EXERCISE AND LYMPHEDEMAO

Delphine S. Adams
July 6,2014
Davis CTTC: February 1 —May 18, 2014
 ABSTRACT

EXERCISE AND LYMPHEDEMA

Lymphedema is a condition in which fluid, also known as lymph, is retained by

the lymph nodes and causes swelling (edema), often in the arms or legs, and sometimes
in the neck, face and abdominal areas. The swelling occurs when a blockage in the
lymphatic system prevents the fluid from draining properly or adequately. The condition
has a definite negative effect on fitness. Those suffering from the condition may benefit
from managed exercise in connection with lymph drainage therapy.
This paper discusses lymphedema's effects on the body and suggests a Pilates
exercise regiment based on the BASI Block System for people suffering from or at risk of
developing lymphedema. It concludes with a case study of a lymphedema sufferer and a
Pilates program designed for her.
 TABLE OF CONTENTS

Abstract Page 1

Table of Contents Page 2

Overview of Lymphedema Page 3

What Is Lymphedema? Page 3
What Causes Lymphedema To Develop? Page 3
The Lymph System. Page 3, 11
Signs ofLymphedema Page 4
Treatment of Lymphedema Page 4,5
Fitness and Exercise for Lymphedema Sufferers Page 5
The Importance of Exercise Page 5
Pilates for Lymphedema Sufferers Page 5,6
Considerations for Designing An Exercise Program Page 6
Case Study for Hypothetical Lymphedema Sufferer Page 7
General Recommendations Page 7
BASI Block System — Modified Page 7, 8
Conclusion Page 8
Appendix 1 Page 9, 10
Diagram 1.1: The Lymph System Page 11
Bibliography Page 12
 EXERCISE AND LYMPHEDEMA
Overview of Lymphedema.1
What Is L~phedema?
Lymphedema is a build up offluid known as lymph in the fatty tissues just under
the skin. The build-up of this fluid causes swelling, also known as edema. The edema is
most often concentrated in the arms or legs, although it can also affect the face, neck,
abdomen and genitals. There are two types oflymphedemea. Primary lymphedema
occurs in individuals born with genes that put them at an increased risk for developing
the condition. This type oflymphedema is caused by lymph nodes that are missing or not
working as they should and is rare in its occurrence. Secondary lymphedema is a result
of cancer, cancer treatments, tumors, diseases, or anything that can change or damage the
normal, healthy lymph system.
What Causes L~phedema to Develop?
Lymphedema can be caused by a number of different occurrences. Perhaps the
most common cause is a treatment for cancer. It can become a problem after surgery or
radiation or chemotherapy treatment for any type of cancer. And it is not gender specific.
It is often linked to treatments for breast cancer, prostate cancer, lymphoma, melanoma,
and pelvic area cancers such as bladder, testicular, uterine, vulvar, ovarian andlor cervical
cancer.
The L~ph SXstem.
The lymph system (see diagram 1.1) is a network of nodes and vessels tluoughout
the body that carry watery, clear lymph fluid, much like veins collect and carry blood
from distant parts ofthe body back to the heart. Envision blood pumping to the tips of
your toes or the tips of your fingers and then back to your heart; this pumping is
applicable as well to the lymph system. Lymph fluid contains proteins, salts, and water,
plus white blood cells that help the body fight infections. Lymph vessels within the
lymph system have one-way valves that work with body muscles to move the fluid

1 The information contained in the Overview ofLymphedema section is derived from an article published
by the American Cancer Society, Understanding Lymphedema —For Cancers Other than Breast Cancer,
published Apri15, 2013 at www.cancer.orQ. Further References relative to this article are found in the
Bibliography at the end ofthis paper.

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through the body. Lymph nodes, also part ofthe lymph system, are small collections of
tissue that work to filter out harmful substances and help the body fight infection.
Many treatments for cancer impact the lymph system by either requiring surgical
removal of affected lymph nodes or by destroying the functionality ofthe lymph nodes
via radiation and/or chemotherapy, reducing the number offilters throughout the body
and increasing the opportunity for infection.
Si ns of L~phedema.
Among the signs oflymphedema are the following:
• Swelling.
• Part ofthe body, particularly the arm, leg, belly or genitalia, feels full or heavy.
• Skin on the affected area feels tight, hard or looks red, or there is a change in
texture ofthe skin.
• The affected area is newly achy, tingles, or there is a noticeable discomfort
associated with the area.
• There is less movement or flexibility in nearby joints, such as the hand, wrist,
ankle, or even the eyelid or lips.
• There is trouble fitting into clothes, such as a jacket sleeve, pant leg, or shoe.
• Collars, rings, watches and/or bracelets feel tight.
• Apart ofthe body feels hot or looks red, has red blotches or streaks, or gets
tender or sore to the touch.
• Over time, skin ofthe affected area becomes hard and stiff
• A sudden increase in temperature (100.5°F or higher) not related to a cold or the
flu occurs.
• Any new pain, particularly ofthe arm, leg or abdomen, and even the neck and
face, with no known cause.
Treatment of Lvmphedema.
Lymphedema is often treated by physical therapy. More moderate or severe cases
are treated by a lymphedema therapist with special training in skin care, massage known
as manual lymphatic drainage or MLD,special bandaging, exercises and compression
garments.

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 Maintaining a healthy weight and exercise are also vital components for those at
risk for lymphedema, as well as for those suffering from this condition.
Fitness And Exercise For Lymphedema Sufferers.2
The Importance ofExercise.
The importance of being physically fit and maintaining a healthy weight for those
who suffer from lymphedema cannot be stressed enough. Using the body part that has
been affected by cancer for normal, everyday activities to help the healing process and to
regain strength and normalcy is imperative. Such activity also helps the lymph fluid
drain as it should. Those suffering from lymphedema or at risk of developing the
condition must first consult with their oncologist and a lymphedema therapist, and both
ofthese professionals should work closely with the Pilates instructor to ensure beneficial
exercise therapy. Regular exercise is recommended, but with constant self-observation
and a slow, progressive program increased cautiously. Well-fitted compression garments
may also be required tluoughout and for an hour after exercise. (Step Up, Speak Out:
Lymphedema: What Fitness Professionals Shozrld Knoti>>, pg. 8, 2013,found at
www.stepup-speakout.org.)

Pilates Resistance Exercises For The L~phedema Sufferer.

The effects ofPilates' training on lymphedema are not yet fully known. At least
one study, predicated on non-modified aim series exercises involving breast cancer
survivors at risk for lymphedema,found increased susceptibility to swelling after
exercising.(Pilatesfor Breast Cancer Szrr•>>ivors: Impact on Physical Par°ameters and
Qzraliry ofLife after' Mastectomy, Daniella Stan, et al, Clinical Journal of Oncolo~v
Nursing, Vol. 16, No. 2.) However,common-sense guidelines extrapolated from weight-
lifting studies can be used to adapt Pilates exercises for those with and at risk of
lymphedema. (What Fitness Professionals Should Knotin, supra.)
Those suffering from lymphedema, and those training a lymphedema sufferer,
whether from breast cancer or pelvic region cancers, must pay close attention to the
amount of exertion and resistance placed on the extremities when participating in a

2 The information contained in this section is derived from the prior article cited in FN 1, as well as two
related articles published in Apri12013 at www.ste~up-speakout.or~ by Step Up, Speak Out, entitled
Ly~rlplaedema: YYhat Fitness P~•ofessionals Should Know and B~~east Cancer-Related Lynaphedema &
Exe~~cise.
Pilates program. When first starting, body movements should be limited to a few
repetitions with little or no spring resistance. Body weight-bearing exercises, such as
planking, push ups, and Back Support on the mat, and excessive work using strap
resistance, such as hundred, the rowing series, hug a tree, salute, pulling straps, kneeling
arms, and the hamstring series on the reformer should be avoided until the client is
sufficiently advanced and the effects ofthe Pilates program on the client's condition are
observed over a period of time.
Deep breathing and alternating exercises with sufficient rest periods in between,
inherent in the BASI Block System, as well as staggering increases in repetition and the
introduction of resistance, are fundamental to aiding the lymphedema sufferer in
beginning and continuing a Pilates exercise program.
Considerations For Designing An Exercise Pro r~ am•
It is essential that a client disclose the existence oflymphedema or the risk of
developing it to the Pilates' instructor. As with all contraindications, care must be taken
by the instructor to learn as much as s/he can about the client, the type of cancer for
which the client has been and/or is treating, the client's treatment program and on-going
medical conditions. As an instructor, proceed cautiously in designing a program and do
so only after first consulting, with the client's permission, with the client's lymphedema
therapist and oncologist. Be mindful of any expression of pain or discomfort by the
client, and be attentive to any excessive exertion on the part ofthe client, which can
increase the risk of developing or causing aflare-up oflymphedema. Keep a watchful
eye for any evidence ofswelling or discoloration in the client's extremities.
When designing an exercise regime, be sure to include exercises that will
stimulate the flow oflymph through the body. Those suffering from lymphedema ofthe
lower extremities will benefit from exercises that stimulate the thoracic duct, the part of
the body where the lymph fluid fiom the legs ultimately drains(see figure 1.1). Focusing
on muscle movements that provide the pumping action that moves lymph through the
lymphatic system coupled with deep breathing will stimulate the flow of lymph,
preventing it from building up in the client's body.

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 Case Study For Lymphedema Sufferer.
This Case Study is based upon a real person. Unfortunately, the individual for
whom it was designed lost her battle with ovarian cancer in June 2014.
Janice Campbell was diagnosed with Stage 3C ovarian cancer in February 2012 at
the age of 64.5. After undergoing extensive surgery to remove as much ofthe tumor,
which had wrapped itself around her femoral artery, as possible, Ms. Campbell
underwent chemotherapy with carboplatin and taxol for the better pant of one year. As a
result ofthe chemotherapy, she developed lymphedema in her lower extremities,
particularly her left leg, which became swollen, hard, and difficult to move.
General Recommendations.
Ms. Campbell, besides being afflicted with cancer, struggled with her weight for
most of her adult life. Exercise was not one of her favorite things. Nonetheless, she was
open to a plan that would address the swelling in her legs, provide increased mobility
and allow her to enjoy activities with her grandson. Due to her weight, complicated by
the swelling in her legs from lymphedema, and after consultation with her oncologist, it
was determined that any exercise had to be free of any load-bearing or resistance, with a
focus on moving the lymph tluough her body. Legwork on the reformer using a jump-
board with atrampoline-like surface was determined to be the best alternative. As Ms.
Campbell also suffered some neuropathy in her feet, special attention was required to
ensure that the amount of pressure on her feet and legs was sufficient but not excessive.
Moreover, because sustaining one position for prolonged periods was ill-advised for Ms.
Campbell, and because stamina was an issue, a severely modified Block System with a
focus on breathing, legwork, mild abdominal work, and fun was essential.
BASI BLOCK SYSTEM — SEVERELY MODIFIED3
Each session would, at a minimum,consist ofthe following:
WARM UP
• Deep diaplu•agmatic breathing while standing or sitting.
• Focused intercostal breathing while lying supine on reformer, all springs attached.

3 A full BASI Block System exercise regime that could be adapted to an increase in Ms. Campbell's
stamina level is set forth in Appendix 1.

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 • Alternating spinal positions predicated on neutral spine and the clock face; 12, 6,
3 and 9 o'clock, to orient the client to proper pelvic positioning while lying supine
on reformer.
ABDOMINAL WORK
• Mini Roll-Up on Cadillac
• Mini Roll-Up Oblique on Cadillac
LEG WORK
• Parallel Position Jumping Series on refoi~rner (zero to light resistance only and
reduced repetitions).
• V-Position Jumping Series on reformer (zero to light resistance only and reduced
repetitions).
• Leg Changes Jumping Series on reformer(zero to light resistance only and
reduced repetitions).
• Single Leg Parallel Position Jumping Series on reformer(zero to light resistance
only and reduced repetitions.)
Conclusion
Prior to her passing in June 2014, we were able to implement the Warm Up and
Leg Work segments ofthe above exercise regime. The Jumping Series relieved the
feeling of pressure in Ms. Campbell's legs and produced some reduction in the swelling,
increasing her mobility for a brief time. The deep breathing helped her breathe through
the pain in her legs when it became intense and also helped her focus on the exercises in
the Jumping Series. This same deep breathing helped her attain a sense of calm in the
face of mounting ar~iety in her final hours as well.

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 APPENDIX 1
BASI Block System (ModifiedZ
Essential to the treatment oflymphedema ofthe type suffered by Ms. Campbell is
deep breathing and legwork to move the lymph tYuough her body. Each session would
include the warm up, consisting of deep diapluagmatic and intercostal breathing and
pelvic positioning, and leg work on the trampoline-like jump board. Depending on her
stamina on the day in question, other blocks could be added for a complete work-out
regiment as follows:
WARM UP
• Deep diaphragmatic breathing while standing
• Focused intercostal breathing while lying supine on reformer, all springs attached.
• Alternating spinal positions predicated on neutral spine and the clock face; 12, 6,
3 and 9 o'clock, to orient the client to proper positioning.
FOOTWORK(No resistance with carriage control by instructor and reduced repetitions)
• Parallel heels on reformer
• Parallel toes on reformer
• Pilates V-position on reformer
ABDOMINAL WORK
• Mini Roll-Up on Cadillac
• Mini Roll-Up Oblique on Cadillac
~iII,iiiL~)7:/

• Leg circles on reformer with no resistance using fuzzy straps and modified so as
to keep lumbar spine down and pelvic stability.
STRETCHES
Due to the potential for cording and other extremity issues, stretches should be
prescribed by and done under the strict supervision of a lymphedema therapist.
Possible non-inflammatory beneficial stretches may include one ofthe following:
• Shoulder Stretch (Pole Series)
• Side Stretch (Pole Series)
• Shoulder Stretch 1 on Ladder Barrel

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 • Adduction on reformer with no resistance.
• Aim Circles up and down on reformer with no resistance.
• Triceps on reformer with no resistance.
LEG WORK
• Parallel Position Jumping Series on Reformer (light resistance only and reduced
repetitions).
• V-Position Jumping Series on Reformer (light resistance only and reduced
repetitions).
• Leg Changes Jumping Series on Reformer (light resistance only and reduced
repetitions).
LATERAL FLEXION/ROTATION
• Spine Twist Supine on Step Barrel.
BACK EXTENSION
• Swan on floor on Wunda Chair, modified to eliminate pressing pedal down and
only slight trunk extension with minimal lift to alleviate any pressure on back,
shoulders and legs.
• Alternatively, if client cannot lie prone on floor, Prone 1 on Cadillac, modified to
eliminate too high of an extension so as to eliminate pressure on back, shoulders
and legs.

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Diagram 1.1

The lymph system

 BIBLIOGRAPHY

• B~°east Cancer'-Related Lymphedema: Essential Knowledgefor Pefsonal

Trainers, Fitness Instf•uctors, Yoga Teacher's, Pilutes Teacher•s, www.stepup-
speakout.or~, Apri12013;
• Br•enst Cancer•-Relented Lymphedema and Exercise: What You Shozrlc~ Knotii~
for• a S»zar•t, Safe Wor~koart, w~vw.stenun-sneakout.org, 2013;
• Understanding Lymphedema For• Cancers Other° than Breast Cancer,
American Cancer Society, Apri15, 2013, available at www.cancer.org;
• Position Paper: Exercise, Lymphnet October 2013,
www.lymphnet.orb/resources/position-Uaper-exercise;

• Exercisesfor• Lymphedema zn the Legs, Kat Lieu, August 22,2010,

www.livestrong.com;
• Lymphedema: Exercise Guidelines, Sonja M. Maul,PT, CLT-LANA., St.
Lukes Idaho Ellcs Rehabiliation Services(SLIERS), March 2009;
• Pilates and Lymphedema, Melanie Byford-Young,November 2008, Pacific
NW Pilates Blog;
• Cance~~ Survivors: Pilates and czrr Improved Quality ofLife, Dr. Joseph Camp,
Winter 2008, Balanced Body Pilates COREterly;
• Pilatesfor• Breast Cancer:• Get Yozrr~ Life Back Toolbox, Pia°t II, Karena,
October 2009, Osteo Pilates Blog;
• Pilates and Life Style Coaching Benefit Breast Cancer Szrr•>>ivors, Lorri
Wilson-Clarke, Bay Pilates and Wellness, www.baypilates.com; and
• Lymphedema Managementfor' Breast Cancer, www.cancercenter.com,2014.
• Interview with Janice Campbell, May 2014, San Jose, CA.

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