Exercise, Lymphedema, and the Limb at Risk

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Exercise, Lymphedema, and the Limb at Risk

Postby patoco » Sun Jun 11, 2006 5:34 am

Exercise, Lymphedema, and the Limb at Risk

Lymphedema People

http://www.lymphedemapeople.com

......

Bonnie B. Lasinski, MA, PT, CLT-LANA

How many clinicians are at a loss for words when they are asked about
what kind of exercise is "good" for individuals with lymphedema? How
many individuals living with lymphedema or a limb at risk for
lymphedema have asked their healthcare professional for advice
concerning exercise only to receive conflicting information? It is
difficult to "recruit" presenters to provide workshops/discussions on
exercise for both patients and professionals alike. Exercise and
lymphedema - it is a controversial subject.

Twenty-four years ago, I was asked to do a presentation on exercise
after mastectomy for a one day seminar sponsored by the American Cancer

Society's Long Island Division, entitled "Living With Cancer". When I
contacted the coordinator of the workshop, Diana Rulon, she informed me
that she was not "interested in exercise after mastectomy - she was
interested in exercise for lymphedema!"

You can imagine my shock and fear at that moment. I had no special
training in lymphedema management, in fact, no one did. We were just
beginning to hear strange tales of a treatment from Europe that seemed
ridiculously mild for the severe swellings I had seen in my limited
experience. But, I figured no problem. I'll just go to the medical
library, research the articles, and develop my talk from there. Well,
that was 1980 and there were no articles, except for a few abstracts of
German and French studies. Now, I was really in trouble. Well, long
story short, I was inspired by the dedication of Diana Rulon who tried
to find help for other women like herself, who had long been ignored by
their doctors and told to live with their problem. Thus began my
journey in lymphedema management.

Trial by fire, you might say! We presented a very basic, common sense
talk on lymphedema, trying to define it in simple terms (no small feat
when the literature was so poor - the definition at that time was a 2
centimeter difference between forearms - as if that was the only place
one could have lymphedema!). Next, Diana presented some practical
suggestions for nutrition that she had found helpful to her and several
other women she knew. Finally, I wrapped up the session with some very
basic information on exercise progression and then opened the floor for
questions. The response was overwhelming. The participants were so
grateful that their problem was finally acknowledged, even on such a
basic level.

Twenty-four years later, although the medical management of lymphedema has come a long way, thanks in great part by the advocacy of Saskia Thiadens and the NLN, there is still much work to do. Basic and
advanced research on the effects of exercise as a lymphedema risk
reduction modality must be explored. The basic criticism of the
precautions about exercise contained in the 18 Steps to Prevention of
Lymphedema and other risk reduction guidelines is that they are
"anecdotal" at the present time, due to the lack of controlled
double-blind studies to prove their efficacy. Some medical
professionals have taken the position that the individual with a limb
at risk (or with lymphedema) should go ahead and pursue whatever
exercise/activity they wish and "see what happens". Unfortunately,
lymphedema is a chronic condition, which, presently, has no cure. While
it is true that not all individuals who have had lymph node disruption
(surgical or radiological) will develop lymphedema, until physicians
can better predict who is at greater risk for lymphedema, a prudent
approach to exercise is advisable. In the case of individuals with
primary lymphedema or established secondary lymphedema, working up to a level of exercise that promotes fitness while avoiding exacerbating the lymphedema is a good goal.

I'm sure that some of you may have been told in the past that you
should not exercise if you have lymphedema, or that certain types of
exercise are contraindicated if you have lymphedema. This is not the
case. I would like to review some basic principles of anatomy and
physiology and pathophysiology of lymphedema and how these relate to
exercise and lymphedema. Lymphedema occurs when there is an imbalance between lymph transport capacity and lymph load. After any surgical disruption or radiation treatment to a lymph node region, a state of latent lymphedema occurs. That is to say that the lymph transport
capacity is reduced but it is still greater or equal to the lymph load.
Acute/chronic lymphedema develops when that balance is shifted and
lymph load exceeds the impaired lymph transport capacity. In the case
of Primary Lymphedema, where there is a malformation/malfunctioning of
the lymphatic transport system that results in a reduced lymphatic
transport capacity, lymph load often exceeds that transport capacity,
and progressive lymphedema develops over time.

Our lymphatic system, in addition to filtering out waste products,
helps our bodies maintain fluid balance so that we are neither
dehydrated nor edematous. 90% of the water component of our blood that perfuses the capillary network and nourishes our cells returns to the
heart via the venous system. The 10% that is left behind in the tissues
along with the extracellular protein that filters out of the
capillaries, can only return to the heart via the lymphatics. That 10%
can amount to up to 2 liters a day. While 2 liters may not seem like
much, it adds up day after day, if there is impairment in lymph
drainage. In addition, the extracellular proteins can only return to
the central circulation via the lymphatic vessels. The diameter of
these molecules is too large to fit into the openings in the vein walls
- the openings in the lymphatic vessel walls are large enough for these
protein molecules to enter easily.

So lymphedema is not only a problem of excess water remaining in the
tissues, but of excess protein that remains in the tissues as well.
Unfortunately, the body always moves for a state of balance so it
actually tends to pour more water into the tissues to "dilute" this
protein concentration - thus a vicious cycle develops. This problem is
compounded by the fact that the white blood cells called macrophages,
which are part of our immune response, do not work properly in the
lymphedematous fluid. This is why anyone with lymphedema is at
increased risk for infection in his or her affected limb.

What does all this have to do with exercise?

A review of the acute and chronic effects of exercise is helpful to understand how the limb at risk or a lymphedematous limb might respond to various types of exercise. The acute responses to exercise include increases in heart rate, stroke volume, cardiac output, blood flow to active muscles, systolic blood pressure, arteriovenous oxygen difference, ventilation, oxygen uptake, and a decrease in blood pH and plasma volume. Chronic adaptations to exercise include biochemical changes in skeletal muscles, decreased resting heart rate, decrease in total body fat,
blood lipids, and the density and strength of bone and connective
tissue. During exercise, blood is redirected to the muscles. At rest,
only 21% of the cardiac output goes to the muscles, compared with as
much as 88% during exhaustive exercise. As the body heats up, an
increasing amount of blood is directed to the skin, to conduct heat
away from the body core.1 Remember that lymph transport has to be equal to or greater than lymph load. When you exercise, your muscles need extra blood to supply the oxygen needed for your muscles to do the work of the exercise. Extra blood flow means that extra water will remain in the extracellular spaces needing transport via the lymphatic system.

The question is how much is too much? That is very individual. It is
important that any exercise program be gradually progressed to avoid
sprain/strain. More importantly, a slow progression allows the
individual to monitor their affected limb or limb at risk for any
sensation of aching or fullness that could indicate an overwhelming of
the lymphatic system.

Exercise can increase the uptake of fluid by the initial lymphatics and
enhance the pumping of the collecting lymphatics. In addition, exercise
mobilizes the joints and strengthens the muscles of the involved
limb/limbs/trunk quadrant, thus decreasing the risk of strain/sprain.2
Exercise is best done with compression on the affected limb either from
compression bandages or compression garments. The bandages provide a new "tight" skin for the muscles to contract against, assisting in
pumping the lymph out of the extremity into the central circulation.

When lymphedema exists, the remaining lymph vessels that are
functioning are working double time to try to carry the load. These
vessels become over dilated (stretched) and eventually, their walls can
overstretch and fail, causing a worsening of the swelling. Wearing
compression bandages/garments provides support to the skin and to the
lymphatic vessels directly under the skin, called the superficial
lymphatic network. It is these vessels that help to carry the load when
the larger vessels have been cut away from the lymph nodes or have been damaged due to trauma or chronic venous disease, or in the case of
primary lymphedema, when there are too few large lymph collectors in a
region due to improper vessel/node development during fetal growth.

Of course, certain types of exercise are considered higher risk than
others. For example, high speed activities like tennis, bowling and
racquetball, place more stress on the upper limb while jogging,
stair-climbing machines, downhill skiing, water skiing, football,
soccer place more stress on the lower extremities or have higher injury
risk than other activities such as swimming, brisk walking, and
cycling. That is not to say that someone with lymphedema of the leg
should not jog for exercise, or that the person with lymphedema of the
arm and hand should not play tennis or golf. It is also important to
know whether an individual was skilled at a sport/activity prior to
their developing lymphedema. A sport-specific exercise program can be
developed for the individual to build strength, flexibility and
endurance in the muscle groups most used in that sport/activity.
Ultimately, the decision to "play" should be an individual one, but an
informed one.

Many men and women with lymhedema or a limb at risk want to work out
with weights. A slow progression of light weights can be done safely
and can allow an individual to develop good strength and power in any
muscle group. The important thing to consider is whether you feel good
after the exercise and how your affected limb reacts after you
exercise. You must also consider your level of daily activity and
modify accordingly - if you have had a particularly difficult day and
your affected limb is more swollen, you may choose to do a different
activity i.e. swim instead of walk, or you may realize that the best
activity for that day is to rest with your limb elevated. The
importance of deep abdominal breathing exercise should not be
overlooked. Deep breathing enhances the pumping in the thoracic duct
(the major lymphatic vessel draining the lower body and the left upper
trunk/arm/hand).

A recent series of case reports published in the Journal of Surgical
Oncology3 challenges the theory that vigorous upper body exercise is
contraindicated for individuals who have had axillary dissection during
surgery for breast cancer. The study followed a group of 24 women for 9
months. These women were recruited to participate in a training program
to prepare for competition in the World Championship Dragon Boat
Festival in Vancouver, British Columbia. Dragon Boat racing involves
strenuous repetitive upper body exercise. 18-20 women paddle 40-60 foot boats for a distance of 500-650 meters. Circumferential measurements were collected on 20 of the 24 participants (limbs were measured at 4 places) pre training, at the start of the racing, and 7 months after the races. According to the authors, only two women, who had pre-existing mild lymphedema, had increases in their upper arms (5/8 inch) and none of the other participants developed lymphedema.

One of the authors of the study, herself a breast cancer survivor participated in the program. The authors conclude that strenuous upper body exercise may not cause lymphedema or worsen a pre-existing lymphedema.

It is important to note that the participants in this study completed a
two-month training program of stretching, strengthening, and aerobic
exercises prior to engaging in the actual strenuous activity of Dragon
Boat racing. Many individuals who undergo breast surgery/axillary
dissection/radiation are not enrolled in supervised progressive
exercise programs like the participants of this study. Providing
structured, individualized exercise programs should be a goal of all
centers that perform cancer surgeries. While I do not discourage
individuals from participating in sports and exercise, I do caution
them that they should consider themselves "athletes" in the "game" of
life. As such, each individual should engage in a
stretching/strengthening program to prepare them for full participation
in whatever activity they choose.

References:

1. Nieman, David C. Exercise Testing and Prescription: A Health Related
Approach, 4th ed. Mountain View, California, Mayfield Publishing Co.,
1999: P, 190-205.
2. Casley-Smith, Judith R, Casley Smith, John R. Modern Treatment for
Lymphoedema, 5th ed. Adelaide, Australia, The Lymphology Association of
Australia, 1997: p. 188-189.
3. Harris, Susan R, Niesen-Vertommen, Sherri. Challenging the Myth of
Exercise-Induced Lymphedema Following Breast Cancer: A Series of Case
Reports. Journal of Surgical Oncology 2000; 74:94-99.

Lymphedema Therapy

http://www.lymphedema-therapy.com/Exercise.htm
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Re: Exercise, Lymphedema, and the Limb at Risk

Postby rellen » Thu Sep 10, 2009 6:17 pm

I had 15 lymph nodes removed during a hysterectomy for endometrial cancer at the Mayo Clinic in June, 2007. No one there nor back at home ever mentioned the possibility of developing lymphedema. And, obviously, there was no mention of what to do for exercising. A little more than a year later, my leg swelled up after I had been riding an exercise bike vigorously for 1/2 hour every night for a couple of weeks. Two days later I had cellulitis. It's very frustrating that I may have been able to avoid my now chronic condition. How can we get the message out to health care professionals to tell patients about lymphedema?

While Googling I ran into the use of mini-trampolines for rebounding. Does anyone know if rebounding is an OK exercise?

Thank you. :roll:
rellen
 
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Re: Exercise, Lymphedema, and the Limb at Risk

Postby patoco » Fri Sep 11, 2009 5:47 am

Hi Rellen :)

Super welcome to our family!

That my friend is the million dollar question about doctors. What is even more maddening is that even those who do know, like so many oncologists, refuse to either tell their patients about LE or to allow brochures in their offices. The excuse they give is that they "don't want to scare" the patients.

That's all fine and dandy for them, but we are the ones paying the price and having to live with the consequences. Someone recently suggested maybe we should all be filing complaints with the medical boards as this really is gross mispractive (not mal - mis). Witholding critical information is anything but kosher or compassionate.

Here's the thing too. Gynecological cancers and LE are relatively new in the sense that they are being talked about. But - the frightening thing is that some of the first stats I've seen indicate a much worse probability of contracting leg LE from cancer biospies/treatments etc. then breast cancer patients have. Combine that with the fact that cancer treatments are getting better and better with more surivors - and long term ones at that. Maybe if these doctors started having to be answerable for this gross omission of critical information they might start thinking twice.

Clearly, we need to stand up and be counted in getting the word out.

On the trampoline - I really haven't seen any clear studies that indicate it really is a benefit. Some people say they have been helped, but I'm kind-of leary about it. First, I am concerned about the injuries that can occur when using it and there are no guidelines that really spell out how and what to do with it.

Take a look at my page on leg lymphedema and see if there are any tips that can help. It gives info on treatment, compression wraps, skin care. We also have info on exercises that are safe ranging from lite to heavy duty, depending on your condition.

Leg Lymphedema

http://www.lymphedemapeople.com/wiki/do ... lymphedema

So glad you posted and look forward to hearing from you!

Pat
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