Exercise Class for Female Cancer Patients Offers More than Fitness

When Newark resident Violet Williams was diagnosed with breast cancer in 2006, all of her immediate family who might provide support lived out of state, leaving her to face her treatment alone.
Throughout her treatment and recovery at The Frederick B. Cohen Cancer Center for Blood Disorders at Newark Beth Israel Medical Center, Williams took advantage of several support programs, including Recovery Fitness, a free, all-female exercise class for cancer patients.
"Those groups really carried me through the whole thing," Williams said. "Both the support group and the exercise class helped me mentally and physically to recover and get my strength back."
Recovery Fitness, offered at NBIMC on Mondays and Wednesdays at the new Beth Fitness Center, helps female cancer patients to have fun, get strong and reduce stress. It is one of only a few such programs in the state to specifically offer exercise classes tailored to the needs of female cancer patients. Recovery Fitness is made possible by grants from The Jewish Women’s Foundation of New Jersey and Eisai Co., Ltd., which were made through the Newark Beth Israel/Children’s Hospital of New Jersey Foundation.
"I like everything about it," said Williams. "Just being there and mingling with the other cancer patients is helpful, especially for the newly diagnosed women who can get a bit of hope from the ones who have been through it already."
Williams, who also suffers from Lymphedema, a condition of fluid retention and tissue swelling caused by a compromised lymphatic system, says that she has seen improvement in her arms with much better range of motion and less joint pain.
The class' instructor, Carol Michaels is a Certified Cancer Exercise Specialist who meets with each participant individually to learn about problem areas and to find ways to benefit each person. Goals of the class include increasing muscle mass, decreasing body fat, increasing flexibility, strength, posture and balance, strengthening the heart and bones, reducing stress and increasing self-confidence.
Many cancer patients experience secondary complications as a result of their cancer, such as frozen shoulder after a mastectomy and stiffness and discomfort as a result of lymph node dissection, Michaels said.
"Some female cancer patients experience the added aggravation of chronic conditions after treatment, and through this exercise program they can increase their range of motion and feel stronger again," said Dr. Alice Cohen, director of the Frederick B. Cohen Comprehensive Cancer and Blood Disorders Center. "Exercise improves function and also helps with overall stress reduction."
Studies have shown that exercise can aid in the recovery process during cancer treatment as well as to possibly decrease the likelihood of cancer recurrence, said Cohen.
Most importantly, Recovery Fitness offers a warm environment for patients who are at all different levels of recovery.
"This isn’t boot camp," said Michaels. "The exercises are safe and gentle and we have an appreciation for every fitness level. Someone might be able to work out with weights while another person sits in a chair to lift hers. It is very individualized."
Michaels said the group becomes, in effect, a support group with each person learning from one other and offering words of encouragement.
"Many people do not feel comfortable returning to their gyms right after surgery or treatment," she said. "Gym classes can be large and impersonal. At our class, the participants can even remove wigs and head wraps without feeling self-conscious. Gaining confidence through support is part of the whole recovery process."
After a year of participation, Williams plans to continue with the program.
"I even lost a few pounds," she said. "I’m going to keep going."
– Staff reports

http://newarknj.patch.com/articles/exercise-class-for-female-cancer-patients-offers-more-than-fitness

Manual Lymph Drainage and it’s Role in the Treatment of Lymphedema

By Joachim Zuther, on December 21st, 2011

Manual lymph drainage (MLD) is one of the main components of complete decongestive therapy (CDT).  In combination with compression therapy, skin and nail care and decongestive exercises, MLD performs the crucial role of re-routing stagnated lymphatic fluid, which is essential in the treatment and management of primary and secondary lymphedema. This gentle manual treatment technique is based on four basic strokes, which were first described by Dr. Emil Vodder (1896-1986), PhD.
The goal of MLD is to stimulate healthy lymph vessels and lymph nodes, which generally are located adjacent to the area of non-functioning or blocked lymphatic drainage, and to re-route the lymph flow around these blocked areas into more centrally located healthy lymph vessels and nodes. This is achieved with specific stretches and manipulations – a common denominator in all MLD strokes – to the skin and those structures located directly beneath the skin, the subcutaneous tissues.
The resulting increase in lymphatic activity in the healthy areas creates a “suction effect”, which stimulates the accumulated fluid present in lymphedema to move into an area with normal lymphatic drainage.

What is the difference between MLD and traditional massage?
It is unfortunate that the term massage is often wrongly used to describe MLD. The origin of the word massage is derived from the Greek massain (to knead) and is used to describe such techniques as effleurage, petrissage, vibration, etc. Massage techniques traditionally are applied to treat ailments in muscle tissues, tendons and ligaments, and in order to achieve the desired effect, these techniques are generally applied with considerable pressure.

Cross section through skin, subcutis and muscle layer

MLD on the other hand is a very gentle manual technique, designed to have an effect on fluid components and lymphatic structures located in superficial tissues, i.e. the skin and the subcutis. Lymphedema almost exclusively manifests itself in the subcutis, which is a layer of connective tissue between the skin and muscle tissues.
The only commonality between MLD and traditional massage is that both techniques are applied manually. There are significant differences in technique, pressure and indications for which these two therapeutic measures are used.
There are a number of reasonable explanations why MLD and massage are often confused with each other. One is that there is a tendency to call any hands-on manual therapeutic technique a form of massage; the other is that massage can be very helpful if applied to treat edema.
However, lymphedema and edema are two very different conditions and it is important to understand the differences. Although both conditions involve swelling, edema and lymphedema have very different causes and are treated differently. A previous blog post “When is it Lymphedema?” compares these two conditions:
Additional Resources:
http://www.lymphedemapeople.com/thesite/edema_or_lymphedema.htm

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Update on Lymphedema: Exercise After Breast Cancer Treatment Is OK

By Heidi Anne Duerr, MPH | December 20, 2011

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Lymphedema, swelling caused by a blockage in the lymphatic system, can occur as a result of surgical or radiation therapy associated with breast cancer treatment. Since some research has shown that exercise after breast cancer treatment has been associated with developing lymphedema, clinicians often advise patients to avoid exercising. But is this truly necessary?

To better understand the actual risk, Dr Marilyn L. Kwan, research scientist at the Kaiser Permanente Northern California Division of Research, and colleagues conducted a systematic literature review of contemporary studies. After applying exclusion criteria, Kwan et al. identified 19 articles for review and synthesis. The researchers rated the evidence in the studies utilizing the Oncology Nursing Society Putting Evidence into Practice Weight-of-Evidence Classification.

Of the included studies, seven examined the effects of resistance exercises, seven examined regimens including aerobic and resistance exercises, and the remaining five studies looked at other exercise modalities. Kwan et al. found that slowly progressive exercise of varying modalities was not associated either developing or exacerbating lymphedema associated with breast cancer. Further, the studies indicated that, with careful supervision, patients should be allowed to participate in such exercise regimens. However, data from the studies examining combined aerobic and resistance exercise did not yield as conclusive results or recommendations. While the studies showed that these exercise regimens appeared to be safe, confirmation of their safety requires larger and more rigorous studies.

“Strong evidence is now available on the safety of resistance exercise without an increase in risk of lymphedema for breast cancer patients,” Kwan and colleagues concluded. “With reasonable precautions, it is safe for breast cancer survivors to exercise throughout the trajectory of their cancer experience, including during treatment.”

“Exercise can be beneficial and not harmful for breast cancer survivors,” Dr Jane Armer, one of the study’s co-authors and director of nursing research at the Ellis Fischel Cancer Center at Sinclair School of Nursing, explained in a statement to the press. “Each individual should balance the pros and cons of the activity she chooses, but keep in mind that being sedentary has risks and being active is beneficial in many ways, including possibly reducing the risk of cancer recurrence.”

References:
Kwan ML, Cohn JC, Armer JM, et al. Exercise in patients with lymphedema: a systematic review of the contemporary literature. J Cancer Surviv. 2011;5(4):320-3.
Craven S. MU researchers recommend exercise for breast cancer survivors, lymphedema patients. University of Missouri Press Release. Nov. 30, 2011.

Cancer, Research, Stanford News, Women's Health

New Stanford registry to track lymphedema in breast cancer patients

John Stafford on December 12th, 2011 No Comments

Increasing numbers of women are surviving breast cancer, but some of the therapies used to treat the cancer can cause a serious side effect: lymphedema. That disorder is, unfortunately, often misdiagnosed or ignored in breast-cancer survivors, so Stanford researchers are launching a registry to aid in better understanding the problem. As my co-worker explains:

…The information and records of breast cancer survivors gathered in the registry will be used in a study to determine whether early diagnosis of lymphedema can help treat and, possibly, prevent it.
“There is early evidence to suggest that prompt diagnosis may reduce the severity or eliminate this problem,” said Stanley Rockson, MD, the Allan and Tina Neill Professor of Lymphatic Research and Medicine, the lead investigator of the study. “If you take a wait-and-see treatment approach, by the time the lymphedema becomes noticeable, it can be quite advanced. Caught earlier, it may be more manageable, or even reversible.”

Head over to our release for the rest of the story.

New registry will track lymphedema among breast cancer patients

http://www.healthcanal.com/cancers/24492-New-registry-will-track-lymphedema-among-breast-cancer-patients.html

BY TRACIE WHITE - More and more woman are surviving breast cancer, but lifesaving surgical and radiation therapies can cause a grave side effect: an incurable chronic condition called lymphedema that involves swelling of the arms and often debilitating pain and discomfort.

Stanley Rockson

While this disorder frequently has been ignored, misdiagnosed and untreated in breast-cancer survivors, that’s beginning to change.
In an effort to find better treatment and preventive strategies for lymphedema, researchers at the Stanford University School of Medicine are launching a patient registry to study breast-cancer-related lymphedema. The information and records of breast cancer survivors gathered in the registry will be used in a study to determine whether early diagnosis of lymphedema can help treat and, possibly, prevent it.
“There is early evidence to suggest that prompt diagnosis may reduce the severity or eliminate this problem,” said Stanley Rockson, MD, the Allan and Tina Neill Professor of Lymphatic Research and Medicine, the lead investigator of the study. “If you take a wait-and-see treatment approach, by the time the lymphedema becomes noticeable, it can be quite advanced. Caught earlier, it may be more manageable, or even reversible.
“Oncologists and surgeons are becoming more aware of the need, and there are new technologies that help with early diagnosis.”

A leading expert in lymphatic diseases, Rockson, who directs the Center for Lymphatic and Venous Disorders at Stanford, helped establish the first patient registry and tissue bank for patients with lymphatic disorders in 2009.
For this new study, Stanford researchers hope to recruit an estimated 1,000 breast-cancer survivors for the Stanford National Breast Cancer Lymphedema Registry.
“Members of the American Society of Breast Surgeons will have the opportunity to collaborate in this project,” according to a statement from the society. “Member surgeons can choose to help Stanford in the identification of patients to be enrolled in the registry and will facilitate participation through the society's web-based quality reporting initiative.”
Participants will periodically update information about any symptoms, test results or treatments in 15-minute online sessions. They’ll give approval for their surgeons to provide their treatment information to the registry. Identifying information will be removed.
Currently, there is no cure for lymphedema, a disorder that arises in 15-60 percent of breast cancer survivors. A lifelong problem of disrupted lymph circulation characterized by fatigue, limb swelling and loss of the integrity of the skin, the condition’s severity can range from mild discomfort to disabling disfigurement, pain and loss of function.
When lymph circulation is delayed or interrupted, swelling and inflammation can result from a traffic jam of lymph that builds up in the limbs. There are multiple sources of blockages but often they are caused by tumor removal surgery, radiation treatment or lymph node biopsy. The only available treatments are physical therapies, including skin massage, drainage and pressure bandages, though the long-term effectiveness of these therapies has not been carefully studied.
Patients interested in enrolling can log into the Stanford National Breast Cancer Lymphedema Registry website at: http://breastcancer-lymphedema.stanford.edu. For more information, patients can call (650) 723-1396 or email lymphatic@stanfordmed.org.
Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.

Treatment of various secondary lymphedemas by microsurgical lymph vessel transplantation

Felmerer G, Sattler T, Lohrmann C, Tobbia D.
Microsurgery. 2011 Nov 24. doi: 10.1002/micr.20968. [Epub ahead of print]

Source
Division of Plastic Surgery, Department of Trauma Surgery, Plastic and Reconstructive Surgery, University of Medicine, Göttingen, Germany; Department of Plastic, Aesthetic and Hand Surgery, Klinikum Kassel, Kassel, Germany; Department of Radiology, University of Freiburg Medical Centre, Freiburg, Germany. gunther.felmerer@med.uni-goettingen.de.

Abstract
Chronic lymphedema is a debilitating complication of cancer diagnosis and therapy and poses many challenges for health care professionals. It remains a poorly understood condition that has the potential to occur after any intervention affecting lymph node drainage mechanism. Microsurgical lymph vessel transplantation is increasingly recognized as a promising method for bypassing the obstructed lymph pathways and promoting long-term reduction of edema in the affected limb. A detailed review of 14 patients with postoperative lymphedema treated with autologous lymph vessel transplantation between October 2005 and November 2009 was performed. In this report, the authors gave an account of their experience in utilizing this operative method to alleviate secondary lymphedema including upper limb, lower limb, genital, and facial edemas. Lymph vessel transplantation enhanced lymphatic drainage in patients with secondary lymphedema. In the upper and lower extremities, three patients had completed symptomatic recovery and another nine patients achieved reasonable reduction of lymphedema, four of these needed no further lymph drainage or compression garments and the remaining maintained their improvement with further decongestive therapy with or without compression garments. The patients with facial and genital edemas also experienced significant symptomatic improvement. The authors were able to establish long-term patency of the lymph vessel anastomosis by magnetic resonance lymphangiography. © 2011 Wiley Periodicals, Inc. Microsurgery, 2011.

http://www.ncbi.nlm.nih.gov/pubmed/2211 ... t=Abstract

Mohawk College Offers Lymphedema Program

Submitted by LymphedemaDepot on Dec 05, 2011

Lymphedema is one of the most feared and least understood complications of breast cancer treatment. Mohawk College in Hamilton, Ontario, is offering a day-long overview that will prepare the student to understand the causes of lymphedema as well as its treatment and management.
John Mulligan, RMT/CLT-LANA will present an Overview of Lymphology and Lymphedema Management at Mohawk College at the Mohawk/McMaster Institute of Applied Health Sciences Hamilton Campus in the Applied Health Sciences building, on Saturday February 4th, 2012, 9:00 a.m. to 4:30 p.m.
This unique one day workshop will explore the different types and stages of lymphedema, clinical pathways for treatment and the need for skilled care. Topics include basic lymphology, differentiating among different types of edema, the role and mechanics of compression, manual lymph drainage and complex decongestive therapy. We will also discuss the International Lymphedema Framework Movement, research resources and educational opportunities in the field of lymphology.
This one-day introduction to the basics of lymphedema and lymphedema management will immediately give the attendees a solid base of knowledge of the lymphatic system and disorders of the lymphatic system.
For more information visitwww.LymphedemaDepot.com and click on EVENTS in the left-side menu. This will bring you to the Mohawk online course catalogue where register for the daylong overview. To locate the course listing, simply go to page 53 of the catalogue. To register, click on Registration Information.
For further assistance contact John Mulligan directly at john@lymphedematherapist.com.
For more information about Mr. Mulligan and his practice, please visit www.LymphedemaTherapist.com.

MLD/CDP Manual Lymphatic Lymphedema Certification course, February 14-19th, 2012

The course layout would be as follows: 

Module I:  30 hours/home study.  Start as soon as you can.  It consists of a paperback book to read, questions to answer, and CD's to listen to.

Module II:  Tuesday/Wed the 14th-15th, of February, 8am-6pm,  (plus a few hours of practice/homework in the evenings)

Module III:  Thursday the 16th-19th, 8am-4:30pm, except for Sunday, we release at 2pm.   The students just starting Module II on Tuesday the 14th will continue until 6pm

Module IV:  Compression bandaging portion, April 19th-22nd.  8am-4:30pm

See the attached document for costs, and content/objectives and then let me know what questions you have!.  Looking forward to having you.  We have a great time and the classes are very relaxed. 

email me for complete course details:  carmenethompson@gmail.com

Great article on Lymphedema of the Trunk and Breast, by Joachim Zuther

Lymphedema Affecting the Breast and Trunk

By Joachim Zuther, on October 5th, 2011

Lymphedema affecting the chest, breast and posterior thorax, also known as trunkal lymphedema, is a common problem following breast cancer surgery, but is often difficult to diagnose, especially if the patient does not also present with lymphedema of the arm, or it may be dismissed as a side-effect of breast cancer surgery, which will resolve by itself over time.
While trunkal lymphedema is often not reported, poorly documented and available studies are not easy to compare, the literature suggests an incidence of up to 70% of lymphedema affecting the trunk and/or breast following breast cancer treatment.
Given the fact that the breast, anterior and posterior thorax and the upper extremity share the axillary nodes as regional lymph nodes, it is predictable that disruption of lymphatic drainage pathways by partial or complete removal of axillary lymph nodes, with or without radiation therapy can cause the onset of swelling in the chest wall and breast on the same side. The swelling can either be subtle or quite obvious in presentation and may be present with or without swelling in the arm.
The disruption of the natural lymphatic drainage pattern is further complicated by scars on the upper trunk wall following lumpectomy, mastectomy, and reconstructive breast surgery, biopsies or drain sites. Fibrotic tissues in the chest wall or armpit following radiation treatments may further inhibit sufficient lymphatic drainage.
Certain breast reconstructive procedures, such as the TRAM-flap reconstruction also disrupt lymphatic drainage in the abdominal area, which may cause the onset of additional swelling in the lower trunkal (abdominal) area.
Like lymphedema in the extremities, swelling affecting the breast, chest and posterior thorax is typically asymmetrical in appearance if compared with the other side. However, there are often other symptoms present prior to the onset of visible swelling, which may include altered sensation (numbness, tingling, diffuse fullness and pressure, heat), pain and decreased shoulder mobility. Once lymphedema is visibly present, the swelling may include the entire thorax wall, or may be localized to the armpit, the scapula, the area over the clavicle or around mastectomy/lumpectomy scar lines, around the reconstructed breast or implants, or it may be limited to the breast tissue only.
The breast in patients who underwent lumpectomy or reconstructive surgery may be larger and heavier, or the shape and height of the breast tissue may change due to fibrotic tissue, resulting in added psychological distress due to problems involving clothing, bra fit and body image issues.
Post-operative swelling following breast cancer surgery is to be expected and generally lasts up to about three months; it appears almost immediately following surgery and places additional stress on the lymphatic system by contributing to the lymphatic workload. The difference between “normal” post-operative edema and lymphedema is its perseverance following the completion of treatment, and the presence of changes in tissue texture, such as lymphostatic fibrosis.

skin fold caliper

While several methods are available to assess trunkal and breast edema (skin fold calipers, bioimpedance), subjective examination of the anterior and posterior aspect of the thorax and breast focused on the observation of signs of swelling (asymmetry, bra strap and seam indentations, orange peel phenomenon, changes in skin color), palpation of the tissue texture and comparison of skin folds between the affected and non-affected side, remain the most practical means for assessment of lymphedema affecting the trunk. Serial photographs depicting the anterior and posterior view are helpful tools in assessing changes before and after treatment.
Most of the symptoms associated with trunkal lymphedema can be treated successfully with Complete Decongestive Therapy (CDT), to include Manual Lymph Drainage (MLD), especially if combined with self-MLD, skin care, exercises and compression therapy. Fortunately, trunkal swelling responds well to treatment, often with markable improvement within 10 treatments. Treatment may be necessary only during the initial period following breast cancer treatment to facilitate edema removal and wound healing, or it may be applied at a later point; trunkal lymphedema with or without the involvement of the arm may appear at any time following surgery for breast cancer.
Manual Lymph Drainage: In case of localized trunkal lymphedema without involvement of the arm, MLD techniques concentrate on the neck, the anterior and posterior aspects of the upper trunk, as well as the inguinal lymph nodes, followed by techniques focused to redirect lymphatic fluid from congested areas into areas with sufficient lymphatic drainage. If necessary, additional techniques aimed to soften fibrotic tissues may also be applied.
For patients who underwent TRAM-flap procedures, careful attention should be given to address scar tissue that could lead to trapping of lymphatic fluid.
During the initial stages of the treatment, patients should be instructed in self-MLD and encouraged to perform self treatment for at least 20-30 minutes daily.
Skin Care: Patients who have lymphedema are susceptible to infections of the skin; areas between skin folds or the underside of the breast are particularly prone to skin damage and infections. Edematous areas should be kept clean and dry and suitable ointments or lotions formulated for sensitive skin, radiation dermatitis and lymphedema should be applied.
Exercises: Trunkal lymphedema is often associated with restrictions in thorax and shoulder movements, which should be evaluated by a Physical or Occupational Therapist. Specific exercises addressing these issues and to increase range of motion and function with daily activities should be performed.
Depending on the location and quality of scars, mobilization of adhered scar tissue by a qualified therapist may be necessary to improve range of motion. Breathing and aerobic exercises further facilitate decongestion by improving drainage in superficial and deep lymphatic pathways.
Compression Therapy: Oftentimes compression of the affected area may be challenging due to tenderness of the tissue, or irritated skin secondary to

compression bra

radiation therapy. However, in order to address fluid accumulation and to avoid worsening of the swelling, the application of compression bandages and/or compression bras or vests is very important. Compression bandages are applied circumferentially around the chest with special care not to impair blood supply to grafts and/or healing scars.
Due to the lack of muscle pump activity in the trunkal area, the use of wide-width (15-20cm) medium and long-stretch bandages is preferable over the normally used short-stretch bandages for lymphedema affecting the extremities.
Custom cut or commercially manufactured foam pads or foam chips may be inserted underneath the bandages or compression bra/vest to increase localized pressure in areas of excess fluid pooling, or to soften localized fibrotic tissue. Flat foam pieces can be used to shape and stabilize the compression bandages and to distribute the pressure evenly over a greater surface area.
The patient should be fitted with a specially designed lymphedema bra or compression vest following decongestion of the trunk to assist with maintaining the positive results of CDT. Compression bras and vests have minimal seams and wide straps, are available as off-the-shelf or custom-made garments and ensure that the trunk and breast tissues are properly supported. Compression bras and vests should fit comfortably, provide sufficient support around the trunk and not squeeze breast tissue; pockets to accommodate a prosthesis can be sewn into these garments.
Patients using regular bras or sports bras should make sure to avoid narrow bra straps and obtain bra strap pads or wideners, if necessary, to avoid restriction of lymphatic pathways on the shoulder.
Additional Resources:
http://www.stepup-speakout.org/breast_chest_trunckal_lymphedema.htm
http://www.lymphoedema-uk.com/journal/0101_breasttrunk.pdf

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