In my previous post I wrote about returning to the pool and how helpful I have always found this to be. This resulted in a number of questions which I feel are answered in this article from Aqua Lymphatic Therapy. If we can find a group like this or similar it would be great, but I am not going to hold my breath for that!!! I am sure however with this guidance you can put some exercises together yourself.. Tread water, walk in water and use a buoyancy belt or noodle to help…. Join a water aerobics class…. Enjoy
Water – is it good for lymphedema?
Aqua Lymphatic Therapy
By Dorit Tidhar
Article reprinted from the Spring/Summer 2011 issue of Lymphedema Matters, a publication of the Lymphedema Association of Ontario.
Mrs. G’s birthday is coming up and her husband decided to surprise her with a gift, a day of pampering at a spa. His wife was pleased, yet concerned. She did not know whether a spa would be safe for her lymphedema. She called her therapist for advice. “It seems as if lymphedema does not respond well to high temperatures” said Mrs. G. to her husband. Regrettably, she asked him to return the gift and he decided to buy her a swimming pool membership instead. Was he doing the right thing?
Lymphedema is defined as an abnormal accumulation of a protein-enriched fluid accompanied by chronic inflammation, due to the damage or blockage of lymphatic vessels. People with lymphedema, or at risk of developing lymphedema, should adopt strategies in order to prevent or reduce the exacerbation of lymphedema. These include avoidance of trauma or injury, intact skin preservation, avoidance of constriction, use and exercise of the body, arms and legs. On a similar note, exposure to extreme heat could be of major concern. But why? Exposure to high levels of external temperature (hot water bottles, electric blankets, hot tubs and jacuzzi) causes the capillaries in the skin to dilate; this may lead to an increase in interstitial fluid and can exacerbate existing lymphedema, or trigger the beginning of lymphedema. Therefore it is highly recommended to avoid direct heat applications on the affected area. Sauna or steam rooms do not project direct heat to the skin (heat transfer is much slower in air than in water). Nonetheless, they can cause elevation in body temperature and lead to the worsening or development of lymphedema.
A safe temperature is one that will not elevate body temperature and as a result will not cause the response of vasodilation in the skin. Is there any optimal temperature, or a “safe” temperature? A safe temperature
depends on several factors: The activity that is being performed in the water (whether it is just immersion such as sitting in the tub or swimming), the duration, and the medical condition of the person. Immersion alone is likely to be safe up to 35°C. Consequently, hot baths or jacuzzi are probably hazardous since the temperature is usually above 38°C (100.4°F). When exercising in water, the temperature should be adjusted to lower levels: 29 to 33৹C (84-91.4৹F) is considered to be safe. Importantly, when swimming or exercising in aqua fitness, the temperature of the water needs to be cooler than when one is just walking in the water.
It is important to get physician clearance before participating in any pool activity, and to check the sanitary condition of a pool. Interestingly, the bacteria that causes erysipelas (cellulitis) is not present in pool water, but is actually harbored on the skin. Intact skin preservation is of utmost importance.
Beyond safety concerns, one should ask the question: what types of exercises in water could be of benefit to lymphedema treatment?
Compression garments are generally recommended to treat lymphedema. These garments apply gradient force from higher to lower pressure. Hydrostatic pressure applies its force with an analogous mechanism to compression garments. Importantly, the pressure gradient by water exceeds the pressure gradient by compression garments. Hydrostatic pressure increases directly with the depth of water. When immersing in water, the addition of each centimeter of depth will increase the hydrostatic pressure by 0.73 mmHg (1.85 mmHg/inch). For example, the pressure on feet at a depth of 100 centimetres, would be 73 mmHg (more than a pressure applied by a class 3 compression garment). This pressure is pleasant and imperceptible. In addition, the pressure exerted on a body that is immersed in water is equal from all directions at every depth. This is of utmost importance as some parts of the body (i.e. chest, breast, genitals, ankles, wrist, fingers and toes) often do not experience equalized pressure by compression garment or by bandaging.
Lymphotome is a skin area that drains lymph fluid into regional lymph nodes. For example, the chest lymphotome drains the skin of the arm, front and back chest into the lymph nodes under the armpit. Excess lymph fluid has to pass through healthy lymphotomes and into functional lymph nodes. Immersion in water may be insufficient for treating lymphedema. Hydrostatic pressure lacks the ability to redirect the lymph fluid to healthy lymphotomes. Therefore, there is a need for supplementary exercises such as the Aqua Lymphatic Therapy (ALT) – the Tidhar method©.
ALT is based on the Casley-Smith remedial exercises and uses the same principles, yet in an aquatic environment. The method uses the anatomical principles of the lymphatic system and the force of the water to achieve the goals of lymphedema therapy. The water temperature ranges from 31°C to 33°C (78.8-91.4°F). This temperature enables slow movements in a safe way that will not cause increased swelling. The buoyancy force enables elevating of the limbs and thus performing exercises and self massage with minimal effort. The hydrostatic pressure of water increases lymph and venous flow, thereby protects the limb from swelling and reduces edema. Chronic lymphedema of the limbs can cause muscle weakness. The viscosity of water provides resistance to body movements. ALT uses different ways to minimize water resistance:
• Reducing the surface of progression (for example, in lymphedema of one arm, side walking instead of frontal plane walking)
• Moving through the water in a slow and gentle manner
• Exercising certain movements with flexed instead of stretched extremities
• Over time the resistance will promote strengthening as well.
The sequence of exercises in ALT is important. First, healthy lymphotomes are activated proximally with breathing exercises in order to clear the reservoir. Second, proximal movements of the thorax, abdomen and shoulder girdle are performed in conjunction with self-massage. Lastly, exercises are performed to clear the affected lymphotomes into the healthy ones by performing self-massage and movements that involve distant joints of the limbs (ankle, wrist etc)
ALT is usually performed in a group setting, in which people with similar conditions exercise together. Each session lasts 45 minutes. Once a week, meas- urements of limb circumferences are taken before and after each session to enable the participants to receive immediate feedback on their performance and on their progress between sessions. It is recommended to bandage the limb or to wear a compression garment immediately after an ALT session in order to preserve the volume reducing results of the treatment.
The ALT method was studied in a randomized controlled trial published in 2009, in which 48 women with lymphedema of the arm were divided into study and control groups. The study group participated in a weekly session of ALT and both groups were supposed to keep on performing self management therapy (included self massage, use of compression garment or bandaging and remedial exercises). The women were treated for 3 months and arm volume measurements, quality of life and self-management care were evaluated. Quality of life improved over the 3-month intervention in both psychological and social dimensions in the ALT group while the control group saw a decrease in quality of life over time.
There was a mean volume reduction of 54 ml after the first ALT session and a mean reduction of 98 ml after the last session. These differences were statistically and clinically significant. However, these reductions were not maintained over the study period. This could be due to low adherence (28%) with compression sleeve wearing. ALT was found to be safe as no woman experienced infection during the intervention period. On a similar note, ALT was found to improve strength, shoulder range of motion, pain and disability in a second randomized control pilot study (unpublished data; 2007).
Mrs. S had lymphedema of the left leg due to removal of inguinal lymph nodes and radiation after gynecological cancer surgery. She suffered from 23% volume increase in her lymphedematous leg as compared to her healthy right leg. After an intensive therapy of Complex Lymphatic Therapy (CLT) her lymphedema reduced to 3% volume difference and was maintained for 6 months. Following an allergy attack and a second tumor removal from her genitals, her lymphedema worsened and reached 17% compared with her healthy leg. Swimming 3 times a week and wearing the compression garment did not stop the exacerbation. She could not afford to take time off from her work once more for intensive CLT. Fortunately, 2.5 years later, an ALT program was launched close to her home. She attended the group sessions once weekly for 18 months. Furthermore, she wore a compression garment during the daytime between sessions and continued swimming twice weekly. In 4 months she reduced her swelling from 17% to 2% (-88%change) and maintained that for the rest of the year.
In summary, an aquatic environment is safe as long as it is being used in accordance with the principles discussed above. ALT is a method that can improve lymphedema and maintain the results of the intensive therapy. When summer comes dive in and take the pressure off your limbs!
Dorit Tidhar was trained in lymphedema therapy by Prof. Judith Casley-Smith in 1999 and was certified by her as a teacher in Self Management and Exercise for Lymphedema in 2003. Dorit designed a program of Aqua Lymphatic Therapy to help people who suffer from lymphedema maintain and improve results of conventional treatment. She is an active member of the steering committee of the Israel Lymphatic Interest Group of Physiotherapists. She has published five articles in scientific journals. She is now working at the McGill University Health Centre’s Lymphedema Clinic in Montreal as a clinician and instructor. She is coordinator of the educational program for lymphedema therapists and nurses in various subjects related to lymphedema.
Thank you for this article Aqua Lymphatic Therapy ALT and Dorit Tidhar http://www.aqua-lymphatic-therapy.com/ If you wish to know more please click on this link…
Breathing before starting the exercises
Self massage in the water
Video to show an Aquatic exercise for Lymphedema of the legs.
Video to show Aquatic exercise for the arm.