Exercise
Exercise and lymphedema
The evolution of exercise research and protocol for lymphedema By Karin Johansson
I
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