Lymphedema is swelling in the soft tissues of a limb caused by a build up of protein rich fluid. There are two types of lymphedema: primary and secondary. Primary lymphedema is a rare genetic condition in which the individual’s lymph nodes are absent or abnormal. Secondary lymphedema can be caused by a blockage or cut in the lymphatic system, usually in the armpit or groin after cancer treatment. As a result, water and protein can accumulate in the limb. On the other hand, edema is swelling due to injury or surgery, but the lymphatic system is still intact. Breast cancer survivors make up a significant number of those with secondary lymphedema due to cancer-related surgery and/or radiation. This is the population we will focus on for this article. Lymphedema is a common complication of cancer treatment and can result in long-term physical, psychological and social issues for many women. It can develop months or years after surgery and can be triggered by infection, injury, repetitive motion, plane flight, bug bites, temperature changes or vigorous massage.
Anatomy and Physiology of the Lymphatic System
The purpose of the lymphatic system is to help the body maintain fluid balance while filtering out waste products and to produce lymphocytes that are part of the body’s defense system. Excess water, proteins, bacteria, viruses and waste products are carried through the lymph vessels to the nodes. The lymphatic system is made up of nodes, ducts and collecting vessels and is one of the ways that breast cancer is spread. Lymph nodes produce the lymphocytes that help to destroy bacteria, cancerous cells or other waste and act as filters. We have about 600 nodes distributed throughout our bodies except in the brain, spinal cord, cartilage and nails. There are approximately 30-45 lymph nodes in the axillary region (armpit) and 10-15 may be removed during surgery. Breast cancer surgery and axillary dissection disrupts the lymphatic system, and scarring after radiation further compromises the chest wall and axilla. This makes it difficult for the lymphatic system to function effectively.
The lymphatic system works on changes in pressure from muscle contractions, which allows protein rich fluid to return to the heart - a one way drainage system. The right lymphatic duct collects lymph from the right arm and the right side of the head and chest, emptying into a large vein under the right collarbone. The left thoracic duct collects fluid from the legs, left arm and left side of the head and chest, emptying into the large vein under the left collarbone. This is important to know when performing exercises. Deep abdominal breathing enhances pumping in the thoracic duct, the major vessel that drains the lower body and left upper trunk. In addition, muscle contractions performed in a specific sequence can enhance lymphatic return. However, too much exercise can increase the fluid that the lymphatic system has to pump, which overwhelms the system. That is why one must be cautious when working with cancer survivors.
There are certain precautions that one must take if a client is at lymphedema risk. Trainers should be aware of these advisories.
- Protect the affected arm from sunburn by avoiding sunlight when able and wearing sunscreen. Try not to exercise from 10:00am to 3:00pm when the sun is strongest.
- Avoid insect bites by wearing insect repellent.
- Wear gloves when gardening.
- Wear gloves when doing housework.
- Use mitts when moving hot plates from oven.
- Keep arm as cool as possible.
- Elevate arm when sleeping and after exercise.
- Keep arm clean, supple and well moisturized.
- Use warm not hot water when bathing.
- Wear loose clothing, jewelry and watches.
- Use an electric razor that is well maintained to shave under the arm.
- Push back cuticles rather than cutting them.
- Alert all health professionals to only take blood pressure, blood drawings, vaccinations or shots to the unaffected arm. If both arms are involved, blood pressure should be taken in the leg. However, some medical professionals advise taking blood pressure in the arm that had the earlier surgery.
- Wear a compression sleeve when traveling by air.
- Pack soaps, moisturizers and antibiotics for emergencies.
- Symptoms of lymphedema include sensation of ache, fatigue, bursting, swelling, cramping, jewelry not fitting, numbness or heaviness at times in the arm. Should any of these symptoms be present, refer the client to a medical provider.
- Signs of infection include redness, inflammation, heat, blotchiness, fever, pain in the axilla and itching. Should any of these signs be present, the client should see their physician immediately.
Exercise is an integral part of lymphedema prevention and management. The participant must be medically cleared for exercise after undergoing breast cancer surgery and treatment. Other co-existing medical conditions such as cardiac disease, arthritis, hypertension, orthopedic issues or diabetes may dictate exercise design and necessitate medical intervention and clearance. As previously stated, lymphatic fluid moves through muscular movement and deep breathing. This causes a pressure change in the abdomen, which works like a vacuum in the thoracic region, helping to drain lymphatic vessels. However, blood flow is increased, possibly increasing the lymphatic load during exercise. In addition, improper exercise technique can cause inflammation and trauma. It is advised that clients wear either bandages or a well fitting compression garment when exercising to decrease the lymphatic load. These garments should be recommended and properly fitted by the client’s lymphedema therapist. However, these bandages are not required when swimming as water provides compression to the arm.
Flexibility and Range of Motion
Flexibility exercises to the shoulder, axillary region and latissimus dorsi can prevent tightness and scarring, which can block lymph flow. These flexibility exercises should be performed daily. In addition, there are specific lymphedema exercises that are performed in a proximal to distal fashion. These exercises are formulated with the following goals in mind: to increase the mobility of the spine and shoulder; to increase muscle strength to perform functional activities; to clear the trunk of the body before moving lymph from a more congested area; to promote better posture; and to clear the chest for increased fluid from the arm. Deep abdominal breathing followed by neck, shoulder, elbow, wrist and hand exercises is the preferred sequence. The amount of activity that can be tolerated varies with each individual.
This has been the area of greatest controversy, especially for women who do not have lymphedema but who are at risk. Recent studies by Harris and Niesen-Vertommen (2000) and McKenzie and Kalda (2003) used resistive type exercises such as dragon boat racing and strength training for women at risk of lymphedema. All women who participated wore compression sleeves and did not demonstrate a clinical difference in the arm circumference (lymphedema is measured by a tape measure to obtain the circumference of various points on the arm) after exercising.
Weights should be gradually introduced to the affected arm once good range of motion has been achieved. Strength training should only be initiated when the client's lymphedema has been adequately managed. Strength training may pose the greatest risk to those diagnosed with lymphedema. The load is increased on the lymphatic system due to the increased blood flow, risk of injury and the production of waste products. If at lymphedema risk, start slowly with one- to two-pound weights. The back and shoulders should be a priority with an emphasis upon the triceps, rotator cuff, rhomboids and deltoids. Rotate muscle groups from upper to lower body in the beginning until you see how your client responds. Adequate rest intervals are important between sets. Properly fitted garments should be worn from shoulder to hand. Either the weights or repetitions are increased but not both at the same time. Start with one to two sets of each muscle group. A frequency of three to five strength training sessions per week is recommended. Yoga positions that weight bear on the hands and military push ups should be avoided. Monitor the response of the arm via observation and client response. If the arm is visually swollen after exercise, then the exercise was too demanding for the limb. It is advisable to consult with rehabilitation specialists such as occupational therapists and follow their guidelines. Strength training to the unaffected arms, legs and abdominals can proceed in the usual manner.
The goal of aerobic conditioning is to improve cardiovascular fitness. It is advised that women who are undergoing cancer treatment exercise at a low intensity or 50-65% of heart rate reserve or RPE of 10-12. Moderate intensity exercise is recommended for all others at 50-75% of heart rate reserve or a RPE of 11-14. However, one's original fitness level is going to be a factor. Again, the risk of exacerbating lymphedema associated with cardiovascular exercise is related to increased blood flow and increased metabolic waste.
Stationary cycling, swimming, walking and cross trainers are all appropriate. A frequency of three to five times per week is recommended for at least 20 to 30 minutes. However, it is better to start slowly and increase the frequency and duration of the activity rather than the intensity.
Exercise is a modality that is quite therapeutic after undergoing treatment for cancer. In addition, it is an important part of a healthy lifestyle. However, your programs may need to be modified to reduce the risk of lymphedema. Before working with women living with cancer, trainers should network and consult with rehabilitation specialists. These therapists can recommend appropriate and safe training schedules for clients and modifications. By communicating with these providers, you will have the opportunity to both promote your services and ensure best practice.
- Burt, J and White, G Lymphedema (1999) Hunter House Publishers Alameda, California.
- Casley, Smith, J and JR. Modern Treatment for Lymphedema (1997) University of Adelaide, Adelaide SA 2005 Australia.
- Harris, S and Niesen-Vertomimen, SL. "Challenging the Myth of Exercise Induced Lymphedema following Breast Cancer: A Series of Case Reports." Journal of Surgical Oncology (2000) 74 2: 95-99.
- McKenzie, D.C. and Kalda, AL. "Effect of Upper Extremity Exercise on Secondary Lymphedema in Breast Cancer Patients." (2003) Journal of Clinical Oncology (21) 463-466.
- Miller, L. The Enigma of Exercise (1996) National Lymphedema Newsletter. Oct/Dec. 55.
- NLN Medical Advisory Committee Position Statement of the National Lymphedema Network (2005).