Exercise
Exercise and lymphedema
The evolution of exercise research and protocol for lymphedema By Karin Johansson
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n Western countries cancer treatment is one of the most common causes of lymphedema. In particular when both lymph node surgery and radiotherapy are given, the incidence is 30-50% both in the upper limb after breast cancer treatment and in the lower limb after gynecological or prostrate/urological cancer treatment. During the last decades the cancer survival rate has increased significantly, leaving many survivors with impairments such as lymphedema. For a long time, exercises for lymphedema patients were recommended to be “remedial” which in the 1970’s and 1980’s, mostly included different range of motion movements of the limb, performed slowly and without weights. These recommendations were most likely based on the theory that simple obstruction of the lymph flow by lymph node surgery was the sole cause of cancer related lymphedema. It was believed that if cancer survivors performed vigorous exercises, the lymph production would increase and thereby increase the limb volume. Therefore,
movement therapy should only be used to support the venous and lymphatic flow in the bandaged limb, meaning muscle contractions without increased blood flow1. Another historical reason for not performing vigorous exercise might have been based on the doctor’s experience that patients had claimed that lymphedema developed after (for example) lifting a heavy object, and therefore doctors suggested that patients not do any heavy lifting. Specific recommendations were even given not to carry anything heavier than two litres of milk. At that time recommendations were very easily established without any evidence. Unfortunately, that still happens quite often today. When a new medicine is introduced, it has to be vigouresly tested step by step on animals, healthy subjects and patients before it is allowed into the market, but advice and recommendations are never tested that way and are most often not evidence based. For breast cancer patients, the recommendations were to avoid heavy work with the arm and not to “overload” the lymphatic
Karin Johansson RPT, PhD is a lymphedema specialist, Department of Oncology at Skåne University Hospital, Lund, Sweden; Associate professor, Dep of Health Sciences, Division of Physiotherapy, Lund University. Editor of the National Lymphedema Guidelines in Sweden, her research focuses on early diagnosis and physical activity for prevention and treatment of lymphedema following breast cancer treatment, and measurement of health related quality of life for lymphedema patients.
Spring 2017
system and “to be careful.” Furthermore, this was recommended not only to lymphedema patients but also as prevention for lymphedema development. This was the advice I was taught in the early 1990’s, to give to the breast cancer patient post surgery. Hearing this advice from professionals created fear in the patients about potential development of lymphedema and promoted the idea that inactivity was beneficial. Due to this, many breast cancer patients became physically inactive with the arm on the affected side even before lymphedema developed (Johansson et al.2002)19. In that way they most likely slowly reduced strength and circulation to such a low level that even a small exertion, which normally would have been of no damage, may have suddenly provoked an impairment. Another reason for the recommendation of inactivity during the 1990’s was due to the introduction of chemotherapy as an adjuvant cancer treatment causing side-effects like fatigue that, in those days, were “treated” with rest. Later we learned that fatigue should instead be treated with physical activity and exercise. Around the same time in the late 1990’s, both patients and physiotherapists, based on their experience, started to question the exercise restrictions that had been set previously. In the early 2000’s evidence came forward supporting exercise (done a couple of hours per week at medium level) as preventive for breast cancer2. Some years later it was also shown that physical activity after breast cancer diagnosis could reduce mortality3. L y m p h e d e m a p a t h w a y s . c a 13
Later on, there were similar findings of the benefits of exercise prevention for other cancer diagnoses, like prostate cancer4 and colon cancer5. These findings, that the survival rate was dependent on exercise level, had a strong impact on the exercise restrictions for lymphedema patients, showing that patients with breast cancer related lymphedema may actually be risking their health by being less physically active than recommended. At this time it was also found that a high Body Mass Index (body weight correlated to height) was a risk factor for development of lymphedema. Though we know that the reduction of body weight requires a change of diet, increased physical activity is also an important component. This finding also increased the need for lymphedema patients to exercise. We have come a long way in our understanding of the lymphatic system and how it works. In particular we have learned that the obstruction theory described above is a far too simple and causal explanation6. Rather, theory today is based on the assumption that the lymphatic system and lymphedema may
actually benefit from exercise. Already in 2000 Susan Harris, PT and professor at the University of British Columbia, Vancouver, published a paper on Dragon boat racing among women treated for breast cancer, showing that a two-month muscle strength training program followed by an eight-month competition season did not increase the risk of developing lymphedema8. In other, later studies; no risk of developing lymphedema by vigorous exercise was revealed. In one study, among breast cancer survivors who undertook a supervised progressive weight-lifting program for a year, only 7% developed lymphedema in the arm compared to a control group (no exercise) where 22% developed lymphedema9. These results point out that exercise may even serve as prevention. Even more studies have been published to show that an already established lymphedema A program of
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does not get worse by vigorous exercise10. However, it is very important to note that weight bearing exercises with the aim of increasing strength should be progressive— meaning that if the patient had not previously been exercising, the exercise should be started at a low level and slowly increased and supervised by skilled professionals checking for signs of increased swelling. On the other hand, a lot of studies show that cancer patients can do vigorous exercise during cancer treatment and benefit from it. The more these findings are applied in practice within health care the less will be the risk that cancer survivors are totally sedentary during a long period of cancer treatment. Such behaviour will most likely also reduce the incidence of lymphedema over time. However, not all exercises are about weight lifting. Swimming has been tested in several studies11, 12, 13 with the idea that the pressure of the water may increase the effect of the exercise on the lymph flow. This benefit has not yet been proven, however, most likely because some of the exercise programs that were tested were only performed once a week, which is too low a frequency to be able to show an effect after any exercise. The higher exercise frequency of 3-5 days of training per week is probably the key to the success that Nordic pole-walking as been found to be effective for lymphedema volume reduction14. The benefit may be due to increased capillary supply providing a larger surface for capillary filtration and conductance7. Exercise like yoga and Qigong are very popular among cancer survivors and have been found to improve sleep quality and overall quality of life, as well as reduce fatigue15. However, very few studies of their effect on lymphedema have been published. A recent yoga protocol for breast cancer related arm lymphedema16, including compression treatment and slow joint movements, appears very similar to what was recommended in the 1970’s by the Vodder school. Breathing exercises have been added; however, deep breathing has never been observed to increase lymph flow, except during high force inhalation in healthy Spring 2017
subjects17, and is not considered to produce any clinical effect on lymphedema. There are very few studies published concerning leg lymphedema. This is most likely due to the fact that it is much more difficult to obtain reliable comparative measurements for leg lymphedema where a healthy side cannot be guaranteed. In cancer related leg lymphedema nodes are often taken and radiation is often given to both sides. This remains a challenge for researchers. Still, there is no reason to believe that exercise for patients with leg lymphedema should be performed in any other way than exercise for patients with arm lymphedema. It is also reasonable to assume that water-based exercises like standing and walking on the bottom of the pool would be beneficial to leg lymphedema as the water pressure around the foot at depth is even higher than that provided by most compression stockings.
Not all lymphedemas are secondary or caused by cancer treatment or other traumas. Some are primary, resulting from faulty lymphatic vascular development. However, it is likely that the principals of exercise for secondary lymphedema may also be applied to patients with primary lymphedema, starting with low levels for non-trained persons accompanied by slow progression and regular check ups with a health professional on the lymphedema status. Finally, there is the question of wearing or not wearing a compression garment while exercising. A recent review found that there is no consistent evidence for wearing compression during exercise. There may be a small preference for wearing compression but on the other hand no (statistical) deterioration was found when patients were not wearing compression. The conclusion was that the compression should be applied on an individ-
Weight-bearing exercises should be progressive, with the aim of increasing strength. ual basis, that is, it is better to refrain from using compression than to refrain from exercise because the compression is not comfortable. (Singh et al 2016)20 In summary, patients with lymphedema in the arm or leg can be encouraged to regularly perform vigorous exercise, starting at a low level with slow progression and with no upper limit as long as there is no deterioration noted. The type of exercise is less important than the involvement of large muscle groups of the affected limb and a high frequency of training. And remember, exercise at any level is better than none. LP A full set of references can be found online at www.lymphedemapathways.ca.
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