Exercises for Lymphoedema
Judith R. Casley-Smith
Lymphoedema Association of Australia Inc.,
94 Cambridge Tce., Malvern S.A., 5061, Australia
Exercises are one part of coping with lymphoedema that should be a pleasure rather than a chore and make one feel much better after performing them. Similarly, self or carer massage should be enjoyable.
A number of people have shown the value of exercise in lymphoedema. Swedborg1 showed the efficacy of isometric exercises. Olszewski2 showed that massage and exercise increased the lymphatic pulse frequency by 6 to 10 times but that was not increased by external elastic compression. Leduc and his group3, 4, 5 found a considerable increase in protein removal with exercise, if the arms were bandaged with a "low stretch" bandage, which continued to increase after exercise ceased. They also showed that low-stretch bandaging produced much greater variations in pressure beneath them, and therefore in lymphatic functioning, during walking, than did high-stretch ones. This emphasises the importance of wearing compression garments or bandages whilst exercising.
We did an open trial of 618 lymphoedematous limbs6, where patients were treated by many different therapists that we had trained and we calculated results on all the data that therapists produced, provided they had treated the patient for 5 days or longer. We found a significant improvement in the reduction, particularly over the 12 month intermediate treatment period, of patients that returned for a second treatment and were compliant with the special exercises I had designed, as against those who did not perform them. In this trial, interestingly, patients who had done the exercises for at least 3 months prior to the treatment course, obtained significantly less reduction during it. This suggests that the exercises caused reductions which would otherwise have been made by complex lymphatic (or physical) therapy (C.L.T. or C.P.T.). We included both primary and secondary lymphoedema's and all grades of these.
Relative amounts of oedema compared with normal, in unilateral limbs, at the end of the First Course were not significantly different with or without these preliminary exercises: without Pre-Course Exercises 114.7% (SE 0.82%, n=394); with Pre-Course Exercises 111.1% (3.56%, n=14). At the start of the Course these oedemas relative to Normal were: without Pre-Course Exercises 137.1% (SE 1.56%, n=394); with Pre-Course Exercises 128.6% (6.54%, n=14). So, exercises before treatment did not improve the final result, but did reduce the amount of oedema by the time C.P.T. was started, which would have improved the patient's comfort while waiting.
At the end of the Second Course, patients doing exercises over the Intermediate Period had Difference / the Volume at the start of the Intermediate Period of -15.3% (SE 2.83%, n=24); those who did not only had -1.77% (SE 1.21%, n=51); very significant (P = 0.00011). Exercises over the Intermediate Period were most helpful, not only then, but for the Second Course.
The aims of exercise are:
During the exercises, a 'reservoir' in the adjacent normal truncal quadrants and the nodes into which they drain is cleared by both these and by self-massage. The Casley-Smith order of the exercises was designed to follow the same pattern as the order a therapist performing manual lymph drainage for lymphoedema would use, but of course, exercises are performed wearing compression. This will cause a greater variation in total tissue pressure, thereby increasing lymphatic drainage from the affected limb. For both lymphoedema of an upper or lower extremity, they therefore start with clearance of the supra and sub-clavicular areas, breathing exercises, both thoracic and pelvic, to enhance return from the lymphatic system to the venous system and clearance of the main drainage points (nodes) of the appropriate adjacent normal truncal quadrants, both with exercise and manually. The patient then, having emptied a space and created new pathways for lymphatic drainage and stimulated drainage across the watersheds to these from the affected area, can exercise the limb. The exercises always start by involving the most proximal part of the limb first, gradually working to involve the distal part and finally the whole limb. Nodal clearance and self-massage are performed frequently, but briefly, during the sequence, which takes from 30-45 minutes to perform. Those exercises that are possible to perform with the affected limb or limbs elevated are done in this position.
Patients need to be taught these exercises to obtain maximum benefit from them. The therapist must also be taught how to do them and teach them to achieve the best results. One of the most effective methods of teaching patients, is to take them through the sequence with the aid of the exercise book7, 8 on their first day of treatment, show them the video tape9 on the second day and let them do them at the same time to learn correct timing and then encourage them to do them on a daily basis both during and after treatment with the help of the music cassette.10, 11 After this, during the treatment course, they are better off doing them at the opposite end of the day to their appointment time. Exercises are not only more pleasant to do but also more effective if done at the right rhythm and tempo which will allow the filling and increase pumping of the lymphatics - for this reason it is important that any music used is of a suitable tempo and it is hard to provide this from commercially available music - whether it is classical or otherwise! To this end I made music cassettes with a voice over that has both a long side, for when the person with lymphoedema is learning the exercises and a short side for when they know them, and do not need the full explanation each time, to make these not only more fun to perform but to use the exercises to the best advantage.
Demonstration of the exercises by the therapist must always be done to the greatest extent of movement possible for the therapist. As a limb reduces and the patient can wear a compression garment as against the more bulky bandages, their range of movement will of course increase. Care must be taken with a heavy limb to support it and the exercises should therefore be tailored or altered to suit the individual patients capacity and needs. The patient also needs to be aware of how and when to exercise. If, for example, they have already done a lot of exercise during the day, some self-massage with the affected limb elevated and minimal, but pertinent exercise, may be indicated. Patients should be warned about over-doing the exercise; too much exercise can be as harmful as too little. The order of exercises is extremely important. It is better to do fewer repeats, but in the same order, than to just pick a few at random or speed them up! Carers, if performing massage, should also not be expected to continue on a daily basis for a long period. They should not feel guilty or obliged to do this. It should be enjoyable for both parties or it is contraindicated. They should also be taught suitable positions that the patient can be in so that they can do this without strain. A low bed is not a substitute for a massage table of the correct height for them. Some patients have improvised and put a mat on a kitchen table with success! Many patients and carers say this is a very positive thing to do together and that they enjoy it and become closer; some patients feel exactly the opposite and some dislike self-massage. These are again individual preferences which must be taken into account.
People with problems of movement, either for example, with very large legs, or lack of lymphatic return due to paralysis, should firstly be helped to elevate their limbs and do what exercises and self-massage they can, rather than keep them in dependent position in the former case. In the latter case, exercise aids or assisted movement by a therapist can be of great help. There are also machines, that can assist, such as a 'bicycle' where the feet can be strapped to the pedals with the patient lying supine.
With these special exercises, patients have found that they have obtained reduction from carefully using the instruction book alone and exercising daily. They are not, however, a complete treatment for lymphoedema. A good therapist will achieve a 60% reduction or greater, in most cases, over a three week treatment course, whereas exercises plus compression will give about an 18% reduction over several months.
Hydrotherapy is an excellent form of exercise and can be used either as an adjunct or in place of 'land' exercise. The pressure gradient that the water creates will aid with clearance of lymph. If desired, although it is not necessary, a garment can be worn during this, but should be washed down well afterwards to prevent damage from salt or chlorine. They again follow similar order and principles, but may be as simple as walking in the water (with arms swinging vertically in a downwards direction or simple swimming e.g. breaststroke.
Relaxation plays an important part in the above, but is also of great necessity in between movements, as well as before and after exercising, to allow the greatest lymph flow possible or to prevent its onset. It is now well recognised that 'tense shoulders' due for example, to a psychological trauma such as the death of someone close or some other closely related anxiety or misfortune can trigger the onset. In a questionnaire I sent as part of the 1992 newsletter which asked for events that triggered onset of lymphoedema, I asked about trauma. I had been thinking of physical trauma e.g. a bite, fall etc. A surprising number of patients answered this by saying onset was triggered by death of a close relative or a divorce i.e. a psychological trauma. This is now widely recognised as a risk factor in the precipitation of lymphoedema in a limb (particularly in an arm) 'at risk'.
This is why I teach relaxation both at the beginning and end of the session. I also use breathing exercises to help the pumping of the deep collecting lymphatics by increasing either intra-thoracic or pelvic pressure which is otherwise difficult to achieve. One of these, which is a deep breath out and forward 'drop-over' from the outmost curvature of the thoracic spine, (6-9th vertebrae) then slowly breathing in and straightening the spine. If performed correctly this makes one feel as if they are floating on air. (It is a similar feeling to pressing the backs of the wrists hard against a door frame, and then walking forwards and experiencing one's arms float sideways into the air.) However this must be taught or someone must help the patient to feel this, by 'walking slowly up' the spine with their fingers as they breathe in until an upright position is reached with the chin at no more than a 90 degree angle to the front of the neck. Then a single strand of hair is taken gently lifted and extended vertically to give them a feeling of being suspended and growing taller. The patient stays relaxed but fully upright. (The pelvis and lower body must be stabilised for this to work.)
If people, who previously played and enjoyed sporting activities, wish to return to these, they should be encouraged to do so, but also educated as to what signs to look out for which give an indication of overdoing their activity. This may, for example, with a tennis player or golfer be aching at the back of the shoulder with lymphoedema of the arm, or aching legs if one or both of those are affected. The resumption of a previous sport is better than taking up a new one, as the muscles have already been trained for this particular use and there is less risk of damage and worsening of the lymphoedema. High impact sports are contraindicated; walking is better than jogging! Water aerobics are definitely preferable to those on land! A number of people who have the opportunity, have found that scuba diving is of considerable benefit and some have reported that although they do not wear a compression garment, the reduction that occurs during the dive can last up to three days. Sports where the risk of falling or knocking an affected limb are also a risk. Some people wish to continue weight lifting. Linda Miller, who has worked in this field with lymphoedema patients suggests that they should start at 1.5 kgs (3lbs) and work up to no more than 3 kgs (6lbs).
When pressure is lowered such as in aircraft flights and the patient does not move about both in these or in long car or bus travel, then periodic exercise is extremely important to prevent further swelling.
There is a particular problem with children and the fact that they may not be able to join all their normal school sports activities. This may alienate them from their peers and can cause psychological problems for them, as can the fact that they need to wear a compression garment. This can be overcome, to some extent at least, by educating the parents about the condition, who can, in turn, talk to their child's teacher and classmates so that they understand the problem and can help devise a solution e.g. keeping the score during a game rather than playing. Finding some sort of responsible position during activity in which the child can safely participate, will help greatly with their self-esteem. Sometimes children have to learn the hard way and their lymphoedema may become much worse and they may suffer frequent bouts or serious episodes of infection before they (and sometimes their parents!) will take the necessary steps.
The aim of exercise both for the therapist and the patient is to reduce lymphoedema, or prevent its onset, and to encourage and enable the patient to lead a normal life, without taking undue risks and yet still being able to enjoy their physical activities fully.