Blurred lines between axillary web syndrome and Mondor's disease after breast cancer surgery: A case report

Tolerability, Safety and Efficacy of a Specific Rehabilitation Treatment Protocol for Axillary Web Syndrome: An Observational Retrospective Study

Axillary web syndrome (AWS) is a highly prevalent surgical complication affecting BC survivors. It presents as a subcutaneous cording that limits the upper limb range of motion (ROM) and causes pain. Its etiology is still debated, and its treatment is not well defined. Therefore, we aimed to investigate the safety, tolerability and efficacy of our specific AWS rehabilitative treatment protocol. We conducted an observational retrospective study on a cohort of 92 AWS patients referred to the oncological outpatient service of a university hospital. We collected data from medical records before (T0) and after (T1) the treatment. The studied protocol was composed of 60-min sessions, carried out 3 times/week by specialized physiotherapists, until the clinical resolution of AWS. We found that a mean of 8.74 ± 2.12 rehabilitative sessions were needed, and only one patient stopped early. At T1, shoulder ROM was complete in both abduction and flexion in 98% of patients; AWS was no longer detectable in 64% of them, and pain significantly decreased compared to T0. In conclusion, our protocol proved to be safe, well-tolerated and seemed to be effective in treating AWS.

Algorithm-Based Risk Identification in Patients with Breast Cancer-Related Lymphedema: A Cross-Sectional Study

Background: Breast cancer-related lymphedema (BCRL) could be one consequence of breast cancer (BC). Although several risk factors have been identified, a predictive algorithm still needs to be made available to determine the patient's risk from an ensemble of clinical variables. Therefore, this study aimed to characterize the risk of BCRL by investigating the characteristics of autogenerated clusters of patients. Methods: The dataset under analysis was a multi-centric data collection of twenty-three clinical features from patients undergoing axillary dissection for BC and presenting BCRL or not. The patients' variables were initially analyzed separately in two low-dimensional embeddings. Afterward, the two models were merged in a bi-dimensional prognostic map, with patients categorized into three clusters using a Gaussian mixture model. Results: The prognostic map represented the medical records of 294 women (mean age: 59.823±12.879 years) grouped into three clusters with a different proportion of subjects affected by BCRL (probability that a patient with BCRL belonged to Cluster A: 5.71%; Cluster B: 71.42%; Cluster C: 22.86%). The investigation evaluated intra- and inter-cluster factors and identified a subset of clinical variables meaningful in determining cluster membership and significantly associated with BCRL biological hazard. Conclusions: The results of this study provide potential insight for precise risk assessment of patients affected by BCRL, with implications in prevention strategies, for instance, focusing the resources on identifying patients at higher risk.

Effects of Ultrasound-Guided Injection Combined with a Targeted Therapeutic Exercise in Breast Cancer Women with Subacromial Pain Syndrome: A Randomized Clinical Study

In this randomized controlled study, we aimed to assess the effects of US-guided injections of the subacromial bursa followed by a personalized rehabilitation program for breast cancer (BC) survivors. We assessed patients with subacromial pain syndrome without tendon lesions and with a history of post-surgical non-metastatic BC. Thirty-seven patients were enrolled and randomly assigned 1:1 to receive US-guided corticosteroid injections combined with a personalized rehabilitation program (Group A; n: 19) or US-guided corticosteroid injections alone (Group B; n: 18). The primary outcome was pain relief, assessed using a numerical pain rating scale (NPRS). The secondary outcomes were muscle strength, shoulder function, and quality of life. No major or minor late effects were reported after the multidisciplinary intervention. Statistically significant within-group differences were found in terms of NPRS (p ≤ 0.05) in both groups. No significant between-group differences were reported after one week. However, the between-group analysis showed significant differences (p ≤ 0.05) after three months of follow-up in terms of pain intensity, muscle strength, shoulder function, and quality of life. Our findings suggested positive effects of a multidisciplinary approach including US-guided corticosteroid injections combined with a personalized rehabilitation program in improving pain intensity and quality of life of BC survivors with subacromial pain syndrome.

Prediction model of axillary lymph node status using automated breast ultrasound (ABUS) and ki-67 status in early-stage breast cancer

Background

Automated breast ultrasound (ABUS) is a useful choice in breast disease diagnosis. The axillary lymph node (ALN) status is crucial for predicting the clinical classification and deciding on the treatment of early-stage breast cancer (EBC) and could be the primary indicator of locoregional recurrence. We aimed to establish a prediction model using ABUS features of primary breast cancer to predict ALN status.

Methods

A total of 469 lesions were divided into the axillary lymph node metastasis (ALNM) group and the no ALNM (NALNM) group. Univariate analysis and multivariate analysis were used to analyze the difference of clinical factors and ABUS features between the two groups, and a predictive model of ALNM was established. Pathological results were as the gold standard.

Results

Ki-67, maximum diameter (MD), posterior feature shadowing or enhancement and hyperechoic halo were significant risk factors for ALNM in multivariate logistic regression analysis (P < 0.05). The four risk factors were used to build the predictive model, and it achieved an area under the receiver operating characteristic (ROC) curve (AUC) of 0.791 (95% CI: 0.751, 0.831). The accuracy, sensitivity and specificity of the prediction model were 72.5%, 69.1% and 75.26%. The positive predictive value (PPV) and negative predictive value (NPV) were 66.08% and 79.93%, respectively. Distance to skin, MD, margin, shape, internal echo pattern, orientation, posterior features, and hyperechoic halo showed significant differences between stage I and stage II (P < 0.001).

Conclusion

ABUS features and Ki-67 can meaningfully predict ALNM in EBC and the prediction model may facilitate a more effective therapeutic schedule.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10034-3.

Axillary Web Syndrome in Breast Cancer Women: What Is the Optimal Rehabilitation Strategy after Surgery? A Systematic Review

Background: Axillary web syndrome (AWS) is one of the most prevalent and underrecognized disorders affecting breast cancer (BC) women. However, the optimal therapeutic strategy to manage AWS is far from being fully characterized. Therefore, this systematic review aims to provide a broad overview of the available rehabilitation treatments in this burdensome condition. Methods: On 13 January 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for clinical studies assessing rehabilitation interventions in post-surgical BC women with AWS. The outcomes analyzed were pain, AWS clinical resolution, upper limb function, and health-related quality of life (HR-QoL). Results: The search identified 1115 records, of which 11 studies were included. A total of 174 patients were assessed (ages ranging from 37 and 66 years old). The interventions included manual lymphatic drainage, manual therapy, stretching, resistance training, mobilization techniques, and Kinesio tape. Positive improvements were reported in terms of pain relief (in 7 studies), AWS clinical resolution (in 9 studies), upper limb function (in 10 studies), and HR-QoL (in 2 studies). Conclusions: Our findings suggest that rehabilitation might be considered an effective therapeutic strategy in AWS patients. Further RCTs are needed to characterize the optimal rehabilitative interventions.

Long-Term Patient Satisfaction and Quality of Life Following Breast Reconstruction Using the BREAST-Q: A Prospective Cohort Study

Background

Breast reconstruction is a promising surgical technique to improve health-related quality of life (HRQoL) in patients with breast cancer. However, the long-term risk factors associated with HRQoL after breast surgery are still unclear. Our aim was to evaluate breast satisfaction and HRQoL following breast reconstruction to identify clinical factors associated with each domain of BREAST-Q in the long-term.

Methods

Patient-reported BREAST-Q outcomes were analyzed 1 and 5 years after breast reconstruction in a single-blinded, prospective study. Multiple regression analysis was performed to identify the risk and protective factors associated with BREAST-Q scores. These scores at 1 and 5 years were also compared across three types of operation: mastectomy only, tissue expander/implant (TE/Imp), and a deep inferior epigastric perforator (DIEP) flap.

Results

Surveys were completed by 141 subjects after 1 year and 131 subjects after 5 years. Compared to mastectomy only, breast reconstruction was significantly associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001), higher body mass index (BMI) resulted in lower “Satisfaction with breasts” (p = 0.004), and a history of psychiatric or neurological medication was significantly associated with “Physical well-being” at 1-year postoperatively (p = 0.02). At 5 years, reconstructive procedures were significantly positively associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p = 0.03; DIEP, p &lt; 0.001), and a bilateral procedure was a significant risk factor for lower “Psychosocial well-being” (p = 0.02).

Conclusions

The results of this study show that breast reconstruction improves “Satisfaction with Breasts” and “Psychosocial well-being” compared to mastectomy. Among all three types of operation, DIEP gave the best scores at 5 years postoperatively. Thus, autologous reconstruction is recommended for promotion of long-term HRQoL after breast surgery.

Breast Cancer Survivorship: the Role of Rehabilitation According to the International Classification of Functioning Disability and Health-a Scoping Review

Purpose of Review

The population of breast cancer (BC) survivors is growing due to earlier diagnosis and effective combined treatments. A scoping review was performed to explore the role of rehabilitation in BC survivorship and the major issues in BC survivors with International Classification of Functioning Disability and Health (ICF) perspective.

Recent Findings

The authors searched PubMed from January 1, 2018, up until November 9, 2021. The 65 selected publications were analyzed with the Comprehensive ICF BC Core Set (CCS) perspective and assigned to the categories of the CCS components along with the 3 areas of health (physical, mental, and social health). The multidimensional aspects of BC survivor disability are evident, whereas the topics of the articles concern several categories of the ICF BC CCS and all 3 areas of health. However, the current ICF BC CCS does not include certain categories related to emerging issues of BC survivorship recurring in the papers.

Summary

Rehabilitation is crucial in BC survivorship management to give personalized answers to women beyond BC, and the ICF BC CCS remains an essential tool in rehabilitation assessment for BC survivors although it needs updating.

Early Denosumab for the prevention of osteoporotic fractures in breast cancer women undergoing aromatase inhibitors: A case-control retrospective study

BACKGROUND

Aromatase inhibitors (AIs) might have a detrimental impact on bone health in breast cancer (BC) women. Denosumab has been shown to reduce the risk of fractures, but the appropriate time for starting is yet to be clearly defined.

OBJECTIVE

To evaluate the effects of early treatment with Denosumab (⩽ 12 months after starting AIs) compared to a delayed treatment in BC women.

METHODS

In this retrospective case-control study, we included medical records of BC post-menopausal women, treated with AIs therapy; they were divided as: study group (starting Denosumab ⩽ 12 months after AIs) and control group (> 12 months). At the baseline (T0) and at 18 months (T1), we evaluated the lumbar spine (LS) Tscore and femoral neck (FN) Tscore. Furthermore, at T1 we assessed the incident fragility fractures.

RESULTS

Fifty-nine BC survivors (mean age: 61.5 ± 11.5 years) were included: 28 with Early Denosumab and 31 with Late Denosumab. At T1, the study group did not show any incident hip or vertebral fragility fracture, whereas the Late Denosumab group showed 2 incident hip fractures (6.5%) and 4 (12.9%) vertebral fragility fractures. Early Denosumab showed a significant positive effect on both LS (p= 0.044) and FN (p= 0.024) Tscore variations.

CONCLUSION

Taken together, our findings suggest that an early start of Denosumab might be considered for the osteoporosis management in BC women undergoing AIs.

The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up

Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.

Prevalence and associations of axillary web syndrome in Asian women after breast cancer surgery undergoing a community-based cancer rehabilitation program

Background

Patients who have breast cancer surgery are at risk of axillary web syndrome (AWS), an under-recognized postsurgical complication which can result in shoulder morbidity and functional impairment. Emerging studies have indicated that AWS may persist beyond the first few months after surgery, although few studies have assessed the prevalence and association of AWS beyond a year after diagnosis. Therefore, the aim of this study was to investigate the prevalence and associations for AWS in post-operative breast cancer patients up to 3 years after surgery.

Methods

This cross sectional observational study was conducted at a community-based cancer rehabilitation center. Patients were evaluated for the presence of AWS via physical examination. Disease-related data was obtained from clinical review and medical records. Descriptive statistics were utilized to illustrate patient demographics and clinical characteristics. Logistic regression analyses were used to determine associations of AWS.

Results

There were 111 Asian women who were recruited, who had undergone breast surgery and were referred to a national outpatient rehabilitation center. The prevalence of AWS in this population was 28.9%. In the multivariate regression model, significant factors were age < 50 years (OR = 3.51; 95% CI = 1.12–11.0; p = 0.031) and ALND (OR = 6.54; 95% CI = 1.36–31.3; p = 0.019). There was reduced shoulder flexion ROM (p < 0.001) in patients with AWS compared to patients without AWS.

Conclusions

A high prevalence of AWS was reported in breast cancer survivors even at 3 years after breast surgery. Our findings highlight the need to identify breast cancer survivors with AWS even in the survivorship phase, and develop strategies to raise awareness and minimize functional impairment in these patients.

Quality of Life Interventions in Breast Cancer Survivors: State of the Art in Targeted Rehabilitation Strategies

Breast cancer is the most common malignant tumor and the most prevalent cause of mortality in women. Advances in early diagnosis and more effective adjuvant therapies have improved the long-term survival of these patients. Pharmacotherapies and intrinsic tumor-related factors may lead to a wide spectrum of treatment-related disabling complications, such as breast cancer-related lymphedema, axillary web syndrome, persistent pain, bone loss, arthralgia, and fatigue. These conditions have a detrimental impact on the health-related quality of life of survivors. Here, we sought to provide a portrait of the role that rehabilitation plays in breast cancer survivors. Particular emphasis has been placed on recovering function, improving independence in activities of daily living, and reducing disability. This complex scenario requires a precision medicine approach to provide more effective decision-making and adequate treatment compliance.

Muscle-Sparing Skin-Reducing Breast Reconstruction with Pre-Pectoral Implants in Breast Cancer Patients: Long-Term Assessment of Patients' Satisfaction and Quality of Life

INTRODUCTION

Breast cancer is the most frequently diagnosed tumor in women; globally, it accounts 23% of all cancer deaths. Breast reconstruction after oncologic surgery has become crucial to enhance patients' quality of life and alleviate the psychological distress related to the disease. The aim of this study was to assess quality of life and esthetic satisfaction of breast cancer patients undergoing muscle-sparing skin-reducing breast reconstruction (MS-SR) with pre-pectoral implants.

METHODS

Sixty-three patients who met definite oncological and reconstructive criteria were enrolled in the study. Specific questionnaires (EORTC QLQ-C30, QLQ-BR23) were administered preoperatively, 1, and 12 months after MS-SR breast reconstruction to evaluate patients' QoL. Satisfaction with procedure and related Quality of Life were assessed through BREAST-Q questionnaire preoperatively and 12 months after surgery.

RESULTS

Sixty-three breast cancer patients underwent MS-SR. Seventy-eight procedures were carried out; in 15 patients a bilateral reconstruction was performed. One month after surgery, both EORTC QLQ-C30 and QLQ-BR23 average scores demonstrated a slight drop since preoperative values, but a significant improvement in QoL was documented 12 months after BR (p < 0.05). BREAST-Q test showed significant psychophysical and esthetic satisfaction 12 months postoperatively.

CONCLUSIONS

Muscle-sparing skin-reducing breast reconstruction is an established and reliable technique. EORTC QLQ-C30, QLQ-BR23 and BREAST-Q scores showed an improvement of patients' QoL and esthetic satisfaction. Reduction of pain and other surgery-related symptoms are cornerstones of patient well-being. Both physicians and patients should build a thorough awareness of the silver lining of muscle-sparing skin-reducing breast reconstruction based on the high safety profile and highly satisfactory patient-reported results.

Nomogram for predicting preoperative regional lymph nodes metastasis in patients with metaplastic breast cancer: a SEER population-based study

Background

Metaplastic breast cancer (MBC) is a rare subtype of breast cancer, and generally associated with poor outcomes. Lymph nodes metastasis (LNM) is confirmed as a critical independent prognostic factor and determine the optimal treatment strategies in MBC patients. We aimed to develop and validate a nomogram to predict the possibility of preoperative regional LNM in MBC patients.

Methods

MBC patients diagnosed between 1990 and 2016 in the Surveillance, Epidemiology, and End Results (SEER) database were included and stochastically divided into a training set and validation set at a ratio of 7:3. The risk variables of regional LNM in the training set were determined by univariate and multivariate logistic regression analyses. And then we integrated those risk factors to construct the nomogram. The prediction nomogram was further verified in the verification set. The discrimination, calibration and clinical utility of the nomogram were evaluated by the area under the receiver operating characteristic (ROC) curve (AUC), calibration plots and decision curve analysis (DCA), respectively.

Results

A total of 2205 female MBC patients were included in the study. Among the 2205 patients, 24.8% (546/2205) had positive regional lymph nodes. The nomogram for predicting the risk of regional LNM contained predictors of grade, estrogen receptor (ER) status and tumor size, with AUC of 0.683 (95% confidence interval (CI): 0.653–0.713) and 0.667 (95% CI: 0.621–0.712) in the training and validation sets, respectively. Calibration plots showed perfect agreement between actual and predicted regional LNM risks. At the same time, DCA of the nomogram demonstrated good clinical utilities.

Conclusions

The nomogram established in this study showed excellent prediction ability, and could be used to preoperatively estimate the regional LNM risk in MBC.

Lymphedema Rehabilitation Using Self-Adaptive Inelastic Compression in Breast Cancer: A Proof-of-Principle Study

Inelastic compression (IC) has been proposed as a therapeutic option in the management of breast cancer-related lymphedema (BCRL). To date, no studies have investigated the reliability of IC in the rehabilitative management of BCRL. Thus, we aimed at evaluating the safety and tolerability of an instantly adjustable IC device for BCRL patients. We included BCRL patients referred to an Oncological Rehabilitation Unit. They were subjected to complex decongestion therapy using a self-adaptive IC device. The primary outcome was safety and tolerability of IC in the rehabilitation treatment of BCRL patients. Secondary outcomes were: BCRL volume modifications; disability; quality of life; IC application time. Outcomes were assessed at the baseline (T0), at the end of the 2-week rehabilitation treatment (T1), and at 1 month (T2). Nine BCRL women, mean aged 56.7 ± 4.4 years, were enrolled. None showed side effects, except for a low discomfort and moderate swelling reported by 1 patient (11.1%). BCRL volume significantly reduced at T1 (p = 0.001) with a positive trend at T2. IC timing was significantly reduced at T1 (p = 0.035) and T2 (p = 0.003). Taken together, these findings suggested that IC could be considered as a safe, well-tolerated, and effective tool in the rehabilitative management of BCRL patients.

Superficial Thrombophlebitis of the Breast (Mondor's Disease): An Uncommon Localization of Common Disease

Mondor's disease (MD), or superficial thrombophlebitis of the anterolateral thoracoabdominal wall, is a rare disease that presents with a palpable cord-like induration beneath the skin. It is a benign, self-limiting condition with probably underestimated significance due to the fact it may be a rare manifestation of an underlying breast carcinoma. It can also resemble breast malignancy and, if physician is not familiar with clinical features of MD, it may lead to unnecessary biopsy. The diagnosis is straightforward in most cases and it may be based on a thorough history and physical examination and it can be ultrasonographically confirmed. Raising awareness of this condition may facilitate recognition and diagnosing MD and eventually limit unnecessary diagnostic procedures.

Longitudinal changes in sports activity from pre-diagnosis to first five years post-diagnosis: a prospective Chinese breast cancer cohort study

Background

To compare change in level of physical activity between pre-and post- diagnosis of breast cancer in Chinese women.

Methods

Based on an on-going prospective study consisting of a sample of Chinese women with breast cancer, a validated modified Chinese Baecke questionnaire was used to measure physical activity at baseline (12 months before cancer diagnosis), 18-, 36- and 60-months after diagnosis (over the previous 12 months before each interview).

Results

In our cohort of 1462 Chinese women with a mean age of 52 years, the mean level of physical activity at post-diagnosis was 9.6 metabolic equivalent of task (MET)-hours/week, which was significantly higher than that at pre-diagnosis with mean level of 5.9 MET-hours/week (P < 0.001). The mean levels of physical activity at 18-, 36- and 60-months follow-up were 9.9, 9.8 and 9.3 MET-hours/week, respectively. There was no significant difference between any two of the three follow-ups at post-diagnosis. The proportions of participant who met World Cancer Research Fund/ American Institute for Cancer Research (WCRF/AICR) recommendation before and after cancer diagnosis were both low, being 20.7 and 35.1%, respectively. Compared to pre-diagnosis, most of the patients improved or had no change on level of physical activity at post-diagnosis, with the respective proportion being 48.2 and 43.8%.

Conclusions

Adherence to current lifestyle recommendation for cancer survivors, Chinese women with breast cancer significantly increased level of physical activity level after cancer diagnosis, and such improvement was sustained to 5 years post-diagnosis. The proportion of patients who met the exercise recommendation for cancer survivors was still low. Encouraging patients on the importance of durable high level of physical activity in breast cancer survivorship is warranted.

The impact of high-intensity interval training exercise on breast cancer survivors: a pilot study to explore fitness, cardiac regulation and biomarkers of the stress systems

BACKGROUND

Cardiovascular disease (CVD) remains the largest cause of death in breast cancer survivors. The aim of this study was to explore the impact of exercise intensity on aerobic fitness and autonomic cardiac regulation (heart rate variability (HRV)) and salivary biomarkers of the stress systems (HPA-axis, cortisol; sympathetic nervous system, α-amylase) and mucosal immunity (secretory(s)-IgA), markers of increased risk of CVD in breast cancer survivors.

METHODS

Participants were randomly assigned to; 1) high intensity interval training (HIIT); 2) moderate-intensity, continuous aerobic training (CMIT); or 3) a wait-list control (CON) for a 12-week (36 session) stationary cycling intervention. Cardiorespiratory fitness (VO2peak), resting HRV and salivary biomarkers were measured at baseline 2-4 d pre-intervention and 2-4 d post the last exercise session.

RESULTS

Seventeen participants were included in this study (62 ± 8 years, HIIT; n = 6, CMIT; n = 5, CON; n = 6). A significant improvement (p ≤ 0.05) was observed for VO2peak in the HIIT group; 19.3% (B = 3.98, 95%CI = [1.89; 4.02]) and a non-significant increase in the CMIT group; 5.6% (B = 1.96, 95%CI = [- 0.11; 4.03]), compared with a 2.6% (B = - 0.64, 95%CI = [- 2.10; 0.82]) decrease in the CON group. Post intervention improvements in HRV markers of vagal activity (log (ln)LF/HF, LnRMSSD) and sympathetic nervous system (α-amylase waking response) occurred for individuals exhibiting outlying (> 95% CI) levels at baseline compared to general population.

CONCLUSION

High intensity interval training improved cardiovascular fitness in breast cancer survivors and improved cardiac regulation, and sympathetic nervous system (stress) responses in some individuals. High-intensity interval training was safe and effective for breast cancer survivors to participate in with promising results as a time efficient intensity to improve physical health and stress, reducing CVD risk.

TRIAL REGISTRATION

This pilot study was retrospectively registered through the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000684921 .