• #14-3. Lymphedema and Exercise


    Exercise rules


    It is important to avoid sprain or muscle damage while exercising. Carefully observe the response of affected limbs to exercise which is different in each patient. Always wear compression bandages while exercising. Compression therapy applies pressure to the limbs to improve lymph circulation. Lymphedema developing after breast cancer treatment should start exercising as soon as possible. If there is shoulder pain or surgical wound pain, etc., drop and relax arms like pendulums and do passive exercise. Also, stoop forward to let the arms hang low and trace a large circle with the arms. Shake the arms in all four directions. Once arms can be lifted over the head without pain, active exercise can begin.

    People who exercise regularly have low body fat. Generally, body fat increases estrogen level and increases the risk of breast cancer as well as risk of lymphedema from weight increase. However, regular exercise reduces lymphedema. One should be aware of all cautionary measures related to exercise. Depending on the physical conditions, exercise can be more do more harm than good. It is important to consult the physician before starting an exercise routine. Therapeutic exercise for lymphedema include lymph drainage exercise, stretching, strengthening exercise and aerobic exercise, each of which has different therapeutic objective. The most important of these is the lymph drainage exercise whose effects are as follows;

    First, it helps the muscles work as pumps to dissipate the fluids from the affected area. Second, it increases the extent of joint movement. Third, it increase muscle strength. Fourth, it improves lymph circulation. Fourth, it strengthens overall body functions. Wearing compression clothing maximizes the dynamic effect of the joint and muscle on the lymphatic system. Bandages in particular increases the pressure on the skin during exercise. This pressure contracts the muscle to ease the movement of the fluids.


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    Comparing lymphedema to a rice paddy


    The Chinese traditional characters for lymphedema are ‘淋巴浮腫’ or ‘淋巴水腫.’ Basically, it denotes that the forest is submerged in and floating in water. A rice paddy needs a right amount of water. Water flows into the paddy through a small ditch and excess water is sent toward the river through a small tributary. The rice stalks grow healthy when there is a right circulation of water. The rice paddy can be compared to the subcutaneous tissues of the body and water to the lymph fluids, tributary to lymph ducts and river to the vein.


    Water = lymph

    Rice paddy = subcutaneous tissues, skin

    River = vein

    Tributary = lymphatic duct

    Ridges = lymph vessels

    Pump = lymphatic node

    Bank = fibrosis (blocks drainage)


    Lymphedema can be compared to overflooding of the rice paddy due to failed drainage of water into the river. The stasis of fluids cause swelling. As static water becomes spoiled (complications such as dermatitis, cellulitis) and becomes thick creating an environment conducive to bacterial growth. The rice paddy loses its original shape and plants get entangled much like the firbrosis that occurs in the skin. This is why cleanliness is an important preventive measure in lymphedema.

    primary lymphedema (=congenital lymphedema) caused by lymphatic hypoplasia can be compared to lack of tributaries and primary lymphedema caused by lymphatic hyperplasia may be compared to tributaries being too wide and retaining the water rather than sending it to the river. Secondary lymphedema following lymphadenectomy, breast cancer or uterine cancer can be similar to having large banks blocking the tributaries.

    The most widely recognized therapy is a combined physical therapy which pushes the retained water over the banks into the river. The river should be drained so that the water level is lower than that of the rice paddy. The water should be gently pushed over the bank so that ridges (lymph vessels) will not be damaged (This is the basic principles of the lymph drainage massage). However, if the water level of the river is higher than that of the rice paddy, this may cause the water to overflow into the rice paddy. If the water is swept into the river too forcefully using a bulldozer (comparable to overly severe pressure during massage, high air pressure massage device), the ridges are damaged and the stagnant stale water flows into normal rice paddies. Excessive massaging of the lower limb lymphedema exacerbates lymphedema and causes development of perineum. As the water continues to flow into the rice paddy from the valley, the fluid continue to flow into the tissues. This is why the lymph drainage massage should continue throughout the patient’s life. Compression stockings or bandages serve as reinforced banks that prevent overflowing of water into the rice paddies.  

    The surgical removal that was the preferred treatment choice for the last few centuries removes overly enlarged lymph nodes which leaves deep scars and causes recurrence. With the exception of immobilized patients, I do not recommend surgery. lymph vessel transplantation can be compared to building a waterway to connect the lake to the river and draining pumps (lymph nodes) that remove water regardless of the relative water levels in case of severe lack of tributaries (lymphatic duct). The artery provides energy to the pumps and maintain their continuous operation (forced drainage system). Lymph vessel transplantation is currently the most theoretically and practically effective surgery for lymphedema. However, it requires a great deal of expertise due to involvement of micro structures. It also requires general anesthesia and long hours of operation time. Also, healthy autologous lymph nodes need be harvested which can cause fluid retention in donor sites. It is important to only select lymph nodes in areas with well-developed lymphatic ducts. The problem is that such lymph nodes are far and few between. They exist in the armpit, upper inguinal area, neck and greater momentum of the abdomen. If the first surgery is not sufficient in replenishing the lymph nodes, a second surgery is needed. Previous surgical methods depended on natural flow of fluids. Which meant that when the water level of the river is higher than the rice paddy, it caused overflowing in the rice paddy and blockage of the waterway, etc. As such, they failed to provide effective remedy (natural drainage). However, lymph vessel transplantation has excellent forced drainage effect regardless of the water level. The amount of drainage increases with time as more tributaries are built. Around the world, here are only one or two hospitals in Germany, France and Italy that perform this highly advanced surgery. I intend to offer this surgery as well at my practice in the near future.


    Important principles and rules of lymph drainage massage


    I often refer to this massage as the spoon worm massage because spoon worms contract and extend back to its original shape when touched. Similarly, the fluids are drained from contraction and relaxation.

    The hand movements of the lymph drainage massage are based on one principle. Linear stretching opens up the lymph vessels and stimulates lymphangion to drain excess fluid. To provide stronger stimulation, slide the hand in linear motions and extend the motion laterally. After this movement, wait for lymph vessels to close and the fluid to drain through lymphatic duct. Maintain the zero pressure state by keeping the hand on the skin while applying no pressure. Do not push the skin backward but let the skin return to its original place.   

    The basic hand movement is circular and this is called stationary circles. Move the hand so that the fluid is directed toward the right lymph nodes. Lateral stretching movements should be toward the direction of draining lymph nodes. As lymph vessels lie close to the skin surface, stretching movements open the lymphatic ducts. In a few minute, lymphangion contracts acting as pumps to send the fluids into blood vessels. As the massage is to stimulate the skin surface, if muscles and other deeper structures are felt during massaging, it may mean that the massage is too deep and strong.


    Four components of the lymph drainage massage

    1. Accurate pressure

    The pressure should be light yet strong enough to not have the hand glide over the skin. Hand movements are light and nothing other than the skin surface should be felt on the palms. The pressure should be about 28-112g.

    People who have been trained in Sweden tend to apply very strong pressure. They are often skeptical of the effect of very light massage. The key purpose of the massage is to stimulate micro lymph nodes in the skin surface. Pounding, twisting or excessive pressure can damage the lymphatic ducts and the massage fails to bring the desired effect.


    2. Direction of hand movements

    Hand movements are important because they help move the remaining fluid toward normal lymph nodes. If the direction is wrong, the massage becomes ineffective. The final drainage of the fluid is carried out immediately under the clavicle. Under the left clavicle likes the thoracic duct for draining the lymph fluids from the ipsilateral head, left arm and upper leg. The fluids from the right side of the head and right arm are drained under the right clavicle (Direction image 1, Anatomical image 2). Perform the massage with the idea that water remaining in the ground drain can be slowly removed gentle sweeping in the direction of the drain holes.


    3. The rhythm and speed of hand movements

    The linear and slight lateral stretching stimulates lymph vessels and promotes their opening and closing. This contracts lymphangion to drain the fluid into the blood stream (lymphangion contracts 5-8 times per minute). When the massage rhythm is in sync, parasympathetic nerve is also stimulated. Limit about 10-15 movements to one area and spend 2 seconds for each movement.


    4. Sequence of hand movements

    Start the massage with the lymph nodes that need to be drained and move farther away from the lymph nodes. Send the fluid toward the draining lymph nodes (in the same principle that you would clear the floor drain first before sweeping the water toward the drain).


    Lymph drainage massage of the lower limbs

    Trace circles or half circles with hand movements. Do not let the hand glide over the skin or detach the hand from the patient’s skin. Massage gently with a slight pulling sensation. Massage should not cause any pain. Perform 10-15 hand movements in one area and spend 2 seconds per movement. If the skin turns red, it could mean that the massage is too forceful. If both limbs are affected by lymphedema, both need to be massaged. The best position for massage is slightly elevated upper body or completely supine position, or slight elevation of the massaged area. There should be a direct contact between the massaging hand and the patient. Thick clothing hinders the effect of the massage. A single massage session should last about 40-49 minutes and can be performed 2-3 times a day in severe cases.


    -To be continued-

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