In my sixteen years of working with cancer patients, I would say this is the number one “overlooked” issue amongst cancer patients. More often than not, they will not even be told about lymphedema. Following lymph node dissection and/or radiation, the lymphatic pathways do not operate with the same efficacy that they did previously. Therefore, we no longer know what the individuals exercise threshold is. It is critical to START and PROGRESS SLOWLY. This allows for a gradual increase in frequency, intensity, and duration of the exercise program. If at any point there is swelling, the patient should be advised to stop exercising and see their doctor immediately to determine if, in fact, they do have the onset of lymphedema. They should come back with a medical clearance form and the exercise instructor should take a step back with the frequency, intensity, and duration to the point prior to the onset of swelling.
Putting all of these pieces together is very much like solving a mathematical equation. If you are missing any of the information, you will never solve the problem. A typical exercise session should begin with cardiovascular exercise. This too should be gradually increased at a rate that the client is comfortable with and their body responds favorably to. They should stay well-hydrated, they should not wear tight-fitting or restrictive clothing on their upper body, and they should not overheat (all of these factors can increase the risk of lymphedema). Following the warm-up they should be instructed to do a series of lymph drainage exercise to open up the lymphatic pathways and prepare the body for exercise. I reference these exercises in CETI’s Cancer Exercise Specialist Handbook and Breast Cancer Recovery with the BOSU® Balance Trainer Book.
Following the warm-up and lymph drainage exercises, the exercise specialist should determine what the areas of “need” are for the client. Remember to begin with stretching and range of motion exercises until they have close to “normal” range of motion. At that point the goal becomes strength training and choosing exercises that will strengthen the weaker muscles and stretch the tight and shortened muscles. Weight/resistance should also be very gradually increased and attention paid to any potential swelling of the extremity. Typically I chose exercises that will stretch the chest (chest fly, corner or door stretch, assisted stretching) and will strengthen the back (low/high rows, reverse flies, lat pulldown). They often [present with winged scapula following a node dissection. If this is the case, I will incorporate exercises that will strengthen the serratus anterior. If they have undergone an abdominal TRAM procedure, core work will be of the greatest importance in preventing, or minimizing, low back pain.
Because every muscle in the body works synergistically, an imbalance in the shoulder can lead to a multitude of imbalances from the hips to the knees to the ankles etc… Choose your exercises carefully. Put emphasis on the areas of need. This is not and can never be a cookie-cutter workout. No two breast cancer patients are the same. Not only are you taking into consideration their surgery, reconstruction, and treatment, you have to also factor in the remainder of their health history and any additional orthopedic concerns. I urge anyone who wants to work with cancer patients to undergo specialized training. It is very complex and the untrained professional can end up doing more harm than good.