What you need to know about designing a program for clients at risk of post-breast-cancer lymphedema.
Imagine undergoing a year of breast cancer treatment, including surgery, lymph node removal, chemotherapy and radiation. Your body feels as if it were under siege. You are ready to take back your life and undergo a strict diet and exercise program. However, just as you are about to start, you find out about a condition called “lymphedema.” Between 200,000 and 400,000 of the 2 million breast cancer survivors in the United States are thought to have lymphedema, and there is no cure (Petrek, Pressman & Smith 2000; Ahmed et al. 2006).
Until 2005 the National Lymphedema Network advised women at risk for lymphedema not to engage in strenuous activities, including lifting weights heavier than 5 pounds. Yet exercise is one of the most important components in both reducing breast cancer risk and promoting recovery. No wonder breast cancer survivors, as well as the medical community, were confused by the recommendation to avoid strenuous activity—a recommendation based mostly on fear, not solid research. (See “Relevant Strength Training Research” on page 32.)
Lymphedema is a condition of localized fluid retention caused by a blockage in the lymphatic system. In the case of breast cancer patients, the condition causes swelling in the soft tissues of the arm, hand, trunk and chest on the side(s) affected by surgery. Women who have undergone an axillary dissection and/or radiation are at particular risk.
Symptoms of lymphedema include heaviness, aching, fatigue and sometimes pain. Affected women have limited movement in the arms and decreased muscle strength, leading to restrictions in their activities. The arm feels harder to the touch as the lymphedema worsens.
Lymphedema can develop months or years after cancer treatment and can be triggered by infection, injury, repetitive motion, air travel, insect bites, vigorous massage or obesity. Obviously, preventing lymphedema or catching it in its earliest stages is better than dealing with it after the condition has occurred or advanced.
Understanding the lymphatic system is important when designing an appropriate exercise plan. The lymphatic system acts as a drainage system, helping the body maintain fluid balance while filtering out waste products and destroying bacteria and cancer cells. It is made up of nodes, ducts and collecting vessels that work together to remove excess fluid from body tissues, among other functions. The right lymphatic duct collects fluid from the right arm and right side of the head and chest. The left thoracic duct collects fluid from the legs, left arm and left side of the head and chest.
Lymph nodes act as filters, producing the lymphocytes that help destroy bacteria, cancerous cells and other waste. There are approximately 30–45 lymph nodes in the axillary region (armpit); if cancer is suspected in the nodes, 10–15 are typically removed to prevent its spread. If the remaining lymph nodes cannot compensate for the ones that have been removed, lymphedema can result. Radiation can produce further damage by scarring the lymphatic vessels. Finally, the natural tendency to protect the arm after surgery causes tightening of the pectoralis major and trapezius and stretching of the rotator cuff. The subsequent loss of mobility may interfere with normal lymph drainage from the arm.
How can exercise make a difference? Unlike the circulatory system, the lymphatic system has no central pump; it is stimulated by changes in pressure from muscle contractions or deep breathing. Deep abdominal breathing enhances pumping in the thoracic duct; and muscle contractions performed in a specific sequence (usually proximal to distal) can enhance lymphatic return. In addition, exercise can be used to stretch the tight pectoralis major and trapezius muscles and to strengthen the rotator cuff. Exercise modes that focus on deep breathing and flexibility, such as yoga and Pilates, can be particularly helpful.
Warm-Up. A proper warm-up prepares the body for exercise and opens up the lymphatic channels. Incorporate the following:
- deep breathing
- neck rotations
- shoulder protraction/retraction
- shoulder rolls
Strength Training. Strength training in the affected area has been a controversial issue. Proceed slowly and follow these guidelines:
- Always begin with a warm-up before strength training the affected arm.
- Observe the response to exercise. Watch for swelling in the area, which can indicate that the weight or number of repetitions is too high, and adjust the program accordingly. (A physical therapist or an occupational therapist can teach you how to take circumferential measurements, using a measuring tape.)
- Have the client wear a compression sleeve (usually prescribed by the occupational or physical therapist).
- Focus on the muscles of the shoulder and back, including the deltoids, serratus anterior, trapezius, rhomboids and rotator cuff, to optimize shoulder strength and promote alternative lymphatic-pathway drainage.
- Work the abdominal region to encourage lymphatic flow back into the thoracic duct.
- To give the affected arm an opportunity to rest, alternate arms; alternate upper- and lower-body exercise; or do circuit training, incorporating both cardiovascular and strength training.
- Design a 2- or 3-day-a-week program. Start slowly and progress gradually (e.g., 1 set with 1 pound on the first day; 2 and 3 sets with 1 pound on days 2 and 3). When increasing weight, reduce the number of sets.
- Proceed in the usual manner for training the unaffected arm, trunk, abdominals and legs unless TRAM (transversus rectus abdominis muscle) flap reconstruction was performed, in which case you should consult with the client’s medical practitioner before proceeding.
- Incorporate Pilates exercise, which focuses on posture and breathing as it works the abdominal region.
Individualize your client’s program based on health history, exercise preferences and prior activity level. Observe the guidelines outlined in “Exercise Precautions for Clients at Risk of Lymphedema” on page 29 and progress slowly and safely to ensure that your client regains fitness, function and endurance.
Illustration courtesy of the National Cancer Institute