By Julie Mangeot Buren, PT, and cindy Linton, COTA
What types of exercise can help control lymphedema and what types can exacerbate it. The benefits of exercise in the treatment of lymphedema and the need for one technique of exercise over another is most easily demonstrated through a discussion of a normal lymphatic and circulatory system including the effects of the Starling Hypothesis. The Basics The Starling Hypothesis describes how fluids are exchanged between the blood capillaries, the tissue space, and the venous system.1 Ultrafiltration, reabsorption, and tissue pressure are the mechanisms that affect the lymphatic and circulatory systems. Ultrafiltration occurs in the arterial system. This process allows the passing of fluids, proteins, and nutrients from the arteries into the tissue spaces to provide nutrition to the body. After these nutrients have completed their tasks, they, along with fluids and small proteins, are reabsorbed into the venous system to return to the heart. Approximately 10% of the fluid traveling through the body is returned to the heart via the lymphatic system.1 The fluid entering this system is largely composed of dead cells, fatty tissues, large proteins, and noxious materials that will be filtered through the system’s lymph nodes before entering the heart. The portion that is unable to pass into the venous system remains in the interstitial spaces. This fluid causes pressure on the tissues under the skin, which forces the flaps in the capillaries of the lymphatic system to open, allowing the excess fluid to enter and be transported out of the limb or trunk area. The lymph capillaries, which form an extensive plexus throughout the body, lie under the skin and are considered to be the start of the lymphatic system. The capillaries are made up of flat endothelial cells that overlap one another. The purpose of this overlapping is to allow absorption of fluids. Anchoring filaments attached to the capillaries assist in opening flaps when pressure from fluids increases. Some of these filaments are attached in part to the underlayer of skin, which partially explains how the light touch of massage benefits in moving fluids. The slight movement of the skin increases the amount of opening and closing of the flaps in the capillaries, allowing more fluid into the system. The fluid then enters the precollectors and is channeled to larger transport vessels. These vessels have many one-way passive valves that assure the direction of the fluid. Unlike the circulatory system, which has the heart to pump blood through it, the lymphatic system relies on intrinsic contractions of lymph angions. The contractions of lymph angions are influenced by autonomous regulation through the sympathetic nervous system. Pain, external pressure, or increased pressure of fluids stretching the lymph vessels can contribute to increasing the number of lymph angion contractions. In a healthy lymph vessel, the lymph angion can contract 6 to 10 times per minute at rest and 60 to 100 times per minute with exercise, thereby moving more fluid through the lymphatic system and out of the limb or trunk.2 To further understand the importance of exercise when treating lymphedema, one needs to understand an impaired lymphatic system. Lymphedema is the result of a lymphatic system that is not adequately returning fluid at the needed rate to keep the affected limb or limbs clear of excess fluid. Therefore, fluid builds and becomes stagnated. There are several causes for lymphedema. One etiology is hereditary, called primary lymphedema, where the system may have an insufficient amount of valves, therefore permitting fluid to remain in the limb. The lymph vessels may have developed too large for the valves to work properly or too small, hence restricting sufficient flow. Secondary lymphedema is due to a lymphatic system that is compromised because of trauma. The trauma can include surgery, especially that involving the removal of lymph nodes. The scars or burns from radiation may block the lymphatic flow as well. Certain diseases, like chronic venous insufficiency, can cause lymphedema because the lymphatic system has to work overtime to return excess fluid and therefore eventually fails. Successfully treating Lymphedema The successful treatment of lymphedema requires the use of a Manual Lymph Drainage Technique (MLDT) and compression with exercise. MLDT is a particular sequence of light massage that stimulates the lymphatic system and encourages fluid to enter the system. The light external pressure forces the angions to contract. Exercise can assist lymph flow when it is coupled with external compression. Because stagnated edema in the limb stretches the skin and separates it from the muscle, it is imperative that exercise be performed after applying compression bandages or a pressure garment to the affected area. The stretched skin along with the stagnated fluid prevent adequate resistance needed for the muscle pump action. The muscle contraction applies pressure against skin tissue, forcing fluid into the system and inducing lymph angion contractions. This compression is necessary to provide a constant pressure for a continuance of fluid drainage. The compression bandages provide the necessary resistance during light exercise to achieve the proper level of pressure. This maximizes the muscle pump action that forces fluid into and up through the lymphatic system, thereby decreasing the edema. It is important to stress that while mild exercise is vital in the treatment of lymphedema, aggressive exercise can significantly increase heart rate and the inner core temperature of the body. This can in turn increase the ultrafiltration process, hence causing a greater amount of fluid in the interstitial spaces. Aggressive exercise, especially if performed without the compression, may worsen edema. The Importance of Exercise In our clinic at Southern Indiana Rehab Hospital, New Albany, lymphedema patients are instructed to complete a very specific sequence of exercise, which follows the same flow for the MLDT. It begins at the venous angle, where the system empties the fluid into the heart and works backward through the system, stimulating and therefore opening specific clusters of lymph nodes. Similar to the MLDT, the order of the exercises is important in that they are designed to open up and drain one area in preparation for that area to handle more fluid. The MLDT stimulates and encourages lymph flow by lightly moving the skin that opens capillary flaps. The exercises stimulate and open capillary flaps to encourage the flow of fluid as well. The muscle contractions cause pressure against skin tissue that is firmly supported by the compression bandages, thereby forcing reabsorption of the fluids into the venous system and a stimulated lymphatic system. The increase in pressure and activity will be sufficient to increase the amount of contractions by the lymph angions. All of this drainage occurring in the affected limb or trunk with compression further assists in preventing back flow of the fluid once it has left the area. Other benefits of exercise for persons with lymphedema are more basic, ie, increases in range of motion and strength. Generally lymphedema patients cradle and protect the affected limb. Many may have significantly decreased or even stopped ambulating or using the affected limb. They have lost strength and muscle tone along with range of motion. Many report pain in the affected limb, possibly from the lack of motion, which further debilitates the patient. By performing these simple stretching exercises, the patient will gradually increase range of motion as well as muscle tone. This in turn will decrease pain and increase the use of the affected limb. As the patient uses the limb more, with a fuller range and increased strength, the force from the muscle and the stimulation from the movement will further assist in draining fluid. The patient’s self-esteem is greatly increased as the limb reduces in size and she becomes more mobile and independent with daily self-care and general activities inside and out of the home. Another very important role exercise plays in the treatment of lymphedema is the proper breathing techniques that should be performed during exercise. During the massage and the exercise, the patient is instructed in taking slow, deep breaths. This breathing technique is important because it forces the abdomen muscle to contract and put pressure on the cisterna chyli, a reservoir of fluid that drains from the abdomen. This pressure pushes fluid out of the cysterna chyli and up through the thoracic duct, clearing the duct to provide a clearer pathway for the lower extremities to drain. With each deep breath the thoracic duct acts somewhat like a vacuum, having almost a suction-like pull from the vessels in the lower extremities. This is extremely beneficial when the edema is in the lower extremity. Since the left upper extremity is also drained through the thoracic duct, it is apparent that the thoracic duct drains most of the body. Keeping the thoracic duct cleared and functioning at its maximum level will benefit the entire lymphatic system in keeping the body cleared of excess fluid. Precautions Although exercise is important in treating lymphedema, there also are precautions that should be noted. Many recreational activities, such as tennis, racketball, aerobics, and basketball, increase heart rate and body temperature, which can potentially increase edema. A person with lymphedema should do these kinds of activities in moderation, if at all. If patients choose to participate in these activities, they should wear their compression garments. They should also be instructed that prior to returning to this form of activity, they will need to gradually build their endurance. Good warm-up stretching prior to participation is imperative to avoid the risk of injury. Any injury to the affected limb will increase edema. It is important that they monitor the effects different activities have on their lymphedema. This information will enable them to make knowledgeable decisions where more aggressive activities are concerned. Lymphedema patients can enjoy the benefits of exercising in water. Pool therapy is wonderful for them as long as the water remains at or below body temperature. Walking is good, again keeping a slower pace so the person does not become overheated. The main goal is to work the muscles and the skin without overdoing it. Aerobic exercise can be adapted. If doing aerobic exercise, simply performing less movement in the affected limb by slowing down the leg work or less rapidly moving to the affected arm can be helpful. All in all, exercise is considered to be one of the key areas for successfully controlling lymphedema. Explain to your patients why some activities cause more swelling and how others decrease swelling. Generally, if they are provided with a good explanation of how the lymphatic system works, and have a good understanding of why edema occurs, they are empowered with the knowledge to take control of the lymphedema and remove the control that lymphedema has over them. Julie Mangeot Buren, PT, is the director of clinic services and Cindy Linton, COTA, is an outpatient occupational therapy assistant at Southern Indiana Rehab Hospital in New Albany. Linton has also successfully completed training in lymphedema treatment through the Lerner Lymphedema Services Academy, Boston. References 1. Mark B. Evaluation and Treatment of Lymphedema for the Upper and Lower Extremities. Presented at: Excel Rehabilitation Services; December 1998; Indianapolis. 2. Lerner R. Lerner Lymphedema Services Academy Certification Course. Presented at: Lerner Lymphedema Service Academy; January 2000; Fort Lauderdale, Fla. 3. Klose G. Lohmann Lymphedema Bandaging Handbook. Neuwied, Germany: Lohmann GMBH & Co; 1994:13.
