Exercise with Leg Lymphedema

Exercise with leg lymphedema

Fitness Article: Exercise with Lymphedema of the Leg...

I am writing this article from two points of view, as an experienced fitness trainer / strength coach who has studied health issues for many years and as a patient who suffers with lymphedema of the leg daily. I have been able to maintain my lymphedema pretty well, but that is because I have done extensive reading on the subject, I listened to my doctors, and I have extensive knowledge of exercise. It is on my mind every day, at almost every moment because it takes great effort to maintain properly. I have included the description of lymphedema below.

Lymphedema is a difficult thing to deal with and must be maintained all day long, every day. There is no cure for lymphedema. I have had lymphedema in my leg since my 1991 cancer surgery. I went from being a gymnastics coach and fitness trainer who exercised daily to being bedridden after my surgery as a result of the lymph nodes being removed along with the cancer. My life changed drastically, but I went back to work and learned how to maintain it as soon as possible. Several doctors told me that I would be bedridden for the rest of my life and that I would never work again. That was in 1991.

So, what is lymphedema? Here is the definition by the National Lymphedema Network...

"Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue that causes swelling, most often in the arm(s) and/or leg(s), and occasionally in other parts of the body. Lymphedema can develop when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed (secondary).

When the impairment becomes so great that the lymphatic fluid exceeds the lymphatic transport capacity, an abnormal amount of protein-rich fluid collects in the tissues of the affected area. Left untreated, this stagnant, protein-rich fluid not only causes tissue channels to increase in size and number, but also reduces oxygen availability in the transport system, interferes with wound healing, and provides a culture medium for bacteria that can result in lymphangitis (infection)."

So, what types of exercise can a lymphedema patient perform? That depends on the patient and whether they have medical clearance to exercise. Once cleared for exercise, the best exercise to reduce the leg swelling is swimming because the person is horizontal, in motion, and performing a non-impact movement. The second best exercise for a person with leg lymphedema is riding a recumbent bike. It is also non-impact, it's a steady motion, and the legs are elevated slightly.

If the patient is in good physical condition otherwise and they have the lymphedema under control (as much as possible) they can use the elliptical machine. That is, if they can tolerate it from a fitness and medical standpoint. Make sure the lymphedema patient has permission from their doctor to perform exercise, especially an intense exercise such as the elliptical. Keep the person with lymphedema OFF THE TREADMILL. Walking and running cause the leg swelling to become MUCH worse because they are high impact. Picture someone putting ice cream into an ice cream cone and then packing it in. The swelling becomes dense, packed in if not maintained properly. The more severe, the more difficult it is to deal with.

In my experience, it can take an hour with the leg elevated before the swelling even BEGINS to go down and several days or weeks for it to completely drain. People with lymphedema should be wearing their compression stocking if their doctor prescribed it and sleeping with her legs elevated every night, unless their doctor has told them otherwise. It is important to stay in motion and to only perform non-impact exercises. For example, squats are often better than walking lunges for someone with lymphedema. The walking lunge is an impact exercise. Do NOT encourage a person with leg lymphedema to participate any exercise classes that include impact exercises. If they are in good shape the spin classes will keep the circulation going and help will lose or maintain a healthy body weight. It's all about keeping the body in motion without ANY impact exercises.

Keep in mind that of the lymphedema is from a new surgery the patient MUST be cleared to begin exercise because if they begin to exercise before the doctors allow them to exercise they will cause problems with the lymphatic system. My doctors told me the swelling from the surgery would never go down if I started to exercise too soon and that I would cause permanent damage. I was told to wait one full year after my surgery before I was allowed to exercise my legs. I waited 10 months and couldn't stand it any longer. I HAD to return to exercise because it was what I enjoyed and it was my life. Not being allowed to exercise my legs was extremely difficult for me because I spent a lifetime in the gym. Again, make sure the lymphedema patient has FULL medical clearance to exercise.

Here is something that many people do not know. When a person with lymphedema is not in motion and does not have compression stocking on their leg, they must keep their legs elevated in order to prevent swelling. Something as simple as waiting in line at the grocery store could cause enough swelling to keep a person in bed the next day. The swelling begins in less than a minute, literally, when standing still or sitting without the leg elevated. It is truly a challenge every minute of the day to keep the leg from swelling and those around lymphedema patients must be patient and considerate.

There is plenty of information on lymphedema. It is either primary or secondary. Secondary lymphedema would be caused from something such as a cancer surgery. Mine is secondary because my lymph nodes were removed from my upper thigh on one leg during my cancer surgery. If the lymphedema is not controlled it can end up being elephantitis. Yes, it is a real medical condition and it is very serious. There are lymphedema support groups throughout the USA. The National Lymphedema Network has plenty of information.

Let me know how I can help you...
Karen Goeller, CSCS

Karen Goeller, CSCS has been training athletes since 1978. She has an education that includes training in emergency medicine, physical therapy, and nutrition. She has held certifications that include Fitness Trainer, EMT-D, Nutritional Analysis, and many Gymnastics Certifications among others. Goeller has tremendous experience with training in a variety of settings. Karen Goeller is the author of the Swing Set Fitness books, the Gymnastics Drills and Conditioning books, and many additional products. She has written more gymnastics books than anyone in the USA. Her books are used by fitness experts, sports coaches, teachers, and athletes worldwide. Karen Goeller has worked for world's most famous gymnastics coach Bela Karolyi, owned a gymnastics club for ten years, and has been featured in several newspapers and on television many times. Karen Goeller offers sports performance training in NJ and through the web.

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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

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

Rules about exercising with lymphedema should be observed

Several rules about exercising with lymphedema should be observed:

Always start an exercise program gradually to avoid sprains and injury to muscles. It will also allow the person to observe how the edematousextremity responds to exercise. This will differ for each person. A compression garment or bandages should always be worn during exercise. This provides pressure on the limb and assists in pumping lymph from the extremity.

For women with post breast cancer treatment lymphedema in the arm, arm exercises should begin as soon as the doctor okays it. If the shoulder or wounds are sore, begin with mild pendulum exercises. Lean forward and let your arms hang down, then make circles. You can also swing them forward, backward and sideways. Once you can lift the arm over your head, you can begin active exercises.

An exercise program should involve all of the following movements:

a.Flexion (arms over the head close to the ear, palms toward the head) b.Extension (move straight arms toward your back) c abduction (arms away from the body, palms down) d.Horizontal abduction (move arms across the chest) e.External rotation (put hands behind your head) f.Internal rotation (put hands behind your back)

Once you can do these movements 30 times without weights, add one pound per week. Take your time. Begin with 10 and add 5 repetitions each day. If weight lifting adds to increased lymphedema, just do the exercise without the weight. Daily exercise should be done as long as motion is limited. Once you have full movement, you can exercise 3x per week.

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.