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Exercise and Lymphedema--Clearing Up the Misconceptions

Tuesday, August 21, 2012 · Posted in


Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2012 Focus On Melanoma Conference In this blog, she recaps the conference. You can view the conference in its entirety, including presentations here.

In 2010, Katie Schmitz, PhD, FACSM, associate professor of medicine at the Perelman School of Medicine, and a group of her colleagues published a study that changed how patients and doctors think about exercise and lymphedema in cancer patients.

Dr. Schmitz's Physical Activity and Lymphedema (PAL) study demonstrated that a slow, gradual, supervised program of weight lifting not only didn't make lymphedema worse in women who either had the condition or were at risk for it following treatment for breast cancer, it actually had measurable benefits.

These benefits were measured in terms of the ability of patients to function and their overall quality of life. For patients with lymphedema, the risk of flare-ups for patients on the exercise program was reduced by 50%, and for those patients at highest risk for developing lymphedema (those who had five or more nodes removed from their axilla), the expected incidence of lymphedema was 90% less than expected.

Until Dr. Schmitz's data was published, it was standard procedure to tell patients at risk of lymphedema to rest and avoid any kind of activity with the affected arm.

Dr. Schmitz doesn't mince her words. Exercise is important for everyone, including cancer patients. For cancer patients, to be safe and effective, it needs to be done in what she calls a "rehab" mode, meaning that it tailored to the individual needs and abilities and aimed at rebuilding or regaining lost conditioning.

Now, Dr. Schmitz is extending to her work to patients with other types of cancer and those at risk for lower extremity lymphedema, which often occurs in melanoma patients. Her LEG-UP Pilot study is recruiting patients to assess whether the same kind of exercise program is safe and effective for this group. Preliminary results demonstrate that this program works for lower extremity lymphedema as well, with participants experiencing increased strength, increased capacity to walk and no worsening of their condition.

Conditioning and deconditioning are the keys to treatment. When we have cancer and undergo treatment, it is normal to lose some level of strength and flexibility. The disease and its treatment, along with the emotional challenges that are part of the experience, can all lead to a body that is weaker, less able to respond to stress or resist infection and inflammation. The right kind of exercise rebuilds that strength, restores function and enhances overall health and the sense of well being.

Dr. Schmitz's advice to cancer patients, including those who are at risk for or have lymphedema: Find a supervised exercise program that works for you. Go slowly and gradually. Be evaluated on a regular basis by a physical therapist who is knowledgeable about cancer, and keep moving.

If you are concerned about lymphedema following cancer treatment, watch our new video,
"Cancer-related Lymphedema: What You Need to Know.” This video guide features experts from the Abramson Cancer Center and Good Shepherd Penn Partners, recognized as one of the nation's best and most comprehensive lymphedema treatment programs.
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Treatment for Lymphedema

Tuesday, July 24, 2012 · Posted in

The current standard for managing lymphedema is complete decongestive therapy (CDT). CDT is a multifactorial approach combining manual lymphatic drainage, multilayer compression bandaging, exercise to increase the muscle pump to help move fluid from the limb and meticulous skin care.

This “intensive phase” provided three to five times per week can lead to a reduction in the volume of swelling and a softening and improvement in the skin quality. When the swelling has reduced sufficiently, patients are fitted with elastic compression garments (a stocking), which are worn during the day, and replaced by compression bandaging for sleep during what is called the “maintenance phase.” This conservative approach is highly effective in reducing the swelling and daily self-care with garment use, exercise and meticulous skin care maintain the reduction achieved during treatment.

Unfortunately, the underlying damage to the lymphatic system is not able to be repaired and patients must develop good habits to maintain the limb reduction.

Other treatments for lymphedema are currently being investigated, but it is important to consider the long-term implications of any treatment chosen. Treatments such as pneumatic compression pumps, microsurgical procedures and lymph node transfers have yet to show long-term, lasting benefit to their use, and most of these treatments still require the use of compression garments for adequate maintenance of the reduction in the size of the arm/leg after daily use or surgery.
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Preventing Lymphedema

Tuesday, July 17, 2012 · Posted in

The best strategy for treating lymphedema after cancer treatment is prevention education.

In particular, patients should learn how to care for and protect the skin to reduce the risk of infection. The lymphatic system is compromised by treatment, making patients more susceptible to infection in the region of the body close to the damaged lymph nodes. For most patients with gynecologic or colorectal cancer, this includes both legs and the lower abdomen and genital region. For patients treated for melanoma on one leg, that leg and the lower abdomen on that side are at risk for swelling.

Keeping the skin meticulously clean, free of injury and healthy with moisturizing and protection can reduce the risk of cellulitis which, for some patients, may be trigger swelling or increase swelling.

The signs and symptoms of cellulitis include a hot, red, painful, swollen area of skin in the “at risk” region. Many patients developing cellulitis also have a fever or feeling that they are becoming ill. These symptoms require emergency treatment as cellulitis can spread rapidly, causing significant illness and swelling of the limb.

The best advice is to seek medical attention immediately.

While lymphedema cannot be prevented as doctors are unable to predict with certainty who will develop lymphedema after cancer treatment, the best approach is for patients to be well educated about its signs and symptoms, practice risk reduction and find effective treatment early if symptoms of lymphedema appear.

Research at Penn Medicine in breast cancer-related lymphedema has shown that a healthy lifestyle emphasizing weight management and progressive exercise can be beneficial for patients at risk for lymphedema and those who have been diagnosed with lymphedema.

More research is required to determine if these same guidelines can be proven for patients with leg lymphedema.
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How to Find a Lymphedema Specialist

Tuesday, July 3, 2012 · Posted in

The Cancer Rehabilitation Program at the Abramson Cancer Center and at the Joan Karnell Cancer Center along with the lymphedema program at Good Shepherd Penn Partners help patients prevent or treat lymphedema.

Therapists at Good Shepherd Penn Partners are certified lymphedema therapists (CLT) who have attended programs recognized as the most advanced training available. Many of Penn’s therapists have further certification through the Lymphology Association of North America (LANA).

Penn is also home to groundbreaking research on lymphedema caused by treatment for breast cancer, specifically the Physical Activity and Lymphedema (PAL) Trial. This study found that lifting weights may prevent, or relieve, lymphedema.

The National Lymphedema Network is a well-known patient advocacy group for individuals with lymphedema. Its website is a valuable source of accurate information and for locating treatment professionals

The American Physical Therapy Association lists specialists in many areas, including lymphedema, through its ‘Find a PT’ service.
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Diagnosing and Staging Lymphedema

Wednesday, June 27, 2012 · Posted in

Cancer-related lymphedema is characterized as secondary lymphedema since it is ‘secondary to’ known damage to the lymphatic system due to surgery and/or radiation associated with the treatment of cancer.

There are very few medical tests that are valuable in the diagnosis of lymphedema. The diagnosis is made primarily based on an extensive and accurate medical history and physical examination.

Lymphoscinitgraphy is one diagnostic test that may be performed. In this test, radioactive labeled protein is injected beneath the surface of the skin, and the uptake and transport of the labeled protein is observed over several hours. This test can characterize the impairment of the lymphatic system’s ability to transport proteins and fluid, but is rarely necessary to plan and provide appropriate treatment.

Stages of Lymphedema

The stage of lymphedema is determined as part of the diagnosis. Lymphedema can be successfully treated in all stages, but the best and most rapid results occur when the lymphedema is identified and treated early.
  • Stage 0: Achiness, heaviness, increased warmth, sensation of fullness
  • Stage 1: Visible swelling that is soft and ‘pits’ if pressed and may disappear with elevation or overnight in bed
  • Stage 2: Swelling that doesn’t go away with elevation. Often the tissue is becoming more firm and less likely to be indented or ‘pit’ with pressure
  • Stage 3: Hard swelling associated with other changes in the skin- callus formations or small mushroom-like growths called papillomas.
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Treating Lymphedema in Lower Extremities

Tuesday, June 26, 2012 · Posted in

Lymphedema is a possible complication of cancer treatment. While it is a well known complication after breast cancer treatment with swelling in the arm or chest wall, lymphedema can also occur in the lower half of the body after treatment for cancers in abdomen and pelvis.

 

 

What is lymphedema?

The body’s lymphatic system performs several important functions.
  • Drains protein and excessive fluid from the tissues
  • Helps to digest fat
  • Works as part of the immune system to protect against infection and cancer
Lymphedema is the accumulation of protein-rich fluid causing swelling, or edema, in the soft tissues. This edema irritates the tissues causing inflammation that can lead to thickening and hardening of the tissue. Lymph node sampling (removal) or radiation therapy, as part of treatment for cancer, are two known risk factors for the developing lymphedema after cancer.

Early signs and symptoms of lymphedema include:
  • Achiness
  • Heaviness
  • Increased warmth
  • Swelling
  • Unusual sensation in the limb
Swelling in the region of surgery is normal after a surgical procedure, but swelling that persists for extended periods of time may be cause for concern.

Lymphedema in Lower Extremities

Cardiac disease, nutritional abnormalities or blood clots (deep vein thrombosis or DVT) are all conditions that can cause swelling in the legs. It’s important to have any swelling evaluated by a physician to determine the cause.

If it is determined that the swelling is caused by lymphedema it’s important to be evaluated by a health professional with expertise in lymphedema management. Only a few physicians in the United States have expertise in lymphedema diagnosis and management, but many specialists in oncology or physical medicine and rehabilitation recognize this condition and make referrals to specialists in lymphedema management.
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Penn Program Helps Breast Cancer Survivors Exercise During and After Cancer Treatment

Tuesday, December 20, 2011 · Posted in , ,

Kathryn Schmitz, PhD, MPH, FACSM, is an associate professor at the Perelman School of Medicine at the University of Pennsylvania. She is an exercise interventionist who has led multiple trials, including the Physical Activity and Lymphedema (PAL) Trial. Dr. Schmitz's goal is to make sure oncologists, fitness trainers, and cancer patients understand the important role exercise has in cancer prevention, and cancer treatment.

Are you a breast cancer survivor who wants her strength back? Have you been looking to get back into an exercise routine but are unsure about what is safe for you to do? You’ve come to the right place.

Many breast cancer survivors want to know: Is exercise is safe during cancer treatment or after treatment is complete? The Strength After Breast Cancer (SABC) program is a new clinical partnership between the Penn Medicine and Good Shepherd Penn Partners: Penn Therapy and Fitness.

Strength After Breast Cancer program is a new program for breast cancer survivors that educates survivors about lymphedema and helps them to build strength. After just a few months, the program is quickly gaining popularity among patients and medical professionals in the breast cancer community.

The feedback from participants has been extremely helpful in shaping the program, with the goal being to deliver the best education possible to patients and empowering women to be strong-- beyond breast cancer, beyond therapy - for life.

Those of us involved in the program plan to continue to integrate the great feedback we are receiving in order to improve the program. Our hope is to develop a positive buzz due to the “word of mouth” of those who have completed the program. 

What Women are Saying about Strength After Breast Cancer

Even after cancer treatment, women are finding their bodies are strong and are learning valuable information from their activity leaders and peers, while gaining support along the way.

“I’m learning to use my body in a way that I never thought I could before cancer….and surely not after cancer.”

“The human body has a second circulation, the lymphatic system. I never knew how important this was, especially for women with breast cancer.”

“I learned a lot from my peers, and exercising in a group setting enabled me to learn more quickly than I would have on my own.”

Women in the program are providing great feedback about what they like about their classes and exercise sessions.

“The class instructors were great; they really explained the exercises well. They supplied me with everything I need to be able to continue to do this on my own.” 

“It was great to be in a class where everyone is just like you. We all could relate to each other and it was a great learning experience.”

“The small class size made it easy to get individual attention when I needed it.”
“I have been doing my exercises every day, but have some general questions.  I wish there was someone I could follow up with without making another appointment.”

“The materials that I received for doing the program at home are great, but an online resource you can visit to get the same information and updates would be even better; or maybe instructional exercise videos so that you can get a refresher if you need it.”

For more information about the Strength After Breast Cancer program, visit PennMedicine.org or email fitpal@upenn.edu.

To speak directly with a therapist about the program, please call 215-662-4793.


More articles about exercise and breast cancer:

From Breast Cancer to Figure Competitor: How I Out-Muscled Breast Cancer

Strength Training Helps Breast Cancer Patients



Penn's Abramson Cancer Center is a national cancer center in Philadelphia providing comprehensive cancer treatment, clinical trials for cancer and is a cancer research center. The National Cancer Institute has designated the Abramson Cancer Center a Comprehensive Cancer Center, one of only 40 such cancer centers in the United States.
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From Breast Cancer Survivor to Figure Competitor: How I Out-Muscled Cancer

Friday, October 28, 2011 · Posted in , , ,


Leslie Spencer is a professor of health and exercise science at Rowan University in Glassboro, NJ, where she coordinates both an undergraduate and graduate degree program in health promotion and wellness. She is married to Stuart Spencer, a Presbyterian minister, and they have two sons, Sam and Miles.

 
Ask the average person how someone’s body is likely to change over the course of cancer treatment and you’ll hear a variety of responses that might include:
  • Weight loss
  • Weight gain
  • Loss of muscle mass and strength
  • A general appearance of aging skin and the lack of a healthy glow
  • Chronic fatigue, resulting in less energy for both pleasure and work
  • Hair loss from chemotherapy treatments, though some people do not lose their hair at all
What you would not expect to hear is that this person became stronger, gained muscle, and that people told her she looked better after cancer treatment than she did before her diagnosis. Yet this is exactly what happened to me!

 
At age 44, I was diagnosed with aggressive cancer in both breasts. In April of 2009, I began my treatment journey with a double mastectomy. In August of 2010, I celebrated its conclusion by competing in my first women’s figure and fitness contest. In between were three additional surgeries (including a hysterectomy for cervical pre-cancer), 18 weeks of chemotherapy and six weeks of radiation therapy. Of the above list of expected symptoms, I managed to avoid the first three entirely and minimize the chronic fatigue. The hair loss from chemotherapy was unavoidable, but it grew back thick and healthy-looking.

 
It’s ironic that a life-long believer in health and fitness who becomes a college health professor should get cancer. When I was diagnosed, people were shocked. My whole life has been devoted to healthful and whole living. I’ve taught courses and written articles that focus on behavior change and what it takes to help people maintain good health habits, including cancer-avoiding ones. What’s not ironic, though, is that I responded to my cancer with the full force of the beliefs and habits I’ve cultivated over my life. As crazy as it sounds, cancer gave me an opportunity to put to the test all I’ve been espousing for the past two decades. What’s been really thrilling is to see that it works! Someone going through cancer treatment can buck the typical, often negative, reaction to it and instead approach it with expectations of improved fitness and an enhanced joy for living.

 
So what motivated me to train for a figure competition through cancer treatment? I did it to experience victory over cancer in a direct, unexpected and powerful way. I wanted to be known as the woman who was training for an athletic competition through her cancer treatment, not just a woman who was going through cancer treatment. Was cancer the dominant theme in my life during that time? Of course it was; I would be in a state of denial if I said otherwise. But that didn’t mean that cancer was the only theme in my life.

 
I also found it highly encouraging to have a vision for something to look forward to and be excited about beyond cancer. When you have cancer, it’s easy to fill every day with medical appointments and research on your treatment options and decisions you have to make. I remember taking “days off” from cancer, i.e. days in which I would have no cancer-related appointments, phone calls or internet research. Planning for the figure competition was a very satisfying way to spend a day off from cancer.

 
Finally, you might be wondering why I chose to pursue a figure competition and not a triathlon or other fitness goal. The answer is that the figure competition gave me something unique that a different goal would not have provided in the same way. It allowed me to feel beautiful to the point of being stage-worthy in a “glitter” bikini and four inch heels! After having both a mastectomy and hysterectomy, it was special to me to feel beautiful, feminine and sexy after losing the parts of my body that are associated with being female.

 
Did I win any trophies? No, but I didn’t need to. I knew I was a winner just being there. Since then, I’ve started a website and blog, Strong and Built, to support and inspire other women to aspire to their dreams after cancer. Please visit and share your story with me!

 
Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.
The Abramson Cancer Center is pleased to present the Focus on Women's Cancers Conference featuring:
20th Life After Breast Cancer
10th Focus On Gynecologic Cancers
Focus On Your Risk of Breast and Ovarian Cancer

 
Attend Penn Medicine’s Focus On Women’s Cancer Conference
Friday, October 28, 2011
7:30 am to 3:30 pm
Hilton Hotel, 4200 City Avenue, Philadelphia, PA 19131

 
Register and view the full agenda at The Abramson Cancer Center, or register by phone at 800-789-PENN(7366).

 
Please register for only one conference but feel free on the day of the conference to attend sessions at any of the 3 conferences.

 
Portions of the program will be livestreamed at PennMedicine.org/Abramson/WomensCancersLIVE on the day of the conference.
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