Lymphedema

Exercising After Mastectomy and Lymph Node Removal

It is important that patients talk to their physicians about when it is safe to begin exercising and using the surgery-side arm again after mastectomy (breast removal). While there are no contraindications to performing any number of exercises after full recovery from mastectomy, there are certain precautions that should be taken after mastectomy, especially if patients have also had lymph node dissection.

Any minor injury to the skin on the side of the mastectomy may become infected more easily than an injury on the other arm. This is because the lymphatics have been disrupted and lymph nodes have been removed, leaving the arm more vulnerable to invading organisms such as bacteria. In addition, there may be a higher chance of axillary vein thrombosis (a clot in the deep vein in the armpit) in women who have undergone surgery in that area; especially if a more complete axillary dissection with the removal of 30 or more lymph nodes is performed. This is because the lymph nodes are normally located near blood vessels, and (unavoidable) scarring at or near the axillary vein may result from surgery. This scarring may tether, kink, or narrow the blood vessel and make it more susceptible to further injury.

While an increased incidence of deep vein thrombosis has not been reported in the medical literature after axillary surgery, it has been, in rare cases, associated with strenuous upper body exercise, since overdeveloped musculature may affect nearby nerves, veins, and arteries (thoracic outlet syndrome). Therefore, many physicians recommend tempering upper extremity exercise after surgery with periods of rest and keeping the arm elevated above the level of the heart for a few hours, to avoid undue swelling. Mastectomy patients should be careful not to exercise too intensely in order to avoid preventable injury.

On a positive note, regular use of the muscles after mastectomy will keep joints limber, stretch and soften scar tissue, help open up new lymphatics, promote blood flow and actually help reduce clot formation. These benefits generally outweigh the risks of a careful exercise program after mastectomy.

Light Arm Exercises That Can Help Prevent/Manage Lymphedema

Because light exercise after breast cancer surgery and lymph node removal can help reduce the chances of lymphedema, patients should discuss how and when to begin arm exercises. Some patients find that taking painkillers (analgesics) 30 minutes prior to exercising helps alleviate discomfort, although all medications should be approved by the patient’s physician.

The following are suggestions of exercises following breast cancer surgery from the Wessex Cancer Trust, an independent charity that provides information and support to patients with cancer. Each exercise may be performed five times in a row, three times a day (morning, afternoon, evening) with the physician’s approval.

• With palms up and elbows straight, stretch arms high above head, linking fingers together.
• Bend elbows and clasp hands at the back of the neck. Push elbows out as far as possible and then bring them together to touch in front of the body. Repeat.
• Place hands behind the back and lace fingers together. Slide hands as far as possible up the body toward the neck.
• Place hands on shoulders (on the same side of the body) and move elbows up and then down toward the sides of the body.
• Place hands on shoulders and make circular movements with the elbows. Circles should be as large as possible. Change directions periodically.
• After breast stitches have been removed, stand with one foot in front of the other. Hold on to a chair or table. Lean forward and swing the arm that was involved in the surgery backwards and forwards, and then from side to side as far as it will go. Hold a small weight to gain momentum. Increase movement until arm reaches shoulder height. Keep elbows straight.
• Stand with one foot in front of one another. Hold onto a chair or table for support. Lean forward and swing the arm on the side of the surgery in circles, first clockwise and then counter-clockwise. Keep elbows straight.
• Face toward a wall. Place hands on the wall and inch fingers up the wall. Try to go higher each day until arms are fully straight over head.

Treating Lymphedema

Treating lymphedema usually includes physical therapy, compression therapy, medications, or a combination of these methods. In extreme cases, surgery (including liposuction) may be performed to remove excess soft tissue. However, this is rarely done to treat lymphedema and the outcomes of these procedures are still under investigation.

A careful examination of the arm should be made before treatment begins to determine whether arm infections have occurred as a result of lymphedema or from other causes (such as blood clots). Antibiotics are often prescribed to treat or prevent further infections in lymphedema patients. Lymphedema treatment often involves combining a number of therapies, called complex decongestive therapy (CDT). CDT includes manual lymph drainage (MLD). In this procedure, an MLD certified therapist gently massages arm tissues to stimulate the movement of lymph to healthy lymphatic vessels. In addition, medical compression bandaging (wrapping the affected arm with low stretch bandages to increase drainage and prevent fluid from refilling the arm), lymphedema exercises while wearing a bandage, patient education (suggestions to reduce and cope with lymphedema), and using compression garments after swelling has been reduced are essential components of decongestive therapy.

Lymphedema is a serious, chronic condition that can cause psychological and social problems in addition to physical ones. Many patients suffering from lymphedema join support groups or seek psychological assistance to help cope with the condition. The National Lymphedema Network provides a comprehensive list of lymphedema support groups across the United States at http://www.lymphnet.org/support.html

Additional Resources and References

• The National Lymphedema Network provides information on a variety of topics relating to lymphedema, including a complete listing of lymphedema treatment centers, support groups, and a special pen pal program to correspond with fellow lymphedema sufferers: http://www.lymphnet.org/.
• The Lymphatic Research Foundation is a non-profit corporation whose mission is to help identify, support and promote research into the causes, treatments, and potential cures for lymphedema and angiodysplasia (abnormal vessel) disorders. To learn more about the Lymphatic Research Foundation and the latest research on lymphedema, please visit http://www.lymphaticresearch.org
• The American Lymphedema Institute provides information on ways to prevent lymphedema: http://www.imsa.edu/~bug/alih.html
• The Lymphedema Association of Australia provides detailed information on a variety of topics related to lymphedema prevention and treatment: http://www.lymphoedema.org.au/
• The article, "Lymphedema: Current Issues in Research and Management," is published in the September/October 2000 issue of CA – A Cancer Journal for Clinicians. While the article is written for an audience of healthcare professionals, it is also a valuable resource for anyone familiar with the basics of lymphedema, http://www.ca-journal.org/
• To learn more about lymph nodes and the lymphatic system, please visit http://www.imaginis.com/breasthealth/lymph_nodes.asp
• To learn more about axillary node dissection, please visit http://www.imaginis.com/breasthealth/mastectomy.asp#axillary
• To learn more about sentinel lymph node biopsy, please visit http://www.imaginis.com/breasthealth/sentinelnode.asp
• The Imaginis Breast Health Bookstore contains helpful books on lymphedema, including Coping with Lymphedema by Joan Swirsky and Diane Nannery and Lymphedema: A Breast Cancer Patient's Guide to Prevention and Healing by Jeannie Burt, Gwen White, and Judith R. Casley-Smith.

Updated: December 8, 2007

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