Managing Lymphedema Through Movement

Per the National Lymphedema Network, “lymphedema is an abnormal collection of lymphatic fluids in the tissues just beneath the skin.” Secondary cancer-related lymphedema (CRL) occurs in the presence of lymphatic system damage or trauma.¹ Breast cancer–related lymphedema (BCRL), a secondary CRL, will be referenced throughout as it has the most evidence-based research, which has guided current clinical guidelines. BCRL occurrence may be as high as 90%, with an estimated 20% in those who are at higher risk.^2-4 Axillary lymph node dissection (ALND), regional node irradiation, taxane-based chemotherapy, body mass index >30, and rurality are considered high-risk factors. Other risk factors include inguinal or pelvic lymph node dissection radiation, advanced cancer, comorbidities, and genetic predisposition.^2-4

Based on severity, CRL may interfere with range of motion, muscular strength, and activities of daily living in the impacted extremity, which worsens overall quality of life. Preventive measures may include reducing the risk for infection and cellulitis, use of gloves for cleaning and gardening, and participation in an exercise program. Early signs and symptoms include a “full” or “heavy” feeling, intermittent edema, or clothes or jewelry feeling more constrictive in the affected limb.^1,3

Overview of the Lymphatic System

The lymphatic system is vital for fluid balance, immunity, digestive absorption, and removal of cellular waste. It is imperative to appreciate the flow of the lymphatic system. It differs from the vascular system in that it lacks a “central pump”; therefore, it relies on other aspects to aid in flow.

Blood capillaries initiate a filtration process to the tissues so that tissue and organs receive the nutrients they need to function. The fluid left over from this filtration process becomes interstitial fluid that is drained into the lymphatic system capillaries. This fluid, known as lymph, then goes into the collecting lymphatic vessels. These vessels are lined with a layer of smooth muscle and have cells that form valves. Lymph is shipped around the body, into and through lymph nodes to ultimately end up in 1 of the 2 lymphatic ducts—the right lymphatic duct or the thoracic duct. Movement of lymph occurs by the contraction of the smooth muscle cells within the vessel walls, skeletal muscle contraction outside of the vessels, and respiratory movement.^5,6

When there is insult (ie, surgery or radiation) to the lymphatic system, there is interference with the normal lymph flow. The lymph vessels, nodes, or valves are damaged and can no longer propel fluid in the intended direction.

When there is insult (ie, surgery or radiation) to the lymphatic system, there is interference with the normal lymph flow. The lymph vessels, nodes, or valves are damaged and can no longer propel fluid in the intended direction. Secondary to the law of gravity, the fluid will ultimately follow the gravitational pull down instead of back up toward the lymphatic ducts. This results in lymphedema.^5,7

Exercise and Lymphedema

Previously, patients at risk for or with BCRL were encouraged to not have the affected extremity lift anything heavier than a couple of pounds for the rest of their lifetime. The infamous Physical Activity and Lymphedema trial completed in 2009 assessed the safety of a supervised 12-month exercise program consisting of strength exercises to the affected extremity in breast cancer patients.^7,8 Interestingly, 11% versus 17% (exercise vs control arm, respectively) experienced BCRL flare-ups. Furthermore, in those considered high-risk with 5 or more lymph nodes removed, 7% versus 22% experienced BCRL.^7,8 This study was pivotal in changing exercise recommendations for those at risk for or with BCRL. The safety and efficacy of exercise regarding BCRL continue to be strongly supported by further evidence-based research with emphasis on limb assessment, appropriate full range of motion prior to adding weight, and slow weight progression.^8,9 The lymphatic system relies on contraction of muscular cells (both inside and outside of the vessels) to aid in lymph movement, thus making exercise a reasonable intervention to help decrease risk for and treat CRL. Current recommendations encourage progressive, supervised resistance programming 2 to 3 times a week for major muscle groups.⁹

Yoga and Lymphedema

Outside of muscle contraction, flow of lymph is also assisted by respiratory movement. Respiratory movement is understood to assist in lymph flow because the thoracic duct, which drains 75% of the body’s lymph, crosses over the diaphragm.10 Because of the movement and breathwork combination, the potential benefits of yoga therapy, specifically lymphatic flow yoga, cannot be ignored. Although more studies need to be completed with larger sample sizes and broader cancer diagnoses to validate findings, early research does show that yoga is not only safe but also beneficial in those with BCRL.^11,12

Barbara Jackson Tobin, a certified yoga teacher, occupational therapist, and Lymphology Association of North America–certified lymphedema therapist specializing in cancer rehab, the lymphatic system, and upper extremity orthopedics, shared this insight:

Teaching lymphatic flow yoga to my mom (breast cancer survivor who has lymphedema), my patients, and my online community has been extremely rewarding. The 4 components of this type of yoga are focused on improving lymph flow through breathing techniques, guided self-manual lymph drainage, muscle pump activation (yoga poses), and mindfulness exercises. I have watched my mom positively transform and manage her lymphedema both mentally and physically. One of my favorite comments from one of my patients is that engaging in lymphatic flow yoga helped her to better understand her body, therefore leading her to be curious about the way she can improve her lymph flow, and in turn created a powerful mind–body connection that ultimately propelled her healing. When dealing with a chronic condition like lymphedema, it is so important to truly understand the lymph pathways and dedicate yourself to lymphatic health practices like lymphatic flow yoga.

To learn more about lymphatic flow yoga, the Lymphatic Education and Research Network (LE&RN) offers an informative video.

Use of Compression Garments With Movement

Use of a compression garment (CG) is standard of care for those with CRL, and the current recommendation is to wear a CG during exercise.¹³ There are times when a CG is contraindicated, such as when acute cellulitis, arterial insufficiency, and severe diabetic neuropathy are present. It is important to provide individualized answers and education regarding use of a CG during exercise.¹⁴ Here is an example that Tobin uses in her practice:

When wearing a daytime CG, the purpose of the CG is to provide resistance on your skin as you move. When you are activating your muscle pumps (ie, bicep curl) while wearing a CG, you are not only activating the lymph system through movement but also the resistance of the garment to help create the skin-stretching effect that causes an intrinsic contraction within the vessels to further improve lymph movement.

A recent study assessed the effectiveness of a CG in decreasing the risk of developing lymphedema in high-risk breast cancer patients who underwent ALND.¹⁵ After 2 years of intervention, there was no difference in BCRL occurrence between the group that wore CGs in addition to conventional education and exercise programming compared with those who did not wear a CG. Interestingly, those who adhered to wearing the CG, specifically for the first 3 months, did have a significantly lower risk of developing BCRL compared with those who were noncompliant.¹⁵

More research needs to be conducted to further guide CG recommendations during exercise for those at risk for CRL. As each patient case is unique, it is best practice to have the patient consult with the physician and/or lymphedema specialist to ensure the proper steps are taken to reduce and/or treat lymphedema while completing activities of daily living and participating in an exercise program.

In adherence to the Oncology Navigation Standards of Professional Practice, the oncology navigator should understand current evidence-based guidelines and collaborate with multidisciplinary teams to provide quality patient care.

The Oncology Navigator’s Role

In adherence to the Oncology Navigation Standards of Professional Practice, the oncology navigator should understand current evidence-based guidelines and collaborate with multidisciplinary teams to provide quality patient care.¹⁶ Screening for CRL risk factors, facilitating education, and referring to a lymphedema specialist when indicated are imperative in the management of CRL. Exercise programming not only reduces the risk for and provides benefit to those with BCRL, it also addresses being overweight and obese (in combination with diet), which are risk factors for developing CRL. It is crucial that the oncology navigator encourage safe exercise programming that follows a “start low and progress slow” resistance training design and consult with a lymphedema specialist regarding CG use.^3,7,8

References

1. National Lymphedema Network. What is Lymphedema? Accessed March 20, 2024. lymphnet.org/
2. Koelmeyer LA, Gaitatzis K, Dietrich MS, et al. Risk factors for breast cancer–related lymphedema in patients undergoing 3  years of prospective surveillance with intervention. Cancer. 2022;128:3408-3415.
3. Chaput G, Ibrahim M, Towers A. Cancer-related lymphedema: clinical pearls for providers. Curr Oncol. 2020;27:336-340.
4. Winters-Stone K, Medysky M, Schwartz A. Immediate Posttreatment Period. In: Exercise Oncology Prescribing Physical Activity Before and After a Cancer Diagnosis. Springer; 2020:249-265.
5. National Cancer Institute. Components of the Lymphatic System. https://training.seer.cancer.gov/anatomy/lymphatic/components/
6. Moore JE, Bertram CD. Lymphatic system flows. Annu Rev Fluid Mech. 2018;50:459-482.
7. Schmitz KH, Troxel AB, Cheville A, et al. Physical Activity and Lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials. 2009;30:233-245.
8. Schwartz AL, Bea JW, Winters-Stone K. Long-Term and Late Effects of Cancer Treatments on Prescribing Physical Activity. In: Exercise Oncology Prescribing Physical Activity Before and After a Cancer Diagnosis. Springer; 2020:267-282.
9. Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51:2375-2390.
10. Lee GM, Stowell JT, Pope K, et al. Lymphatic pathways of the thorax: predictable patterns of spread. AJR Am J Roentgenol. 2021;216:649-658.
11. Wanchai A, Armer JM. The effects of yoga on breast-cancer-related lymphedema: a systematic review. Journal of Health Research. 2020;34:409-418.
12. Saraswathi V, Latha S, Niraimathi K, Vidhubala E. Managing lymphedema, increasing range of motion, and quality of life through yoga therapy among breast cancer survivors: a systematic review. Int J Yoga. 2021;14:3-17.
13. Leonard A. Cancer Exercise Specialist Handbook. 13th ed. Cancer Exercise Training Institute; 2021.
14. NLN Medical Advisory Committee. National Lymphedema Network. Position Statement of the National Lymphedema Network. Exercise. 2011. https://static1.squarespace.com/static/5b741fa71aef1d1e6500b325/t/621c4b9fd985833faafd4117/1646021535820/Exercise.pdf
15. Castells NMJ, Mirabal ER, Archs CJ, et al. Effectiveness of lymphedema prevention programs with compression garment after lymphatic node dissection in breast cancer: a randomized controlled clinical trial. Front Rehabil Sci. 2021;2:727256.
16. Franklin E, Burke S, Dean M, et al. Oncology Navigation Standards of Professional Practice. Journal of Oncology Navigation & Survivorship. 2022; 13(3):74-85.