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The Benefit of Aquatic Exercise for Lymphedema

 

Today I would like to share with you an article on aquatic exercises written by Mary Essert, B.A., ATRIC for this blog.
Mary specializes in creation and delivery of water fitness and post rehab aquatic programs for individuals with disabilities and conditions such as Arthritis, Fibromyalgia, Breast Cancer, Lymphedema, post Polio Syndrome and chronic pain issues. More information on Mary Essert is available at the bottom of the article.
I would also like to inform you that all the exercises for the upper and lower extremities I covered in the last blog entry (Decongestive and Breathing Exercises for Lymphedema) may be performed in the water as well.

Here is Mary’s article:

Following Joe Zuther’s recent article on Resistive Exercises, this article would be a natural sequence and serve as an introduction to another non-invasive tool to use in management of Lymphedema symptoms.
In addition to a number of other benefits, aquatic exercises have a strengthening effect on the musculature.

The buoyancy effect water has on the musculoskeletal system makes movement more comfortable. Range of motion and flexibility are increased when in a warm water pool and the cardio vascular system is working more effectively, so an aerobic workout is possible. Additionally, the hydrostatic pressure acts like a “full-body garment” and helps to reduce edema, and stress is reduced when an individual with Lymphedema is in the water.
In short, the movements in the water are resistive, assistive/supportive, compressive, massaging, relaxing and comforting.

Deep abdominal breathing enhances pumping in the thoracic duct, one of the large lymph vessels located in the abdominal and thoracic area. Muscle contraction performed distally (hands and feet) helps return venous and lymphatic fluid.
A new body of knowledge demonstrates great success with individuals when combining intense one- hour sessions with Manual Lymph Drainage (MLD) procedures. This combination and team approach is proving most effective; Lynette Jamieson, Director of Aquatic and Rehab Services in Mesa, AZ, has utilized this technique with good result.
Education of individuals who have Lymphedema and who desire to participate in aquatic exercise is vital, and knowledge of other conditions or possible side effects from chemotherapy and radiation, such as neuropathy, is necessary.

Learning to listen to our own bodies in terms of frequency, intensity and time spent exercising is our job. My personal experience is that three exercise sessions per week is a minimum, but the alternate days I perform other forms of exercise, to include a cardio workout and gentle to moderate strengthening exercises.

Personal goals need to be expressed and merged with those of the therapist or personal trainer who works with an individual who has Lymphedema.

In general, goals include:
• Pain reduction
• Increased range of motion
• Increased strength
• Increased cardio respiratory conditioning
• Improved posture , balance and energy
• Education/tools re: weight management and nutrition
• Increased relaxation and stress management
• Outlet for support/social/outreach

Some specific goals include:
• To restore proper biomechanics, increase range of motion in the shoulder
• Improve strength/endurance of injured and supporting muscle groups
• Improve lymphatic flow by movement through the water, use of hydrostatic pressure, turbulence and muscle activation
• To reduce susceptibility to hypo-kinetic disease with cardio vascular exercise
• To lose body fat, increase lean body mass to reduce risk of Lymphedema and breast cancer recurrence

Paula Geigle, PT, PhD, Assistant Professor, University of MD is the first recipient of the Aquatic Physical Therapy Section’s $5,000 Swim EX Clinical Research Grant (2010). Her study “Role of Aquatic Exercise” in Breast Cancer Related Lymphedema Management” concluded that aquatic exercise does appear to be a safe method to assist in Breast Cancer related Lymphedema control.
Participants do report volume reduction as well as increased energy, more pliable tissue texture, and socially enjoying the aquatic exercise participation.

In addition to several other important precautions, water temperature is important. Warm water relaxes muscles and decreases postural tone, and cooler water stimulates tone and alertness. Hot water should be avoided with edema….no hot tubs or spas. In general, pool temperature of about 88 deg. F. is a good choice if air temperature and circulation are adequate. Warmer therapy pools may be utilized according to the individual case, for shorter periods.
Paying attention to breathing patterns and posture are important; an average class is about 45 minutes long.

If privacy in the locker room is a concern, individuals may dress for the pool at home. Difficulty of getting into a swim suit or not wanting to be seen in one may be another issue. Most pools will permit clean shorts/shirt or even slacks; these should be comfortable and free from strings. If an individual with Lymphedema is reticent about crowds, pool sessions may be scheduled during “down” times.
Aquatic exercise may be not pleasant for everyone…..some individuals may be afraid, or have other issues. I encourage individuals to try one session to experience the benefits; it certainly doesn’t hurt to have an additional management tool available.

Following are sample aquatic programs for individuals affected by Lymphedema (By Mary Essert (with credits to Judith Casley-Smith©2008*):

It is important to:

• Understand safe entry and exit of the pool.
• Master sculling techniques and recovery to a standing position.
• Water is a substitute for a compression garment/sleeve (no need to wear  sleeve for aquatic ex.)
• Listen to your body and don’t push through pain.
• Avoid fatigue; slow down or stop when needed.
• The intention is to move lymph and reduce edema and to promote range of motion.

Begin with gentle Water Walking
Forward, backward and laterally for 5+minutes

Focus on Posture
Locate neutral and find a comfortable depth so shoulders can be submerged. Stability is desirable. Core muscles will be strengthened.

Breathe Work
Practice thoracic breathing, abdominal breathing and a combination. Intentional breath work blended with stability and balance skills.

Neutral Stance (Perform 5-10 reps as comfortable, increase when ready)

• Reverse Cat Stretch:  Hunch shoulders and lean to front, then return to standing on exhale, shoulders back

• Head Turns: Look to Side for counts 1 & 2 / Center 3 / Relax 4

• Forward Head Roll: Tilt Head Right on count 1 / Roll Head Down & Toward Left 2, 3 & 4 / Return to Start 5. (Repeat other side.)

Shoulders & Arms


• Shoulder Lifts
: Raise shoulders toward ears – count 1 & 2 / Relax 3 & 4 / Lift 5 & 6 / Relax 7 & 8

• Shoulder Rolls with slow count: raise and roll shoulders in circle underwater

• Shoulders Forward & Backward (retract & protract scapulae, elbows move toward back)

• Pendulum Arm Swing (use pool edge): Balance one hand on a noodle, or stand with neutral spine; swing one arm at a time from shoulder, then both together with hands clasped

• Repeat Reverse Cat Stretch as above

• Palm Press: Prayer position; scapular retraction follows (pull elbows toward back…forearms are parallel to water surface)

• Shoulder Touch from Side Extension: Bring fingers to shoulder as elbow bends from straight arm at side

• Shoulder Touch from Side Extension: Fists to shoulder as elbow bends

• Arm Rotation with Pronation & Supination: Shoulder emphasis (arms outstretched in front of body)

• Biceps/Triceps Curls: Add jogging to prevent chilling (change hand position to increase intensity-open hand more intense)

• Shoulder Abduction & Adduction: Outstretched arms to side, bring toward body, then away. Add arms criss-cross front and back (add crossing arms at elbow in front of body if comfortable, both directions)

• Upright Rows (bend elbows, press back)

• Wall Press Away: Front and side position (stand firm on pool floor and lean toward wall to comfort, hold 10 seconds, then push back to neutral stance)

• Elbow Touch: Hands behind head, bring elbows together in front and open with breath

• Asterisk: Pretend you are making a large asterisk shape in front of your body with both arms together then with single arms, underwater)

Hand Exercises: ‘Play the piano’, thumb circles, make a fist etc.  uch as hula hoops (pelvic rotation to comfort)  (use sculling for balance)

Stand on one foot
to perform ankle flexion & extension, ankle circles, etc. (stabilize knee)

Free/Active Stretching: Such as hula hoops (pelvic rotation to comfort)

Balance & Agility Work (use sculling for balance)

Aerobic Work

Combination Aerobic Movements
(cross country ski, half jumping jacks, bicycle, forward and backward kicks with opposite arm movement etc.)

Repeat Walking: Emphasis on heel strike, heel, ball toe in forward walking, toe, ball, heel in backward.

For lower extremity emphasis, add Arthritis Foundation Aquatic Program(see Arthritis Foundation instructor) series of range of motion exercises, standing at wall for support, then graduating to balance in pool, hip flexion, extension, ab- and adduction, hip range of motion, circles from hip, extra ankle/foot work such as pedaling, AVOID KNEE ROTATION . Consider bicycling with belt or noodle support, or one leg at a time at wall. Walking or deep water running and deep water exercise may be advised, using a flotation belt.

Relaxation (use belts or noodles if comfortable) In supine position, perform curl ups and knees to chest, add gentle cycling and free movement with breath work….

Stretches (standing at wall)
• Runners stretch
• Achilles tendon stretch
• Hamstring stretch
• Quad stretch
• Cross over shoulder stretch
• Spider Man Wall Stretch (at wall, bring knees up close….anchor one foot with outstretched leg on wall, lean toward bent knee) Reverse position after holding stretch 10-30 seconds.

End with breathe work

Additional Resources:
Women Fitness: Top 10 Exercises to get fit in the water
Mayo Clinic: Aquatic Exercises – How To
Calgary Lymphedema Rehabilitation: Benefits of Aquatic Exercises with Lymphedema
Lymphedema People: Water Exercises

For more information re: specific exercises , resources and bibliography, see www.maryessert.com Breast Cancer Exercises for Land and Water CD-ROM by Aaronson and Essert produced by Fitness Learning Systems.

Several more recent research studies have confirmed aquatic therapy as a meaningful and effective tool in management of Lymphedema.

D. Tidhar, M.Katz-Leurer. Aqua Lymphatic Therapy in Women Who Suffer from Breast Cancer, Support Care Center.2009

Robert Wascher , MD, FACS. Exercise Improves Lymphedema Symptoms in Breast Cancer Survivors. http://stanford.wellsphere.com. 2009

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16 comments to The Benefit of Aquatic Exercise for Lymphedema

  • Ann Megna

    Thank you for your encouragement for water exercise. I had lymph nodes removed from the groin area and find that water really helps. I must wear a supportive suit and had to wear long tight shorts in the beginning to support my legs but now can wear regular suits that offer good support.I do get achy from time to time but had fogotten to do the lymph drainage after exercise so thanks for that reminder as well.

  • Your blog continues to be a tremendous resource for patients with lymphedema: a recent thread on swimming had started on breastcancer.org, and women were searching for advice on how to use the pool safely and effectively, and you provided it.
    Thank you.
    Here’s the thread
    http://community.breastcancer.org/forum/64/topic/763590?page=1#idx_7

  • Dale Korba

    Thanks for the conection to research using aquatic therapy. I lead a class for women cancer survivors in the therapy at Boulder Community Hospital and we have not experienced any exacerbation of lymphedema in our participants either.

  • Hi Joe

    I have been doing water exercises and teaching my patients the value of doing water exercises for the last 4 years. I started with myself and saw a tremendous difference; i was trying to loose weight that is how it got started and then I thought this would be great to do for my patients. When I showed them some simple exercises to do in the pool they had amazing results. The patients who tried it stated they felt not as exahausted performing these exercises in the pool and patients who had problems in the trunk area with fluid had a decrease in fluid. I highly suggest patients get in the pool

  • HS

    Hi,

    I recently started swimming to control post-breast cancer arm lymphedema. The first few times my arm felt amazing, but the last time it actually didn’t feel so good during the swim, and then swelled up in the couple of hours afterwards. I wonder if this could be due to chlorine (my skin was particularly dry that day), but my LE therapist says it could have been due to cardiovascular pumping, and that I should compress for a couple hours afterwards.

    I have the option to switch to a low-chlorine pool, although this would be more inconvenient and expensive. Any thoughts?

    Thanks!
    HS

  • Vickie Russett

    I have been doing aquatic exercises for many years. It first started out as a way to exercise, but now I am dealing with Lymphedema in both legs and have found the pool to be a lifesaver. The buoyancy of the water makes exercising much more comfortable and easier to do. My range of motion and flexibility are increased in the water. The number of infections have decreased with doing the aquatic exercises on a routine basis. I go three times a week.

  • [...] Lymphedema Guru knocks another one out of the park with his article on exercising in the water to help manage lymphedema. Share this:TwitterFacebookLike this:LikeBe the first to like this post. This entry was posted in lymphedema and tagged Aquatic, Exercise, Lymphedema by richardsonts. Bookmark the permalink. [...]

  • Mary Kay Radnich

    I have lower extremity lymphedema, genetic but exacerbated by injury. I have started doing an aquatic fitness class, which is actually a high energy aerobic class and it is WONDEFUL! I had a lot of soreness the first few weeks but that is passing. The hydrostatic pressre, the cool water temperature (82F) and the ability to move about any way I want has been a real blessing in dealing with the lymphedema and my arthritis. I highly recommend it for lymph patients as well as anyone who wants a refreshing workout!! This article was great, btw, and my instructor has us doing many of the warm up and cool down exercises, including the breathing.

  • Mary Kay Radnich

    I am printing out this article for my trainer. I would love to see a lymphedema acquatic fitness class in my town. Something to work on.

  • Karen

    I am former competitive swimmer, 45 year old recent Breast cancer Survivor with dominant arm and hand lymphedema. Due to getting lymphedema right after my bilateral mastectomy, I have not exercised in nearly 2 years.

    Most of the info I read online about lymphedema and water exercise is for water aerobics, not lap swimming/competitive swim training. I’m not sure I want to compete again, but I really can’t see myself getting “into” water aerobics.

    Can I do swimming (intervals, strokes, etc) with lymphedema? How do I proceed? I especially need help with exercise time and intensity. Everything I read says adults should get 30-60 minutes of aerobic exercise per day. Should I start with that? Other lymphedema blogs say “Start low and go slow”. How low? How slow? Can I sprint? How hard can I push myself? Is it OK to get anaerobic?

  • NJS

    Can someone give me a opinion as to the question of whether one needs to wear a compression stocking while swimming? And, if so, the same pressure as one weras throughout the day or less? I swim with a competitive Masters group. Thanks – NJS

    • Joachim Zuther

      In most cases the compressive forces of the water are sufficient to accommodate lymphatic (and venous) return. However, should you experience an increase in swelling when exiting the pool, I would suggest wearing a garment with moderate compression (20-30 mm/Hg) while swimming. Some individuals I know use their old and worn compression garments for this purpose.

  • NJS

    Hi Karen – I am in exactly the same situation having been a Masters swimmer for 20 years and now working through lymph therapy but ready to swim in about six weeks. I have seen at least one comment aorund that water is compressive enough that one not need to wear compression hose, etc. but my OT suggested it or at least be ready for it if my leg does swell. I hope others on this forum and the forum leader willhave some insight. NJS

  • […] Lymphedema, Post Polio Syndrome and other chronic pain issues) is shared on lymphedema specialist, Joachim Zuther’s, blog, which explains how this type of therapy […]

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