Water-Based Exercise for Patients with Chronic Arm Lymphedema: A Randomized Controlled Pilot Trial.

Jan  2013

Johansson K, Hayes S, Speck RM, Schmitz KH.

Source

From the Institution of Health Science, Department of Physiotherapy, Lund University, Lund, Sweden (KJ); School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, QLD, Australia (SH); Department of Biostatistics and Epidemiology and Department of Anesthesiology, University of Pennsylvania, Philadelphia (RMS); and Division of Clinical Epidemiology, Department of Biostatistics and Epidemiology, and Department of Family Medicine and Community Health, University of Pennsylvania School of Medicine, Philadelphia (KHS).

Abstract

OBJECTIVE:

The aim of this study was to evaluate the feasibility and effect of a water-based exercise program on lymphedema status and shoulder range of motion among women with breast cancer-related lymphedema.

DESIGN:

This was a single-blinded, randomized controlled pilot trial. Twenty-nine eligible breast cancer survivors (median, 10 yrs after surgery) with arm lymphedema (median, 21% interlimb difference) were included and randomized into the intervention (n = 15) or control (n = 14) group. Twenty-five participants completed the study. The intervention was at least twice-weekly water-based exercise for 8 wks, initially supervised but performed independently during the study period. Outcomes of interest were feasibility as measured by retention and adherence; lymphedema status as measured by optoelectronic perometry, bioimpedance spectroscopy, and tissue dielectric constant; and shoulder range of motion as measured by goniometer.

RESULTS:

 Four participants were not measured at postintervention and were not included in the analysis (retention). Four participants in the intervention group did not perform the minimum water-based exercise criteria set (adherence). No effect was found on lymphedema status. Compared with the control group, median range of motion change for flexion was 6 (1-10) degrees and 6  degrees  for external rotation.A clinically relevant increase in the intervention group was found for 36% in flexion and 57% in external rotation (P ≤ 0.05) compared with controls.

CONCLUSIONS:

This study shows that water-based exercise is feasible for breast cancer survivors with arm lymphedema and that shoulder range of motion can be improved years after cancer treatment has been completed.

Physical Medicine & Rehabilitation

Low Impact Exercise Arm Lymphedema

Low Impact Exercise Arm Lymphedema

I. Stand with your feet a shoulder-width apart, stomach tucked in, and back straight. Extend your arms out to the sides with you, palms facing out. Bring your arms in together straight out in front of you, palms out, and extend back out. Do ten repetitions.

2. Keeping your arms extended, bring them straight up together above your head, then drop them so that they extend out to the sides. Repeat ten times.

3. Arms still extended with palms facing out, move

your arms forward in small circles. Do ten of these and then increase to a medium-size circle. Do ten repetitions and then ten more, making the largest circle you can. Repeat this cycle, moving your arms backward.

4. Extend your arms out to the sides, bend them at the elbows, and make fists. Squeeze your bent arms together so that your forearms meet in front of you. This exercise works the chest and arms.

5. To work your biceps, extend your arms straight down at your sides with your inner forearms and fists facing up. Bending at the elbow, squeeze your fists to your shoulders. In order to obtain the maximum benefit, pretend that there is a weight on your inner forearm and resist against the pressure as you squeeze up.

Breathing Exercises for Lymphedema

Breathing Exercises for Lymphedema

Marianne Ross, Ph.D.

A few nice deep breaths can be so relaxing. It can be a quick and easy stress reliever. You can do this anytime. You can do this anywhere. It is not visible to others.

And the good news can be that because you are less stressed, you will handle things more easily.

Word has it that when people are stressed, they tend to take short little breaths rather than deep, relaxing ones. Is this true for you? Check it out.

Quick and Easy Stress Management Breathing Exercise:

·Sit down or lie down.

·Inhale slowly and say to yourself I am...

·Exhale slowly and say to yourself relaxed.

Breathing is not something you DO. Rather it is something which you ALLOW. (p.26) The problem is that we don't allow our breathing to occur smoothly and naturally.

For those who are a bit more ambitious, here is a way to experience more about breathing.

Experiencing a Full Breath While it is not possible or necessary to fully expand the lungs with every breath, it is vital in heightening awareness to experience how a really complete breath feels. Used periodically, this exercise utilizes the lungs to capacity, and extracts great amounts of "life force" from the air.

Directions: Try this exercise sitting, standing and lying down.

1. Exhale deeply, contracting the belly.

2. Inhale slowly as you expand the abdomen.

3. Continue inhaling as you expand the chest.

4. Continue inhaling as you raise the shoulders up towards your ears.

5. Hold for a few comfortable seconds

6. Exhale in reverse pattern, slowly. Release shoulders, relax chest, contract the belly.

7. Repeat.

This exercise will require gentle practice in order that inhalation and exhalation be smooth and balanced. Beginners should only do it 2 or 3 times continuously.

From: The Wellness Workbook. Travis, MD & Ryan; Ten Speed Press, 1988

Self Help Magazine

Tips to Consider for Arm Lymphedema Exercise

Tips to Consider for Arm Lymphedema Exercise

Both light exercise and aerobic exercise (physical activity that causes the heart and lungs to work harder) help the lymph vessels move lymph out of the affected limb and decrease swelling.

Talk with a certified lymphedema therapist before beginning exercise. Patients who have lymphedema or who are at risk for lymphedema should talk with a certified lymphedema therapist before beginning an exercise routine. (See the Lymphology Association of North America Web site for a list of certified lymphedema therapists in the United States.)

Wear a pressure garment if lymphedema has developed.

Patients who have lymphedema should wear a well-fitting pressure garment during all exercise that uses the affected limb or body part.

When it is not known for sure if a woman has lymphedema, upper-body exercise without a garment may be more helpful than no exercise at all. Patients who do not have lymphedema do not need to wear a pressure garment during exercise.

Breast cancer survivors should begin with light upper-body exercise and increase it slowly. Some studies with breast cancer survivors show that upper-body exercise is safe in women who have lymphedema or who are at risk for lymphedema. Weight-lifting that is slowly increased may keep lymphedema from getting worse. Exercise should start at a very low level, increase slowly over time, and be overseen by the lymphedema therapist. If exercise is stopped for a week or longer, it should be started again at a low level and increased slowly.

If symptoms (such as swelling or heaviness in the limb) change or increase for a week or longer, talk with the lymphedema therapist. It is likely that exercising at a low level and slowly increasing it again over time is better for the affected limb than stopping the exercise completely.

More studies are needed to find out if weight-lifting is safe for cancer survivors with lymphedema in the legs.

Treatment of Lymphedema National Cancer Institute

Exercise and Arm Lymphedema

Exercise and Arm Lymphedema

Nicole L. Gergich MPT, MLD/CDT Lymphedema Specialist, Penn Therapy and Fitness Posting Date: May 6, 2001 Last Modified: January 3, 2002

Why Should I Exercise?

One very important component of a comprehensive treatment plan for cancer-related lymphedema is exercise. A program consisting of flexibility, strengthening and aerobic exercise is beneficial in reducing lymphedema when administered under the correct conditions. Exercise also allows cancer survivors a more active role in their own lymphedema management. Recent studies have shown no significant increase in the incidence of lymphedema after breast cancer, between women participating in an exercise program when compared to women who did not exercise.

What Type of Exercises are Helpful To Someone with Lymphedema?

Flexibility exercises help to maintain joint range of motion and allow for elongation or stretching of tissues. Flexibility exercises also help to prevent joint stiffness and postural changes after cancer surgeries or treatments. Muscle tightness may further complicate lymphedema.

Strengthening exercises are also important in reducing lymphedema when done at low intensity levels with the extremity wrapped (see below). These exercises often help increase lymphatic and venous flow, aiding in the removal of fluid from the involved extremity.

Aerobic exercise enhances the lymphatic and venous flow, further reducing swelling in the extremity. Aerobic exercise also combats fatigue, which plagues so many people during and after cancer treatment.

Finally, deep abdominal breathing or diaphragmatic breathing is important with all exercise, but especially so in people with lymphedema. When deep breathing is carried out, the pressure inside the chest and abdomen is altered and creates a pumping activity within the lymphatic system. The central thoracic duct, which carries lymph fluid from the abdomen and legs, travels through the chest cavity. Pumping action around the duct helps to increase lymphatic flow throughout the body. Deep breathing is also important to deliver adequate oxygen supplies to the working muscles so that they may work efficiently.

Exercises should be initiated by a physical or occupational therapist that specializes in lymphedema treatment. As with all exercise, you should discuss beginning a program with your physician.

How Much Weight Can I Lift?

There has been little research to date regarding the intensity of exercise in people with lymphedema and what is a safe level. Previously, intensive exercise was viewed as contraindicated, or not advisable. Currently, exercise and progressive weight lifting activities are used to assist in the removal of lymphedema from the affected areas. Therapists can guide clients in a weight lifting program that is tailored to their present fitness levels. How much you can lift depends on the stage of treatment and most importantly, you previous and present fitness levels. It is important to continuously monitor the limb for swelling or redness, which can be an indication that the exercise was too intense. A weight lifting program should be initiated by a therapist who specializes in the treatment of lymphedema.

Should I Wrap My Arm With Exercise?

It is recommended that the affected limb (arm or leg) be wrapped with compression bandages during exercise to aide the muscle pump force on the venous and lymphatic systems. Wrapping also prevents further fluid from accumulating in the extremity. The bandages used for lymphedema treatment are short-stretch bandages. The short stretch bandages used in lymphedema treatment do not stretch much when applied to the arm or leg. When you exercise the wrapped limb, the muscles and the bandages place a force on the lymphatics that help move fluid out of the arm. ACE bandages stretch too much and are ineffective in the treatment of lymphedema. Do NOT USE Ace wraps when wrapping for lymphedema.

What Exercises Can I do After Breast Surgery?

Following a mastectomy it is important to maintain range of motion or flexibility in the shoulder. Frequently, women decrease the use of the shoulder and arm on the side of the body where surgery was performed due to pain or fear of hurting the incision. Protecting the arm may lead to stiffness and tightness in the shoulder which can make it difficult to move the arm. This is often followed by a loss of muscle strength and stability around the shoulder. Since the shoulder and neck are closely related, it is also important to maintain neck mobility to prevent further complications. Ask your doctor or physical therapist if you have questions about which shoulder exercises are right for you.

If you have recently undergone a mastectomy accompanied by a breast reconstruction REFER TO YOUR SURGEON FOR INFORMATION REGARDING SHOULDER EXERCISE. It is important to discuss beginning an exercise program with your physician.

Oconolink

Lymphedema Stages and Exercises

Exercises with Stage 1

In this stage you are able to participate in just about any and all exercises. The only ones to be concerned with are high impact ones. Also, parachuting, hang-gliding and bungee jumping are definitely out (unless you are slightly jaded like I am, there probably is no need to warn about these).

Exercises with Stage 2

Stretch exercises - flexion, extension, abduction, rotation. The all include movements of the arms toward and away from you body, arms across your chest, behind your head and back.

Walking, Hiking, Jogging Swimming, Canoeing, Rowing Bowling, Archery, Bicycling Dancing, Sailing, Scuba Jiu Jitsu, Karate, Judo Sailing, Frisbee, Fencing Jogging, Skiiing, Shooting

What was that about being limited? This is only a partial list too.

Exercises with Stage 3

See the above - yes, even in stage 3 you can participate in all of the above sports. You may just have to modify how much and how long. It wasn't until the I had the lymphomas that greatly complicated my life that I finally had to eliminate those that put a higher amount of strain on my legs.

The rationale behind doing mild exercise is that muscle contractions, especially in the calf and arm, help to promote lymph flow to veins in the neck region where it returns to the blood circulation. Exercise also helps the proteins in lymph fluid to be reabsorbed. Both result in a lesser severity of lymphedema.

Although there is no consensus on the type of exercise regimen for people with lymphedema, all schools of thought agree that exercise is a necessary part of healing and that it should be tailored to each patient's needs and abilities. In general, it has been suggested that a monitored, progressive exercise program, in which a person slowly builds up their stamina and strength is far better than a strenuous one, no matter what the patient's previous athletic history. High speed activities such as golf, tennis, jogging or hiking at high altitudes are not suggested as they may actually increase lymphedema. Activities such as walking, swimming, light weights or cycling, in contrast are generally safe. For people with severe lymphedema who have a difficult time moving, even breathing enhances the pumping of lymph in the chest region. Deep breathing exercises such as mild yoga may be especially helpful to promote both relaxation and decrease lymph load.

Exercises to help lymphedema

Whether you have arm lymphedema or leg lymphedema, exercise is still critical to your overall health and a vital part in successfully managing lymphedema.

One thing that really bothers me is when I hear of people with lymphedema who give up on any activity of exercise because they have this condition. You have to want more from life than just being a couch potato, exercising only your thumb as you click that TV remote.

I envision life like a football game. The doctor may say you can only go to the 10 yard line. But, you must with all endeavor try for that goal. Even if you only really the 50 yard line, you know that you gave it your best shot!

To stay as healthy as you can, exercise is absolutely necessary, this is true for lymphedema people and non-lymphedema people. The body simply was not designed to sit on that back side for decades. I am a very strong proponent of doing as much as you can despite lymphedema. The key is to understand what type and how much exercise you can undertake.

Remember also, the lymphatic system does not have its own pump, like the heart. It moves through action, exercise and activity. Getting on and keeping an exercise activity will help increase that lymph flow.

I am not going to include the usual list of “exercises to avoid list, because, honestly, what exercise you are able to participate in depends on the stage of your lymphedema, other medical conditions, and the advice of your doctor and therapist.

My favorite exercise is swimming. The gentle pressure of the water against the limb acts in many ways like the natural movements of our body that activates the lymphatics. In early stages of lymphedema, swimming can actually decrease the size of your lymphedema limb.

Cautions and Considerations

Remember, there are only three factors that will affect what type of exercise you will be able to do withlymphedema.

1. Accompanying medical conditions. These include, but are not limited to heart problems, diabetes, pulmonary conditions. You must check with your physician.

2. Stage and type of lymphedema. Obviously those with arm lymphedema would have a problem with bowling. But those with leg lymphedema and no arm lymphedema or involvement shouldn't. Stage 1 & stage 2 lymphedema would present no problem with hiking and walking. At stage 3, it is more difficult. So take the type and stage of your lymphedema into consideration.

3. Risk of injury is also a factor. At any stage you should consider the consequences of broken bones, torn ligaments and sprained muscles. These can be a serious complication with lymphedema.

Other points to remember

1. Work with your therapist and physician to design an exercise program that is both safe and effective for you.

2. Your should always wear the appropriate lymphedema garment when undertaking any exercise.

3. Swimming - Hot tubs, pools (especially community pools) and lakes during the summer (in warmer climates any time of the year) present an increased risk for all types of infections because of bacteria. I urge caution there.