March is Lymphoedema Awareness Month! A brief update on Lymphoedema that may be encountered in exercise clients by Denise Flett, CanRehab Tutor and Lymphoedema Therapist.
Lymphoedema is a manifestation of lymphatic system insufficiency and/or a damaged lymph system. Lymphatic system insufficiently may be congenital (an abnormality we are born with) because of an underdeveloped lymph system that can lead to PRIMARY lymphoedema.
PRIMARY Lymphoedema typically presents as bilateral lower limb lymphoedema in adulthood. Although quite rare (about 1 in 6000 people) (https://www.nhs.uk/conditions/lymphoedema/) you may encounter exercise clients with primary lower limb lymphoedema who have never had the invasive treatments or injuries that can result in the development of SECONDARY lymphoedema.
SECONDARY Lymphoedema is the result of damage to the lymphatic system due to disease, treatments, infection, injury, inflammation, or a lack of limb movement. A predominate secondary lymphoedema is cancer related lymphoedema.
Cancer-related lymphoedema may be related to the cancer itself due to infiltration and growth in the lymphatic system, or pressure on surrounding tissues and lymphatics. This can cause reduced transport capacity and disruption to the fragile lymphatic vessels. The cancers most likely to cause lymphoedema are breast, gynaecological, melanoma, sarcoma, prostate, penile, bladder and head & neck cancers (https://www.thebls.com/public/uploads/documents/document-99191580331254.pdf)
Cancer treatments can separately and collectively cause Secondary lymphoedema. The three big factors are Surgery, Radiotherapy and Obesity:
Surgery – with the goal of removing the solid tumour surgery can cause damage to the lymphatic pathway, the most damaging surgery being the direct removal of lymph nodes (and the relative number of these removed). Post-surgical complications such as infections, prolonged seromas and other healing issues can add to lymphoedema risk.
Radiotherapy – can damage the delicate lymph capillaries in the lymph transport system. Radiation can cause scarring and fibrosis resulting in a loss of elasticity of tissues, this can affect movement of tissues (often long-term) in the treated area and a reduction of localised mobility. External beam radiotherapy is the most common cause of breast and truncal swelling.
Obesity – causes increased capillary filtration resulting in greater lymphatic load for drainage, thus putting increased pressure on a lymphatic system that has a damaged transport network.
Management in brief:
Diagnosis and management by a specialist in lymphoedema is critical, especially as indicated above, cancer growth and spread can be a cause for new or worsening lymphoedema.
The key management strategies involve: Skin care, exercise, compression and specialised massage techniques. Weight management is also an important consideration as is Psycho-Social Support as lymphoedema is most often a chronic and incurable condition.
Skin care is based around cleansing and moisturising and it is important to ‘check in’ that someone with lymphoedema is well educated on this and also that they have no signs of skin infection (red, hot skin, elevated temp). This is to prevent the development of recurrent infections which will further increase lymphatic load and worsen lymphoedema, as well as to reduce the risk of someone becoming systemically unwell.
Exercise: Basic range of motion exercises of the involved extremity is a good starting point. ‘Muscle-pump’ exercises especially combined with wearing a compression garment ideally undertaken as daily activities (walking, cycling, yoga,) are useful.
Studies indicate that more vigorous exercise can be undertaken, and strong evidence exists on the safety of resistance exercise for Breast Cancer related lymphoedema (Schmitz et al, 2009). The recommendation for slow progress of intensity (repetitions, and increased weights) the requirement for frequent rests and a good warm up, and cool down cannot be over emphasized when trying to work within the limitations of someone’s damaged lymph transport system and the possibility for overloading this.
If a client has a prescribed well fitting compression garment exercise should be undertaken whilst wearing this. Compression garments are designed to move swelling in the optimal direction with pressure levels and fabrics that will reduce the capillary filtration into the skin that can be increased when physically active and cause swelling.
The British Lymphology Society is promoting a ‘get moving’ campaign called #EveryBodyCan to raise awareness of the importance of being physically active in the management and prevention of lymphoedema. They have great professional resources (fliers/posters) that may be very useful for exercise clients available at: https://www.thebls.com/pages/health-care-practitioner-resources.
Also the Lymphoedema Support Network in the UK is a peer-based network that provides education and support as well as advocacy for those living with lymphoedema. Further information can be found at: https://www.lymphoedema.org/
Schmitz, K. H., Ahemd, R., Troxel, A., Chevill, A., Smith, R., Lewis-Grant, L., Bryan, C,. Williams-Smith, C. and Greene, Q. (2009) Weight lifting in women with breast cancer related lymphedema. New England Journal of Medicine, 361(7), pp. 664-73