study , when the proper 
 nordic walking technique was performed maintaining the natural gait with the hands 
 performing an open and close cycle in an alternating manner , nordic walking alone was able 
 to reduce the upper limb circumferences and extracellular body water .
therefore , even in the 
 absence of the isa method , when the proper nordic walking technique is practised for 10 
 weeks , reductionts can be achieved in the upper limb circumferences homolateral to the 
 breast cancer surgery site . in conclusion , both a larger study and the use of a more accurate technique for quantifying 
 lymphedema
furthermore , the present results 
 may only be applicable to people with lymphedema lower than class 2 of the ceap - l 
 classification
. however , the addition of the isa method , during both the warm - up and cool 
 down phases , to 10 weeks of walking - based workout could be useful for the management of 
 lymphedema , walking alone seems not to be of benefit . in order to choose a physical exercise 
 having complete efficacy against breast cancer treatment effects on the side of treatment , 
 particular attention should be paid to nordic walking .
nordic walking has been reported to 
 achieve balanced postural changes in breast cancer - related treatment postural disorders10 , increases in upper extremity 
 strength8 , improvements in 
 cardio - metabolic and respiratory measures and has been used in the prevention and treatment 
 of upper limb lymphedema . however , in order to elicit beneficial effects , it is necessary to 
 perform the proper technique and achieve consistency in training .
 [ purpose ] the aims of this study were to verify the effects on upper limb circumferences 
 and total body extracellular water of 10 weeks of nordic walking ( nw ) and walking ( w ) , 
 both alone and combined with a series of exercises created for breast cancer survivors , 
 the isa method . [ subjects and methods ] twenty breast cancer survivors were randomly 
 assigned to 4 different training groups and evaluated for upper limb circumferences , total 
 body and extracellular water . 
 [ results ] the breast cancer survivors who performed nw , 
 alone and combined with the isa method , and walking combined with the isa method ( but not 
 alone ) showed significantly reduced arm and forearm circumferences homolateral to the 
 surgical intervention . [ conclusion ] for breast cancer survivors , nw , alone and combined 
 with the isa method , and walking combined with the isa method should be prescribed to 
 prevent the onset and to treat light forms of upper limb lymphedema because walking 
 training practiced alone had no significant effect on upper limb circumference 
 reduction . 