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Exercise for limb lymphoedema_ evidence that it is beneficial

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					                                                                                                                             Clinical REVIEW




Exercise for limb lymphoedema:
evidence that it is beneficial
                                                           Amanda L Moseley, Neil B Piller

Exercise has been shown to improve lymphatic propulsion, clearance and venous drainage from the
limbs. However, awareness of the positive benefits of different exercise regimens for those with
lymphoedema of the limb has been slow to emerge. Despite this, studies have demonstrated that
various exercise regimens can have a positive impact on limb size, subjective limb symptoms and quality
of life. This article will explore via a literature search, the evidence supporting the benefits of exercise
for those with limb lymphoedema and propose how exercise may be incorporated into the patient’s
self-management programme.
                                                         Exercise and the lymphatic system             increased lymph clearance rate five-fold
  Key words                                              There is a good body of evidence              in the first 15 minutes, while the rest
                                                         which shows that exercise varies              of the time it was increased 2–3-fold.
  Lymphoedema                                            interstitial tissue pressure and              These findings are also confirmed by
  Exercise                                               influences both lymph propulsion and          a study by Lane et al (2005), which
  Limb size                                              clearance, helping to transport fluid         demonstrated increased lymphatic
  Impact on symptoms                                     and inflammatory causing proteins             clearance in the hands of healthy
                                                         (Havas et al, 1997; Olszewski and             women who performed arm crank
                                                         Engeset, 1998) from the site of               ergonometry for five minutes.
                                                         formation and from the swollen limb
                                                         or affected area. These effects were              The effect of exercise on the
Following the debate in the first issue                  first studied in animals, with an increase    venous system is also of importance,
of the Journal of Lymphoedema on the                     in lymphatic contraction frequency            especially in those with lower-
impact of exercise and deep breathing                    and lymph flow being shown to occur           limb swelling. The activation of the
on lymphoedema (Piller et al, 2006),                     in animals that exercised for both            calf muscle pump via exercise has
it is timely to revisit the literature                   short and long durations (McGeown             been shown to improve lower limb
on these topics so that healthcare                       et al, 1987; Coates et al, 1993). The         venous drainage in both healthy
professionals may be better equipped                     increase in lymphatic contraction and         volunteers (Stick et al, 1993; Kugler
to give the best advice to their patients.               lymph flow that follows muscle activity       et al, 2001) and those with chronic
Having a broad understanding of the                      can be explained by experiments               venous insufficiency (CVI) (Padberg
effect of exercise on the swollen limb                   undertaken by Mazzoni et al (1990)            et al, 2004). Specifically, the oedema
will help clinicians to give appropriate                 on the spino-trapezius muscle of rats.        reduction in CVI is achieved through
advice to patients regarding the type,                   This research demonstrated that the           the increase of venous ejection
level and intensity of exercise that                     stretched skeletal muscles pulled on          fraction and the subsequent decrease
can be incorporated into the patient’s                   the anchoring filaments joined to the         in residual venous fraction (Yang et al,
self-management regimen. The role                        initial lymphatics, helping fluid to move     1999), which is brought about by the
of exercise (which generally can be                      into the vessel. When the muscle was          calf muscle contracting and relaxing.
undertaken frequently by the patient                     then contracted, the increase in the          Lastly, the effects of deep breathing
at minimal cost and without taking                       muscle fibre cross-section compressed         (which can be incorporated into
much time off work) must also be                         the connective tissue and therefore           exercise regimens) on the lymphatic
considered when more expensive and                       the lymphatics, resulting in lymph being      and venous systems should not be
labour intensive treatments cannot be                    pushed towards the lymph collectors.          overlooked. Studies have shown that
accessed or are not affordable.                                                                        the changes in intrathoracic pressure
                                                             The positive effects of exercise          produced by deep breathing can
Amanda L Moseley is Clinical Research Officer and Neil    on lymphatic function have also been          increase lymphatic drainage through
B Piller is Team Leader, Lymphoedema Assessment Clinic   demonstrated in human studies, with           the thoracic lymphatic ducts (Shields,
and Department of Surgery, Flinders Medical Centre and   a study by Havas et al (2000) finding          1980) and positively influence venous
University, Bedford Park, Adelaide, Australia            that two hours of steady exercise             return (Sumner, 1995).

                                                                                             Journal of Lymphoedema, 2008, Vol 3, No 1       51
Clinical REVIEW

Does exercise precipitate or worsen            A variety of exercise regimens have   two studies (McKenzie and Kalda, 2003;
limb swelling?                             been shown to be beneficial for people     Johansson et al, 2004) investigated this
Although the effects of exercise           with secondary arm lymphoedema,           combination. Both studies involved
have long been known, the stand-           both in terms of arm volume reduction     resistive weight exercises while wearing
alone benefits of exercise for the         and reported subjective improvement.      a compression garment, with both
lymphoedematous limb have been slow        This includes arm exercise combined       demonstrating a reduction in arm
to emerge. This may be traditionally       with deep breathing (Moseley et al,       volume of 15ml (at 24 hours) and 2%
related to clinicians and researchers      2005), resistive arm exercise with        respectively. Interestingly, Johansson et
being hesitant to recommend                weights (McKenzie and Kalda, 2003;        al (2004) also investigated the same
strenuous exercise in the fear that        Johansson et al, 2004), a 30-minute       resistive weight exercises without
the increased blood flow to the limb       limb exercise programme (Buckley          using a compression garment, which
muscles would exacerbate the swelling      et al, 2004) and hydrotherapy (Box        also produced the same reduction (of
rather than help it. However, research     et al, 2004; Johansson et al, 2004).      15ml) at 24 hours. However, in this
has demonstrated that strenuous            Three of the studies that included        session patients did report a significant
exercise can be undertaken by those        control groups (McKenzie and Kalda,       (p<0.001) increase in physical exertion
at risk of developing lymphoedema          2003; Box et al 2004; Moseley et al,      (which was not significant when
and those who already have the                                                       undertaking the exercises while wearing
condition without adverse effects.                                                   the compression garment).
Two studies have shown that women          However, research has
who have undergone breast cancer           demonstrated that                              Only two studies (Moseley et al,
treatment can participate in vigorous      strenuous exercise can                    2003; Buckley et al, 2004) were found
exercise — in this case boat racing        be undertaken by those                    that fitted the search criteria and which
(rowing) and upper body exercise           at risk of developing                     investigated the effect of exercise on
— without exacerbating their               lymphoedema and those                     secondary leg lymphoedema. These
lymphoedema, in those who have             who already have the                      studies demonstrated that both
the condition, or increase the risk        condition without adverse                 mechanical limb elevation plus passive
of developing it (Harris and Niesen-       effects.                                  exercise (Moseley et al, 2003) and 30
Vertommen, 2000; Lane et al, 2005).                                                  minutes of limb exercise (Buckley et al,
The ability to undertake more active                                                 2004) can produce a reduction in limb
exercise has also been demonstrated        2005) demonstrated either a minimal       volume and subjective improvements
in other studies, including women          decrease in limb volume or an actual      in symptoms. In the study by Moseley
with secondary arm lymphoedema             increase when compared with the           et al (2003), the limb volume reduction
undertaking resistive arm exercise         exercise group. The hydrotherapy study    was quite significant (330ml; p=0.001),
with hand weights (McKenzie and            undertaken by Johansson et al (2004)      while in Buckley et al’s (2004) study it
Kalda, 2003; Johansson et al, 2004), a     provides important information on the     was smaller (55ml; p=n.s.). Both studies
dance programme (Sandel et al, 2005)       optimal pool temperature to undertake     also demonstrated a volume reduction
and a moderately intensive exercise        exercise, with a temperature of 28ºC      at follow-up, including at 20 minutes
programme which included aerobic and       producing an arm volume reduction but     post session (31ml; n=n.s.) (Buckley et
resistive exercise (Turner et al, 2004).   a temperature of 34ºC resulting in a      al, 2004) and one month after the trial
                                           slight increase in volume.                ended (220ml; p=0.032) (Moseley et al,
The effect of exercise on the                                                        2003). Neither study included a control
lymphoedematous limb                            It is also worth noting that two     group so it is difficult to assess what
To explore the benefits of exercise        studies (Buckley et al, 2004; Johansson   would have occurred if no treatment
for secondary limb lymphoedema, a          et al, 2004) demonstrated an average      was implemented.
search of the literature was undertaken.   initial increase in arm volume (12ml in
This search focused upon exercise          both studies; p=n.s.), which presumably       The presented data indicates
studies undertaken in the randomised       is related to an increased arterial flow   how a variety of exercise regimens,
controlled or cohort format and            to the arm muscles. More importantly,     from aqua-therapy, resistive exercise,
involving secondary limb lymphoedema       it was demonstrated that this was         physical therapy, machine-based and
populations (with no active cancer).       only a transient increase in volume,      Tai Chi can have a positive impact
Online databases were searched             with an overall volume decrease being     upon limb volume in people with limb
(limited to English) with the primary      demonstrated after 20 minutes (24ml;      lymphoedema. Moseley et al (2005)
outcomes being a change in limb            p=n.s.) (Buckley et al, 2004) and 24      also demonstrated (through the use
volume (measured via tape measure,         hours (15ml; p=n.s.) after exercise       of multi-frequency bio-impedance
perometry or water displacement            (Johansson et al, 2004). Although         measurement) that there is a reduction
methods) and subjective symptoms. The      limb exercise is often undertaken by      in trunk fluid directly after performing
exercise regimes and their outcomes        patients with lymphoedema while           arm exercises combined with deep
are summarised in Tables 1 and 2.          wearing a compression garment, only       breathing. Follow-up measurements

 52     Journal of Lymphoedema, 2008, Vol 3, No 1
                                                                                                                         Clinical REVIEW


Table 1

Summary of the evidence of the effect of different exercise regimens on arm lymphoedema

Regimen                                                 n       Volume change                              Subjective changes
Moseley et al (2005)
Five cycles of 5 arm exercises involving muscle         38      After 10 minutes: 52ml (5.8%) reduction    Reduced heaviness and
contraction and relaxation and deep breathing                   (p=0.004)                                  tightness (p<0.05)
(10 minutes total)                                              1-week follow-up: 33ml (3.3%)              Reduced heaviness and limb
                                                                reduction (p=0.03)                         size (p<0.05)
Exercise group: arm exercise involving muscle           24      After 1 month: 101ml (9%) reduction        Reduced heaviness and limb
contraction and relaxation and deep breathing for               (p=n.s.)                                   size (p<0.05)
10 minutes morning and evening for one month
Control group: no active treatment. Measurements        28      Control group: 7ml (0.7%) reduction        No change
taken at the beginning and end of one month                     (p=n.s.)
Box et al (2004)
Exercise group: 45 minutes hydrotherapy; 15             8       After four weeks: 48ml (4.8%) reduction    Reduced aching, heaviness,
minutes of slow rhythmical exercise; 20 minutes of                                                         tightness (p=n.s.)
whole body exercise; 10 minutes of warm-down                    Six-week follow-up: 86ml (8.6%)            Reduced swelling, stiffness
exercise three times a week for four weeks                      reduction (p=n.s.)                         and heat (p< 0.05)
Control group: no exercise intervention                 8       After four weeks: 1.2ml (0.1%) increase    Reduced aching, heaviness,
                                                                Six-week follow-up: 32ml (3.2%) increase   and tightness (p=n.s.)
                                                                (p=n.s.)
Johansson et al (2004)
40 minutes hydrotherapy: 15 minutes of swimming         7       After first session: 32ml (12%) decrease   No change
followed by arm exercises with hand weights and a               (p=0.06)
cooling-down period. Undertaken in two different                After second session: 2ml (0.7%)           No change
pool temperatures — session 1: 28ºC (82ºF);                     increase (p=n.s.)
session 2: 34ºC (93ºF). No control group
Johansson et al (2004)
First session: resistive arm exercise with 0.5kg hand   23      After first session12ml (0.5%) increase    No change
weight, plus wearing a compression garment                      (p<0.05)
                                                                24-hour follow-up 15ml (0.7%) decrease
                                                                (p=n.s.)
Second session: resistive arm exercise with 0.5kg               After second session: 10ml (0.3%)          Increase in physical exertion
hand weight, minus wearing a compression garment                increase (p< 0.05)                         (p<0.001)
                                                                24-hour follow-up: 15ml decrease
                                                                (1.0%) (p=n.s.)
Buckley et al (2004)
Five minutes of instructed deep breathing plus self-        7   After first session 12ml (0.4%) increase   Reduced heaviness,
massage followed by 30 minutes of isotonic and                  (p=n.s.)                                   movement limitation, skin
isometic limb exercises. No control group                       After 20 minutes: 24ml (0.8%) decrease     dryness, tightness (p=n.s. )
                                                                (p=n.s.)
McKenzie and Kalda, 2003
Exercise group: resistive arm exercise plus wearing         7   After eight weeks: 2% decrease (p=n.s.)    Improvement in general
a compression garment, 3 x week for eight weeks                                                            health, physical functioning,
                                                                                                           vitality (p<0.05)
Control group: wore compression garment only                    Control group: 3% increase (p=n.s.)        Control: reduced general
                                                                                                           health, physical functioning,
                                                                                                           vitality (p=n.s.)

                                                                                     Journal of Lymphoedema, 2008, Vol 3, No 1             53
Clinical REVIEW


 Table 2

 Summary of the evidence of the effect of different exercise regimens on leg lymphoedema

  Regimen                                                n       Volume change                            Subjective changes
  Moseley et al (2004)
  Machine delivered leg elevation and passive            33      After three weeks: 330ml (33%)           Reduced heaviness, limb
  exercise to the limbs, 5–12 minutes, morning and               decrease (p=0.001)                       size, skin dryness, tightness
  evening for three weeks (no control group)                     One-month follow-up 220ml (22%)          (p<0.05)
                                                                 decrease (p=0.032)
  Buckley et al (2004)
  Five minutes of instructed deep breathing plus self-       7   After session: 55ml (5.8%) decrease      Reduced heaviness,
  massage followed by 30 minutes of isotonic and                 (p=n.s.) After 20 minutes: 31ml (3.0%)   movement limitation, skin
  isometic limb exercises (no control group)                     decrease (p=n.s.)                        dryness, tightness (p=n.s.)



also show that there are often                   (Brennan and Miller, 1998; Kahn                 undertake strenuous exercise without
sustained reductions in limb volume,             et al, 2003) and facilitate weight              adverse effects.
from 20 minutes (Buckley et al, 2004)            maintenance. Weight management is
to four and six weeks (Box et al, 2004;          particularly important for those at                 Obviously, when it comes to
Moseley et al, 2003) post exercise               risk of, or who have limb swelling, as          exercise, common sense on behalf
regimen. Subjective symptoms also                previous research has demonstrated              of the clinician and the patient must
indicate that there are improvements             that obesity can contribute to both             be employed, and certainly going out
in how the limb feels, looks and moves           lymphoedema development (Johansson              and suddenly running a marathon
and in quality of life and general health        et al, 2002) and the incidence of               or lifting extraordinarily heavy
parameters after performing exercise.            cellulitis (Herbertz, 1998).                    weights would not be recommended.
It must be acknowledged that quite a                                                             Undertaking strenuous exercise
few of these studies had small sample            Conclusion                                      must be appropriately worked up
sizes (which may have also affected              It must be acknowledged that a few              to, with the inclusion of a warm-up
statistical significance) and did not             of the exercise regimens presented              programme before exercise and
include control groups, although                 in Table 1 only rendered a small limb           especially a warming-down programme
the control data from two studies                volume reduction, which were at times           after exercise to help the lymphatic
(McKenzie and Kalda, 2003; Box et al,            not statistically significant. However,         system to clear the excess fluid and
2004) does indicate that arm volume              it can be concluded that exercise is            metabolites which have leaked into
will increase if no form of treatment is         of some benefit to those with this              the interstitial space. The studies by
undertaken. This has also been found in          condition as it is likely to result in          Box et al (2004) and Johansson et al
data collected by Casley-Smith (1997)            sustained limb volume reductions,               (2004) indicate that the incorporation
who demonstrated that lymphoedema,               changes in truncal fluid, subjective limb       of a 10–15-minute warming-down
when left untreated, will increase in            improvements and make a positive                programme at the end of active
amount and progress from lower to                impact on quality of life and general           exercise may be adequate to render
higher grades of classification.                  health. A few of the studies also               an overall limb reduction. Cooling
                                                 provide some important information              the limb in cold water for 20 minutes
Other benefits of exercise                        when advising lymphoedema patients              immediately after exercise may also
The other positive benefits that can             on exercise, including that the                 be of benefit, with research suggesting
be derived from regular exercise                 optimal temperature to undertake                that this prevents oedema formation
should also not be ignored. In                   hydrotherapy is 28ºC (Johansson et              in the skeletal muscles (Yanagisawa
general, exercise can improve well               al, 2004) and that an arm volume                et al, 2004). The incorporation of
being (Penedo and Dahn, 2005),                   reduction may be anticipated when               adequate rest periods in between
cardiovascular fitness (Markes et                resistive exercise is undertaken with           exercise sessions and close monitoring
al, 2006) and contribute to stress               or without wearing a compression                of the limb’s response (using objective
management (Taylor-Piliae et al, 2006).          garment (McKenzie and Kalda, 2003;              measurements) should also form
More importantly for those with limb             Johansson et al, 2004). Current                 part of the overall management of
swelling, exercise can improve limb              research also indicates that those at           those with limb lymphoedema who
flexibility plus range of movement               risk of, or with lymphoedema, can               undertake regular exercise. JL

 54    Journal of Lymphoedema, 2008, Vol 3, No 1
Clinical REVIEW

                                                mobility and anthropometric factors. J Vasc
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 56     Journal of Lymphoedema, 2008, Vol 3, No 1

				
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Description: Lying down, arms and legs slightly apart, palms turned to the ceiling, eyes closed, breathe deeply three times, concentrate on each breath completely empty flat body. Then from the toes to the head, tighten and then relax the muscles a little bit, carefully to feel every step. For the shoulder and head muscles, use the rotation instead of tightened. This is a developing body flexibility and effective practice, with a strong relaxation of, but also to ease the tension.