Exercise Improves Lymphedema Symptoms in Breast Cancer Survivors

Arm lymphedema, or chronic swelling of the arm, occurs in 10 to 30 percent of women following treatment for breast cancer. When the lymphatic drainage network in the arm has been disrupted by the surgical removal of armpit lymph nodes by the surgeon, or by radiation therapy to the armpit area (or, sometimes, following both types of treatment), the delicate network of lymphatic vessels that return excess tissue fluid back to the heart can become obstructed. This lymphatic obstruction can result in chronic swelling of the hand and arm. Patients with significant lymphedema of the arm following breast cancer treatment may experience considerable swelling (edema), heaviness, stiffness and discomfort of the affected hand and arm.

Physicians caring for breast cancer patients have traditionally advised against heavy lifting following breast cancer surgery, for fear that doing so might increase arm lymphedema. However, a new prospective randomized clinical research study calls into question the traditional advice against vigorous exercise involving the upper extremities, including lifting weights as a strengthening exercise.

This new study, which appears in the New England Journal of Medicine, included 141 breast cancer survivors with chronic lymphedema. These women were divided into two groups, with a "treatment" group randomized to twice-weekly progressive weight training and a "control" group of women who were randomized to no weight training. All of the women participating in this study were followed for one year, at the end of which the degree of arm lymphedema was reassessed. Of note, all of the women who were randomized to the weight training group were required to wear custom-fitted compression garments when they were lifting weights.

Not surprisingly, the women who participated in regular weight training reported significant improvement in upper and lower body strength during the course of this research study. Moreover, at the end of one year, both the patients and a certified lymphedema specialist reported a significant decrease in the severity and frequency of lymphedema symptoms among the patients who were randomized to the weight-lifting group. At the same time, twice weekly weightlifting sessions had no significant effect on the extent of arm and hand swelling among these women with chronic lymphedema.

The results of this clinical study are good news for breast cancer survivors with chronic lymphedema. Physicians who care for such patients should all be made aware of the results of this research study, and they should begin encouraging their lymphedema patients to engage in regular weight training (provided, of course, that there are no health issues that preclude lifting weights). Not only does regular weight training appear to decrease the severity and frequency of lymphedema symptoms (based upon the findings of this study), but the added health advantages of such training also include increased strength and a decreased risk of osteoporosis as well.

Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, a professor of surgery, a widely published author, and a Surgical Oncologist at the Kaiser Permanente healthcare system in Orange County, California

Robert A. Wascher, MD, FACS

http://doctorwascher.com

Exercise Guidelines for Lymphedema Survivors

When I was diagnosed with lymphedema in 1997, the standard advice was to "baby" my swollen arm. Exercise was limited: anything weighing more than three pounds had to be carried with my other arm. I would feel lopsided as I lugged a gallon jug of milk with my normal right arm. And I hadn't heard of medical problems such as muscle atrophy and frozen shoulder.

Last year a study was conducted at the Abramson Cancer Center of the University of Pennsylvania by an exercise physiologist to determine whether a slowly progressive program of strength-training exercises is safe for breast cancer survivors with and without symptoms of lymphedema. ("Weight Lifting in Women with Breast-Cancer-Related Lymphedema," the New England Journal of Medicine ( August 13, 2009) by Kathryn Schmitz, PhD, MPH.

According to Dr. Schmitz,"This problem(lymphedema) affects up to one-half of the nearly two million breast-cancer survivors alive in the U.S. today - which means that there may be as many as one million women who suffer from some form of lymphedema...Further, the psychological effects are enormous...Indeed, many women have reported that they would rather have another mastectomy than lymphedema - because it's a painful, constant, and debilitating reminder of their breast cancer."

Why should you exercise? Because it is beneficial for people in general (weight loss, feeling of well-being, health benefits, etc.). For those with lymphedema, muscle exercise increases the lymph flow rate multiple times over the resting rate. In addition, exercise is a key element of Complete Congestive Therapy (CDT), the gold-standard treatment of lymphedema, because it helps drain lymph fluid from the swollen limb and into the circulation.

But before you begin any exercise program, check with your therapist or physician. Build your strength up gradually, exercise in a controlled manner, and stop if you experience any pain. Be sure to drink adequate amounts of water, warm up before the activity and cool down afterward, wear your compression garment on your affected limb, and opt for loose clothing. Many therapists also advise that you perform deep abdominal breathing before and after exercise to stimulate lymph flow.

Aerobic exercise is a great way to stay fit when you have lymphedema. Any way you increase the circulation helps. While there are many ways to do it (biking, jogging, and walking), I particularly recommend swimming, which is a great overall endurance exercise that uses water as part of the compression.I joined a club with an indoor pool just to get the year-round benefits that swimming offers. Activities that used to be taboo when I was diagnosed are now allowed, such as golf, tennis, and triathlons if done using the precautions noted above and approved by your therapist. And one activity that had been advised for lymphedema patients in 1997, a mini-trampoline, is now no longer recommended due to the risk of injury.

Resistance training-once frowned upon for lymphedema survivors-is now considered beneficial, thanks to Dr. Schmitz's study noted above. It requires that muscles exert a force against some form of resistance. Dr. Schmitz's study specifically found good results when these strength-training exercises were part of a slowly progressive program. I purchased a set of dumbbells with progressive weights (5, 10, 15, 20, and 25 pounds) that I use to increase my arm strength in a gradual, controlled manner as now recommended. And bench pressing can be beneficial if done properly. Again, it is best to consult your therapist on the proper technique to use.

Stretching exercises, including yoga and pilates, are another way to improve the symptoms of lymphedema, when combined with the other activities noted in this article. Stretching moves the skin, muscle and other tissues in the affected lymph and relieves the feeling of tightness that patients often experience in their affected arm or leg. Range of motion, flexibility and freedom of movement of the lymphedemous limb are also improved by stretching. My therapist taught me active elongation exercises on a stability ball to help to stretch scars to increase flow of lymph fluid to the bloodstream.

Please note that Dr. Schmidt mentions six misconceptions about her exercise study on the National Lymphedema Network Web site:

1. Misconception: Weight training prevents lymphedema. Short answer: The study did not address prevention of lymphedema.

2. Misconception: If weight lifting is safe, and all those years we told women not to weight-lift, then all those other cautions like avoiding blood pressure or blood draws on the affected side must be wrong, too. Short answer: When lymph nodes are damaged or removed, many risk reduction guidelines still apply to avoid infection, inflammation, injury and trauma.

3. Misconception: The study results mean that all women with lymphedema can buy weights or a gym membership and do what they want without fear of their lymphedema getting worse. Short answer: This study was done in a controlled and supervised way with precautions.

4. Misconception: If I do weight-lifting, I will never have another flare-up of lymphedema. Short answer: Lymphedema can flare up if safety guidelines in the study are not followed.

5. Misconception: If it is safe for me to do weight-lifting, then it is okay for me to lift heavy things at work or at home. My boss can ask me to lift heavy things at work now because the trial results show it is safe for me to do so. Short answer: Some of the women in the study never progressed beyond 5-pound dumbbells.

6. Misconception: The trial results mean it is safe for those with lower extremity lymphedema to do weight-lifting, too. Short answer: The results are inconclusive, so they cannot be extrapolated to leg lymphedema.

Please note that this information does not replace the advice of a qualified health care professional.

A retired patent attorney, Jan Hasak authored a memoir, "Mourning Has Broken: Reflections on Surviving Cancer." In this work she shares how her hope in Christ sustained her as she underwent breast-cancer treatment at ages 43 and 52, and dealt with lymphedema.

Her second book, "The Pebble Path: Returning Home from a Forest of Shadows," takes a poetic look at her cancer journey, relating the story of a princess who picks up pebbles of wisdom while traveling down the path following her cancer diagnosis.

Ms. Hasak is listed on the National Cancer Survivor Day Speaker's Bureau roster and is an American Cancer Society volunteer and a patient-advocate for the National Lymphedema Network (NLN). She received a Lymphedema D-Day Award for her service to the lymphedema community.

To read more, please visit Jan Hasak's Web site at http://www.janhasak.com or http://outskirtspress.com/webpage.php?ISBN=9781432754198.