Pumping Iron

The

New England Journal of Medicine,

In the past, doctors advised breast cancer survivors with lymphedema to avoid heavy lifting because of the possibility of infection and symptom flare-ups. But a study, published in August 2009 in shows that weight-lifting may actually be beneficial and help reduce lymphedema symptoms, not exacerbate them.

According to lead author Kathryn Schmitz, PhD, of the University of Pennsylvania Abramson Cancer Center, the study shows that participating in a safe, structured weight-lifting routine can help women with lymphedema take control of their symptoms and reap the many rewards of weight-lifting on their overall health as they begin life as a cancer survivor.

Removing lymph nodes alters the body’s ability to respond to inflammation, infection, trauma, and injury, Schmitz says, and “exercise, apart from this study, has been known for a long time to improve the body’s response to injury, infection, inflammation, and trauma.”

The year-long study involved 141 breast cancer survivors with lymphedema; half took part in a twice-a-week, slowly progressive weight-lifting program and the other half did not. The weight-lifting program included stretching, cardiovascular warm-up, abdominal and back exercises, and weight-lifting exercises. Women in the weight-lifting program began with very light weights and gradually increased by the smallest possible increments. During weight-lifting, participants wore a custom-fitted compression garment on the affected arm and were monitored by a lymphedema specialist throughout the study.

Strength training (weight-lifting) exercises—specifically training the affected limb—reduced the risk of aggravating the condition because these women had trained their arms in a way that they would be less likely to hurt themselves during daily activities, such as carrying heavy groceries or lifting a child. Women in the weight-lifting group also had greater improvements in self-reported severity of lymphedema symptoms and upper- and lower-body strength. They also had a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist (14 percent in the weight-lifting group had flare-ups versus 29 percent in the control group). In each arm of the study, however, the proportion of women who had an increase of 5 percent or more in limb swelling was similar: 11 percent in the weight-lifting group, and 12 percent in the control group.

But these results don’t mean it’s OK to throw all lymphedema precautions and activity restrictions out the window. Women with lymphedema should always be extra cautious when doing any strenuous activity or heavy lifting with the affected arm because of the increased risk of injury and added stress. When doing work where there may be injury to the skin, such as gardening, it is best to wear protective gloves. Women with lymphedema should also avoid getting I.V. lines, shots, or blood drawn in the affected arm and always be aware of any changes, such as heaviness, puffiness, fullness, achiness, or redness in a certain area, and see a doctor immediately if any of these occur.

“Those [traditional] guidelines are real and should always be used,” Schmitz says, “but the likelihood that [women with lymphedema] are going to hurt themselves with the occasional activities of life that require a lot of the upper body will be reduced if they will engage in upper body strength training.”

Strength & Courage: Exercises for Breast Cancer Survivors,

Breast cancer survivor Sharon Cowden, MD, helped create an exercise DVD, for survivors to use at home. Cowden underwent an axillary node dissection seven years ago, which put her at increased risk for lymphedema. She credits exercise and weight-lifting with helping her regain upper body strength and flexibility.

“I’m a pediatrician, so I lift kids all day—a lot of kids,” Cowden says. “Also, I’m a golfer, and upper strength and flexibility are necessary for a good game. My game has never been better. My handicap has dropped 10 points since my surgery in large part because of these exercises.”

Because up to 62 percent of all breast cancer survivors have some kind of arm or shoulder problem resulting from curative surgery, reconstructive surgery, or radiation therapy, Schmitz recommends survivors have a physical therapist evaluate their shoulder and arm for general weakness or changes in range of motion that may require treatment prior to starting an exercise program with the upper body.

“It would be a terrific safeguard to go see a physical therapist,” Schmitz says, “even if you don’t have lymphedema, even if you had few lymph nodes removed, or no lymph nodes removed.”

For some women with lymphedema, however, weight-lifting and strength training may cause more harm than benefit, Schmitz says. This includes women with a lot of symptoms and whose lymphedema is “really reactive. She has a lot of flare-ups and fluctuations, her limbs get bigger and smaller over the course of weeks, or she finds herself at the physical therapist often. She’s likely not going to do well with strength training.”

NEJM

Although several previous studies have suggested weight-lifting is safe for breast cancer survivors, the recent study is the longest and largest to date.

Another strength of the study is its delivery in community fitness centers—primarily YMCAs that offer the LIVESTRONG program, a collaboration between the Lance Armstrong Foundation and the YMCA to develop programs specifically for cancer survivors—which will facilitate future dissemination of the weight-lifting program. However, this study had only one year of follow-up and lymphedema can sometimes develop 5 to 10 years after surgery.In addition to consulting a doctor and physical therapist, Schmitz offers a few tips for women interested in embarking on a new weight-lifting routine:

1. Start low, and progress slowly. Start with the lowest possible resistance with the weight. If you are using a dumbbell, it should be a 2-pound dumbbell or something very light. If using a machine, it should be set on the top plate. Progressing slowly means that you should do a couple of sessions for each upper body exercise before you increase the resistance. When you do increase the resistance, do so by a small amount. Increases in weight should be made gradually, and only after a week or two of doing the exercise at least twice a week to ensure you aren’t having any worsening of symptoms.

2. Listen to your body and respond to your symptoms. If you have a change in upper body symptoms that would be consistent with the symptoms of lymphedema—a sense of heaviness, fullness, puffiness, achiness, and/or redness in a particular area, that would be associated with a cellulitic infection, which means you should stop immediately and see a physical therapist.

3. Learn and use perfect form. Find a trainer who can teach you how to do the exercises properly. For example, back muscles are really big and wrist muscles are not, so if you try to finish a back exercise with your wrist, you will create inflammation in your wrist from doing too much with the tiny wrist muscles.

4. Ease back into it. If you take a break from exercise, either because you have a cold or are on vacation for a week, you need to back off on the resistance and rebuild again.

5. Get the goods. Always wear a well-fitting compression garment during weight training. Consult with a physical therapist or lymphedema specialist on how the compression band should fit and where to get one.

Strength & Courage

6. Find help. Find a lymphedema therapist through the National Lymphedema Network or a specialized trainer with the YMCA program to instruct you a few times before exercising on your own. If you can’t find a trainer in your area, check out Cowden’s DVD, available online at www.strengthandcourage.net/dvd/research.aspx