How to Safely Return to Exercise after Breast Cancer
October was designated as Breast Cancer Awareness month. It is fitting to address what comes after Breast cancer surgery and treatment. Most individuals desire to get back to their previous level of function, but how to do this safely can be a challenge as one returns to exercising and using the arm or arms that may be affected.
The risk of lymphedema is present after lymph nodes have been removed and radiation treatments received. These treatments may interfere with lymphatic system efficiency in clearing lymph fluid from tissues. Lymphedema is the accumulation of protein-rich fluid that may occur in the affected limbs and/or trunk. If you are in this stage of recovery, here is some encouraging news for you regarding exercise.
In 2009, results from the Physical Activity and Lymphedema Trial, or PAL, conducted by Kathryn Schmitz, Ph.D., et al, were published. The results indicated that slow progressive weight training with no upper limit on the amount of weight lifted did not worsen swelling for women with breast cancer-related lymphedema. The study further indicated that women in the weight-lifting group vs a control group had half as many “flare-ups” of their lymphedema that required the therapist to deliver intensive complete decongestive therapy and that the number and severity of lymphedema symptoms were reduced by weight lifting. This is very good news!
Even though this trial was published in 2009, many healthcare providers as well as breast cancer survivors continue to be unaware of the good news. The National Lymphedema Network (NLN) previous to this study, had recommended breast cancer survivors not to lift over 5-15 lbs ever again with their affected limb to avoid worsening of lymphedema.
After the completion of the PAL trial, the NLN Medical Advisory Committee agreed that exercise is important and can be accomplished safely and the upper limits of weight lifting are not the same for all breast cancer survivors. The NLN stressed that patients should be mindful of proper exercise guidelines and should not rush into weight-lifting without following these guidelines as listed below. Guidelines are given by K. Schmitz in an article “Weight Lifting and Lymphedema: Clearing up Misconceptions”
- Be mindful that there is no evidence that weight training prevents lymphedema. Women with lymphedema should not be told that they could have prevented their condition by weight-lifting.
- If weight-lifting is safe, and all those years women were told not to weight-lift, then all those other precautions like avoiding blood pressure or blood draws on the affected side must be wrong too. This is not true. The NLN continues to give sound guidelines to reduce lymphedema and decrease the risk of lymphedema.
- The PAL trial does not infer that all women with lymphedema can buy weights or buy a gym membership and do what they want without fear of their lymphedema worsening. The Trial was done in a controlled way with the following guidelines.
- Lymphedema should be STABLE prior to starting weight lifting. This means that that there should have been no cellulitis infections that required antibiotics over the past three months and no more than 1 “flare-up” that required the therapist delivered decongestive therapy in the past three months. Further, all the women in the study had no fluctuations In their arm volume for the past three months that were greater than 10%.
- Read and understand the following NLN Position Papers: Lymphedema Risk Reduction Practices, Exercise, Treatment, and Training of Therapists BEFORE starting weight lifting. With this education, you can know what to look for and how to respond if you have a change in swelling or symptoms. All the women in the PAL trial were required to attend a lymphedema education session that reviewed this material at the beginning of the study.
- A well-fitted custom compression garment should be worn during all upper extremity weight lifting exercises. The women in the PAL trial wore a sleeve and glove that came to the fingertips. The women took them off at end of the session to complete stretches and shower, then re-donned the sleeve after the session if they wore a sleeve all day. The compression garments should be replaced every 6 months.
- The upper body exercises should be started in a supervised setting, at low resistance, with someone who has training as a certified cancer exercise trainer or a Lymphedema Therapist. If the exercises are done with dumbbells, start with 1 to 3 lbs. If the exercises are done with machines, start with the lightest weights possible.
- Only progress to a higher weight after 2-4 sessions of doing the exercise with proper form (supervised by a certified trainer or PT). Progressing to higher weights only if no changes in lymphedema noted.
- If there is a change in symptoms that last a week or longer, stop doing upper body weight-lifting until you can get evaluated by a certified Lymphedema Therapist to be sure you do not require further treatment. You may continue lower body weight-lifting and aerobic exercise with the lower body during this time.
- If you take a break from exercising that lasts a week or longer, regardless of the reason, (eg, vacation, illness, caring for a sick family member, work) back off on the weight lifted with the weight lifting exercises. If you take a break for more than a month, start over with 1-3 lb weights and rebuild slowly.
- It was hypothesized with the PAL Trial that the women who had injuries or a flare-up with lymphedema were secondary to irregular participation in the weight lifting sessions. Dr. Schmitz recommended that if you cannot do the weight lifting 2x per week on a regular basis it is likely better not to do it at all.
- There is the misconception that if you perform weight lifting, you will never have another exacerbation. There were women in the PAL trial who did experience exacerbations with weight lifting. Most of these flare-ups were due to not following the safety guidelines as noted above.
- Women that engage in weight lifting cannot assume that it is permissible to lift heavy things at work and home. Each woman in the PAL trial increased weights gradually and individually and results varied due to previous fitness level, individual lymphedema, and medical conditions. There is difficulty in translating the strength gains in the gym to strength gains at work and home. We may know how heavyweights are, while we do not know how heavy a specific object at home or work might be. Caution is urged for those women who are weight training not to misjudge their new strength and inadvertently cause inflammation or injury to the affected arm by lifting something too heavy.
- The PAL trial results should not be used to infer that it is safe for those with lower extremity lymphedema to do weight lifting too. It is not appropriate, at this time, to extrapolate the results of the PAL trial to those with lower extremity lymphedema. Further studies need to be performed with those with lower extremity lymphedema and weight lifting.
At the Trails Recreation Center in Centennial are two Certified Lymphedema Therapists, Jaime West, MSPT, and Rene Perez, MSPT, who can help guide you in return to exercise as you recover from cancer surgery and treatment.
The Trails Rec center offers a program called “Journey to Wellness” taught by cancer specialist trainers, which can also help you transition back to exercise in a group setting.
For articles regarding the PAL Trial and Weight Lifting and Lymphedema: Clearing up Misconceptions.