Breast & trunk LE

Jul 31, 2012 12:07 PM carol57 wrote:

Agada, there is no evidence to show that exercise prevents LE, but there is a strong association between exercise -- including strength training -- and reduced risk of LE for those as risk, and reduced incidence of LE flare-ups for those who have been diagnosed with LE.  Association means the relevant studies point to reduced risk, but the risks remain nonetheless. 

Having said that, there's a whopping huge common-sense relationship between exercise and LE.  Muscle movement against the lymphatic vessels is what pulses the lymphatic fluid (lymph) through the lymphatic system.  So movement of muscles promotes lymph movement.  Strain of any kind--including picking up something too heavy for the limb or trunk--signals 'need help' to the lymphatic system, which in turn sends more lymph to the rescue. So--here's the common sense--doesn't it seem logical that if we condition our limbs and our trunk to be able to bear heavier loads, the lymphatic system will in turn not get so excited when we lift, push, or pull something heavy?  The exercise studies of resistance training are showing that this bit of common sense does indeed translate to reality.

Exercise can bring its own LE risk, though, so we have to work on getting its benefits while minimizing those risks.  Raising the core body temperature signals 'stress' to the lymphatic system.  Lifting a dumbbell that's too heavy (haven't worked up slowly to that weight) signals 'stress.'  Repetitive arm motions (like rowing) signal 'stress' to the lymphatic system.  So--be careful about exercising in very hot conditions; drink lots of water to rehydrate; wear wicking fabrics; get in a swimming pool for exercise; follow safe weightlifting guidelines that include adding weight in small increments and avoiding bodyweight or resistance-band exercises where we cannot measure the amount of weight load (nor add to it in small increments).

Patients with LE wear compression sleeves and gauntlets or gloves while exercising and weight lifting.  At-risk patients without a LE diagnosis should consult with a lymphedema therapist to help decide if compression is needed.

On the rowing, my common-sense answer is to get the trunk and arms nice and strong before doing any extensive rowing, so that the unavoidable repetitive motion is tempered by having plenty of strength to push/pull the oar/paddle.  I just completed a five-day kayak trip, paddling as much as 7 hours a day, and I am convinced that my LE would have exploded on me had I not been following an LE-safe weightlifting program (PAL Protocol-compliant) for six months.

Would rowing or other exercises ever cause LE?  I don't think we have an answer on that.  If you are already at risk from BC treatment and surgery, and especially if you are pre-clinical (no visible swelling, but the arm can have up to 30% extra fluid without visible swelling), rowing or similar hard-work exercise might be that straw that break's the camel's back.  (Funny saying, now that I think of it--camel retains water in the hump...).  Or, you might unfortunately be genetically predisposed to getting LE (research supports that), and while the rowing might precipitate the onset of LE symptoms, it would not technically be the cause.

Clear as mud, no?

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Jul 14, 2012 07:05 PM carol57 wrote:

I wrote this long post a while back, to answer some questions from women at risk of LE. So some of the comments talk about avoiding  LE, but the information is just as valid for those of us who already have an LE diagnosis and want to build strength safely.

Guidelines for cautious resistance training--designed especially to address LE risk--were developed as a product of an 18-month research trial called the PAL Trial (for Physical Activity and Lymphedema).

Here are some highlights, and I do recommend that you read the related journal articles--I'll put links at the end here.

--Start with very, very light weights and move up very, very slowly.  I was lifting extensive weight prior to surgery, but when I returned to the gym afterward, I started with one pound dumbbells for my arms and other upper-body lifts.  Talk about feeling silly...but LE is nothing to fool around with, so I gritted my teeth and decided who the heck cares what it looks like.  Then I added weight slowly, meaning one pound per week, initially.

--Use dumbbells or other weights that are marked on them.  Items such as soup cans are handy, but their weights are not standard, so they make it very difficult to know for sure you're adding to your lift load in small, measured increments.  Also, for best form (and form matters, to avoid injuries, LE-related and otherwise), it's best to use dumbbells, for a better grip.  One option is to purchase a set of power blocks that go as low as 1 lb.  If you google it, you'll see what I'm talking about.  That's what they're using in follow-up research being done by the PAL Trial researchers now.

--Resistance bands are not a safe way to do strength training if you have or are at risk of LE, because you cannot know exactly how much resistance you add or subtract when you alter your hand placement or move to a more resistant band.  One key tenet of the PAL Protocol is that they determined that women have the least chance of triggering LE (or making it worse if they already have it) when weight is added slowly and progressively, in small measured increments.  Resistance bands are tempting because they're inexpensive and easy to store, and if you travel, they go right along with you.  But--they invite more LE risk than relying on measured increments from dumbbells.

--And then there are those body-weight exercises, like planks for our abs and pushups for the pectoralis area.  By now you can predict what I'm going to say--not such a good idea for us, because--you guessed it--impossible to say how much added resistance you get when you alter your position to make the move harder. 

--This is not to say you NEVER use resistance bands or do push-ups, and even Dr. Katie Schmitz, the lead PAL researcher, has said it's possible...eventually.  The idea is to build significant strength using the (broken record here, sorry) slow, progressive method with dumbbells.  Then--and seriously only when you have a good long track record of adding your weights slowly--might you begin to add some bodyweight work--and that only if all through your program so far, you never triggered any LE symptoms (ache, heaviness, tingly, and of course, swelling).

--Then there's the question of wearing compression while working out.  Anyone who already has LE should be wearing a compression sleeve and hand compression (glove or gauntlet) while lifting weights, and probably while doing cardio work, too (because just raising your core body temp during cardio adds load to the lymphatic system, and then you add to the challenge by using arms for long, repetitive motion in some kinds of cardio work).  The National Lymphedema Network says that whether to wear compression or not is a judgment call when you do not have LE--but are 'just' at risk (oh, and risk after SNB is not trivial--up to 17% for arm LE and much, much higher for breast LE if you had SNB and breast-conserving surgery, and especially if rads are thrown in).  To make that decision, it's best to consult with a qualified LE therapist, generally a PT who is also a certified LE therapist, hopefully with the letters LANA after his/her name.

(I'm killing you with info here, I know, but LE rots and we do what we can to avoid it, or to minimize flare-ups when we do have it.)

It's a great idea to work out with a certified personal trainer at least a few times, and a trainer can request the actual PAL workout guidelines by going online here: 

www.penncancer.org/physical-ac...

I live in a rural part of w. Michigan and am nowhere near any gyms that offered PAL-compliant personal training, so I recruited support from two hospitals and brought one of the PAL researchers to town last December, for a one-day workshop she gave to a group of personal trainers and LE therapists. So now we have some good PAL training resources here.  You could do that too, and if interested, I can get you started on how to make it happen.

To read the original PAL report explaining how strength training guidelines were developed for breast cancer survivors who have lymphedema:

www.lymphnet.org/pdfDocs/PAL_N... .

Then there is the PAL-Trial evaluation of weight-lifting risks to women at risk of lymphedema,  available at: jama.ama-assn.org/content/earl...

Lead researcher Kathryn Schmitz wrote an article clarifying misconceptions about the PAL Trial results, which were poorly reported in the media when the study was released:

www.lymphnet.org/pdfDocs/Weigh...

The Livestrong program is great, definitely designed for cancer survivors, but their trainers get only a little background in the PAL guidelines.  So at minimum, I hope you'll read the resources I linked here, so you'll know what to ask about and when to object if an unwitting trainer suggests a move that's not really good for you.

Do lift...but do lift intelligently!  40% of us will get LE after BC treatment, and the risk is particularly high during the 3 years post-treatment.  Some lucky women in the 60% club can lift, push, pull, do pushups and yank on resistance bands and never get LE.  No one knows why some get it, some don't.  You cannot know if you're in the 40% or the 60%, but being careful to do smart weightlifting could help nudge you away from the group that gets this crazy condition.

Wishing you only the best--

Carol