Decongestive and Breathing Exercises for Lymphedema

Decongestive and Breathing Exercises for Lymphedema

BY JOACHIM ZUTHER

In this last part of the three-part series about exercises, I would like to address decongestive- and breathing exercises, which are an integral part in the treatment and management of lymphedema.

Unlike the heart in the blood circulatory system, the lymphatic system does not have an active pump to propel lymphatic fluid back to the bloodstream. Effective lymph flow depends on sufficient muscle and joint activity, especially if the functionality of the lymphatic system is compromised. Decongestive exercises are most effective if performed while the patient wears compression garments or bandages, which are also essential components in lymphedema management. Ideally, decongestive exercise protocols are performed two to three times daily for about 10-15 minutes, and the patient should rest with the affected limb elevated for at least 10 minutes following the exercises.

These active, non-resistive and repetitive exercise protocols should be customized by the lymphedema therapist and/or physician to meet individual goals for patients affected by lymphedema. The stage and type of lymphedema, specific restrictions and limitations of joint and muscle activity, as well as additional medical conditions need to be considered.

Breathing Exercises

The downward and upward movement of the diaphragm in deep abdominal breathing is an essential component for the sufficient return of lymphatic fluid back to the bloodstream. Patients affected by lymphedema of the leg benefit greatly from an exercise program including diaphragmatic breathing exercises. The movement of the diaphragm, combined with the outward and inward movements of the abdomen, ribcage, and lower back, also promotes general well-being, peristalsis and return of venous blood back to the heart.

Following are sample decongestive exercise protocols, combined with breathing exercises for the upper and lower extremity, which are published in the book Lymphedema Management. This book also contains self-MLD and self-bandaging protocols for patients affected by lymphedema. The exercise protocols below serve as guidelines and the movements outlined must not cause discomfort, pain, or soreness.

Before you engage in any exercise program, especially if you have additional medical conditions, please make sure to get your physicians approval.

Continuation of Article and additional exercise articles:

Lymphedema Blog

Editor's Note:  I am including this article not only because of the quality of the information, but as an introduction to one of the best lymphedema information sites available.  The blog was founded and is maintained by Joachm Zuther of the Academy of Lymphatic Studies.    You really need to include this blog in your list of reading sites.  Pat O'Connor

Exercise - Position Statement of the National Lymphedema Network

Exercise - Position Statement of the  National Lymphedema Network


TOPIC: EXERCISE

Fitness and Exercise: 
It is very important for individuals with lymphedema to be physically fit and maintain a healthy weight. A safe form of exercise is an essential part of a fitness program for people with lymphedema. Fitness and exercise are not the same. Exercise includes many different types of physical movement. The three main types of exercise are: aerobic, strength, and flexibility. These three types of exercise, along with Lymphedema Remedial Exercises, are addressed in this paper. There are many other types of exercise that have health benefits such as Pilates, yoga, Tai Chi, Qigong, aquatic exercise,1 trampoline rebounding, breathing exercises,2 and relaxation exercise that have not been adequately studied in people with lymphedema. However, the person with lymphedema can use the benefits of any system of exercise if he/she follows the general safety principles of exercise with lymphedema, seeks medical guidance, and uses caution in starting any new exercise program. 

Exercise and types of lymphedema: 
Lymphedema has many causes. The type of exercise that is best for an individual depends upon the severity and cause of lymphedema and other co-existing medical conditions (e.g. heart disease, diabetes, arthritis, etc). Exercise for breast cancer-related lymphedema is the most studied lymphedema condition. Many conclusions about exercise and lymphedema are based on studies of breast cancer survivors that may or may not apply to other forms of lymphedema. 

Lymphedema Remedial Exercise:
Lymphedema Remedial Exercise is a part of treatment for lymphedema when reduction of size of a limb is necessary. Lymphedema Remedial Exercise involves active, repetitive, non-resistive motion of the involved body part. Exercise in Phase I and Phase II Complete Decongestive Therapy (CDT) (see Position Paper “Diagnosis and Treatment of Lymphedema” http://www.lymphnet.org/pdfDocs/nlntreatment.pdf) is performed with compression as an essential part of the total (complete) reductive phase of lymphedema therapy.3-5 Lymphedema exercises, used with compression, help the body’s natural muscle pump to increase venous and lymphatic fluid return to the circulatory system and out of the swollen areas. 

Remedial Exercises for lymphedema are similar to some movements of low impact Tai Chi and Qigong, but are different in that lymphedema Remedial Exercise is used with Phase I treatment of lymphedema to reduce size of the body part. Lymphedema Remedial Exercise has been studied and shown to reduce limb swelling.3-5 It is unknown whether Lymphedema Remedial Exercise alone can prevent lymphedema in at-risk individuals, or whether they can maintain reduction of swelling without compression. 

Flexibility or Stretching Exercises: 
Flexibility exercises include a wide range of activities that stretch muscle and connective tissues to increase and/or preserve range of motion. Flexibility exercises can minimize skin scarring and joint contractures that may lessen lymph flow. Flexibility exercises should be performed slowly and progressed gradually. Flexibility exercises are not a treatment for lymphedema, but are a part of optimal lifestyle management for reducing the complications of lymphedema. Lymphedema has a tendency to restrict motion of muscles and joints. Optimal lymphatic function requires full mobility of muscles and joints. Lymphedema from cancer treatment can be associated with tight muscles and connective tissues due to fibrous adhesions from surgery or radiation. Tight muscles and scars from surgery or radiation may require Physical or Occupational Therapy to treat before attempting to do self-stretching. 

Specific stretching exercises for cancer treatment-related scars and joint restrictions in an area at risk of lymphedema should be prescribed by a provider familiar with the management of lymphedema. A specialized form of stretching exercise may be required for Axillary Web Syndrome (AWS) or axillary cording, a condition that can occur in cancer survivors who have had axillary (armpit) lymph nodes removed.6 AWS may benefit from treatment by a certified lymphedema therapist and specific home stretches taught by a therapist.7

**Important - Please read the full text on the National Lymphedema Network website:

Exercise

Community-based exercise program effectiveness and safety for cancer survivors

Community-based exercise program effectiveness and safety for cancer survivors

Jan. 2012

Rajotte EJ, Yi JC, Baker KS, Gregerson L, Leiserowitz A, Syrjala KL.

Source Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D5-220, P.O. Box 19024, Seattle, WA, 98109, USA.

Abstract

Keywords: Cancer survivors – Exercise – Physical activity – Community – YMCA

PURPOSE: Clinical trials have demonstrated the benefits of exercise for cancer survivors. This investigation determined the effectiveness and safety of a disseminated community-based exercise program for cancer survivors who had completed treatment.

METHODS: Personal trainers from regional YMCAs received training in cancer rehabilitation and supervised twice-a-week, 12-week group exercise sessions for survivors. At baseline and post-program, validated measures assessed patient-reported outcomes (PRO) and physiologic measurements.

RESULTS: Data were collected from 221 survivors from 13 YMCA sites and 36 separate classes. All participants had data available at one time point, while matched baseline and post-program PRO and physiologic data were available for 85% (N = 187). Participants with matched data were largely female (82%), with mean age of 58 (range, 28-91 years). Time since diagnosis ranged from 1 to 48 (mean, 5.6 years), and mean time since last treatment was 3.0 (range, 1-33 years). Physiological improvements were significant in systolic (P < 0.001) and diastolic (P = 0.035) blood pressure, upper and lower body strength, the 6-min walk test (P = 0.004), and flexibility (P < 0.001). Participants reported improvements in overall health-related quality of life (P < 0.001), social support (P = 0.019), body pain (P = 0.016), fatigue (P < 0.001), insomnia (P < 0.001), and overall musculoskeletal symptoms (P = <0.001). Few injuries or lymphedema events occurred during classes.

CONCLUSIONS: Community-based exercise groups for cancer survivors of mixed diagnoses and ages, who have completed active treatment, have physiologic and psychosocial benefits, and are safe. 

IMPLICATIONS FOR CANCER SURVIVORS: Survivors may expect significant benefit from participating in a community-based exercise program tailored to meet their individual needs as a survivor.

Springerlink

When at Lymphedema Risk After Breast Cancer

When at Lymphedema Risk After Breast Cancer

Editor's note:  This article is from one of my personal favorite sites for breast cancer.

EXERCISE

When at Lymphedema Risk After Breast Cancer


By Naomi Aaronson MA OTR/L CHT 


StepUoSpeakOut.org

Low Back Exercises

Low Back Exercises

Relieve Low Back Pain

Take an anti-inflammatory medication (these help to decrease the swelling and inflammation in the spine). 
Apply ice or heat to your back. 
Stop all strenuous activities. 
Relieve the pressure on the sciatic nerve with correct postures. 
Use proper back supports. 
Do low back exercises. 
See your doctor if the pain persists or goes into the leg.

Low Back Exercises

Unless instructed otherwise, do each exercise 1 to 5 times, twice each day. Gradually increase your workout to 10 repetitions twice a day. Use slow, smooth actions as you exercise. 

If you feel any discomfort while doing the exercises, stop immediately and contact your physician. Stop any exercise that increases back pain or causes tingling, numbness, or weakness in your legs.

Double knee-to-chest stretch

a. Lie down on back.

b. Pull both knees in to chest until you feel a comfortable stretch in lower back.

c. Keep the back relaxed.

d. Hold for 45 to 60 seconds.

Pelvic tilt exercise

a. Lie on back with knees bent, feet flat on floor, and arms at sides (a)

b. Flatten small of back against floor. (Hips will tilt upward.) (b)

c. Hold for 10 to 15 seconds and release. Gradually increase your holding time to 60 seconds.Lower trunk rotation stretch

a. Lie on back.

b. Keeping back flat and feet together, rotate knees to one side.

c. Hold for 45 to 60 seconds.Curl-up exercise

a. Lie on the floor on back.

b. Keeping arms folded across chest, tilt pelvis to flatten back. Tuck chin into chest.

c. Tighten abdominal muscles while raising head and shoulders from floor.

d. Hold for 10 seconds and release.

e. Repeat 10 to 15 times. Gradually increase your repetitions.Trunk flexion stretch

a. On hands and knees, tuck in chin and arch back.

b. Slowly sit back on heels, letting shoulders drop toward floor.

c. Hold for 45 to 60 seconds.Alternate arm-leg extension exercise

a. Face floor on hands and knees.

b. Raise left arm and right leg. Do not arch neck.

c. Hold for 10 seconds and release.

d. Raise right arm and left leg. Do not arch neck.

e. Hold for 10 seconds and release.Prone Lumbar Extension
Purpose: To extend your lower back.

1. Lie on your stomach and place your hands on the floor near the sides of your head.

2. Slowly push your upper body off the floor by straightening your arms, but keep your hips on the floor. Hold for 10 seconds, then relax your arms, moving back to the floor.Alternate leg extension
Lie on your stomach with your arms folded under your chin. Slowly lift one leg -- not too high -- without bending it, while keeping your pelvis flat on the floor. Slowly lower your leg and repeat with the other leg.
Hamstring stretch while standing

a. Stand on right leg with left leg on table/chair.

b. Stretch hamstring by slowly bending right knee.

c. Hold for 30-45 sec.

d. Repeat with other leg.

Whole Fitness

Exercise in patients with lymphedema: a systematic review of the contemporary literature

Exercise in patients with lymphedema: a systematic review of the contemporary literature

Dec. 2011

Kwan ML, Cohn JC, Armer JM, Stewart BR, Cormier JN.

Source

Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA, 94612, USA, Marilyn.L.Kwan@kp.org.

Abstract

BACKGROUND: Controversy exists regarding the role of exercise in cancer patients with or at risk for lymphedema, particularly breast. We conducted a systematic review of the contemporary literature to distill the weight of the evidence and provide recommendations for exercise and lymphedema care in breast cancer survivors.

METHODS: Publications were retrieved from 11 major medical indices for articles published from 2004 to 2010 using search terms for exercise and lymphedema; 1,303 potential articles were selected, of which 659 articles were reviewed by clinical lymphedema experts for inclusion, yielding 35 articles. After applying exclusion criteria, 19 articles were selected for final review. Information on study design/objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted. Study evidence was also rated according to the Oncology Nursing Society Putting Evidence Into Practice® Weight-of-Evidence Classification.

RESULTS: Seven studies were identified addressing resistance exercise, seven studies on aerobic and resistance exercise, and five studies on other exercise modalities. Studies concluded that slowly progressive exercise of varying modalities is not associated with the development or exacerbation of breast cancer-related lymphedema and can be safely pursued with proper supervision. Combined aerobic and resistance exercise appear safe, but confirmation requires larger and more rigorous studies.

CONCLUSIONS: Strong evidence is now available on the safety of resistance exercise without an increase in risk of lymphedema for breast cancer patients. Comparable studies are needed for other cancer patients at risk for lymphedema. IMPLICATIONS FOR CANCER SURVIVORS: With reasonable precautions, it is safe for breast cancer survivors to exercise throughout the trajectory of their cancer experience, including during treatment.

Springerlink

A Sample Progressive Exercise Program

A Sample Progressive Exercise Program

This exercise program has been devised to increase your strength and endurance. The program, which takes you from your bed to being up and around in three stages, can be started as soon as your physician says its ok. You can refer to the healthlibrary.stanford.edu/resources/videos.html website for videotapes of appropriate exercises.

Stage I is on one tape and Stages II and III are together on another tape. The demonstrations include warm-up and full-exercise programs with relaxation sessions at the end.

Stage I exercises are simple and help you to maintain and increase your range of motion. They require little exertion and can be done in bed.

Stage II exercises use a small added weight to increase resistance and can be done when you are spending part of the day out of bed. Once you have gotten back to your normal activities, you will need to establish an exercise routine that includes exercises like these to build up your body's reserves so that temporary bouts with bed rest will not deplete your energy stores.

Stage III exercises provide you with a strengthening and maintenance program for when you are able to spend the whole day out of bed. This series of exercises is a progressive and comprehensive physical rehabilitation program for people with acute or chronic illness. With your doctor's permission, you can begin these exercises even while you are recovering from surgery or undergoing cancer therapy.

Cancer Supportive Care Programs

Cancer Supportive Care Programs