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Exercising woman

Lymphedema: Personal Trainer Perspective

Cancer surgery and treatment often results in survivors suffering debilitating physical impairments. These can often be ameliorated by a good exercise program that has the added benefit of helping survivors to engage in those activities in which they participated prior to their diagnosis. This article addresses some of the physical side effects cancer survivors may face, including lymphedema and a series of safe and effective techniques to restore functional fitness for those with or at risk for lymphedema.

feel better

Surgery, chemotherapy, radiation, and hormonal therapy have side effects, which exacerbate the problems faced by cancer patients. Surgery can create adhesions that can limit range of motion, and cause pain, numbness and tightness. Removal of lymph nodes creates scars and may decrease range of motion. Radiation can cause fatigue, tightness and stiffness. It also can increase the risk of developing lymphedema. Chemotherapy may affect balance, a patient’s immune system, and cause neuropathy, fatigue, sarcopenia, and anemia. Hormonal therapy can cause joint pain and early menopause and the side effects associated with menopause.

Before beginning a cancer exercise program, a patient must receive medical clearance. A medical history, base line range of motion and girth measurements, and a general fitness assessment are taken. It is important to note that many exercises and movements may be contraindicated based on a person’s fitness assessment, medical conditions, and particular surgery. There are different exercises necessary for each type of reconstruction. For those who were active prior to surgery it is imperative to slowly work back up to the previous level of activity. It is not wise to go back to a gym and immediately continue with a pre-cancer exercise routine.

Research has shown that exercise is safe for cancer survivors, even those with or who are at risk for lymphedema. Dr. Schmitz stresses the importance of starting slowly and using proper form with a well trained certified professional. Her study demonstrates the importance of exercise after cancer with slow progressive improvement in order to decrease risk of lymphedema. The research shows that breast cancer survivors no longer have to give up activities that they enjoy doing and avoid activities of daily living. Aerobic exercise is essential to good health and we advise a patient to walk as much as possible. Initially, one might start by walking around their house or up and down their block and then slowly increasing the distance walked. Many physicians recommend that their patients try to walk during chemotherapy. This may decrease fatigue. If using aerobic equipment, make sure not to grip on the railing.

Unfortunately, there is no way to know which patients with lymph node dissection will get lymphedema. This makes it imperative to follow the established guidelines and take a prudent approach to exercise. Patients who have lymphedema need to progress slowly and use a properly fitted garment. Our goal is to promote physical activity without exacerbating lymphedema. Severe range of motion issues and cording problems are referred to lymphedema specialists. Moreover, measurement of the limbs that are at risk for lymphedema are performed frequently to make sure they have not changed in size. Symptoms can be managed easier if they are addressed promptly. Progress is monitored in order to make appropriate modifications to a patient’s program. It is important to learn the right exercises for a patient’s particular situation and how to do them properly and with good form. The patient should learn which exercises to perform, the sequencing, and quantity of repetitions. Exercise smartly and under professional guidance!

Lymphedema can be debilitating and painful and can affect the emotional health of the patient. Our bodies work better if engaged in regular physical activity, but it must be done in a safe manner if lymph nodes have been removed or radiated. A cancer fitness program for someone with lymphedema should begin as an individualized program. The patient must be supervised to make sure there are no subtle volume changes to the limb. Ultimately, we want a patient to be able to exercise on his or her own.

The starting point is a low impact exercise program, performing range of motion stretches and techniques to improve venous drainage. First, we elevate the affected area above heart level. Over time, stretches are incorporated until a patient can achieve 80% of range of motion. At that point, we start adding strength training. A stretching program for those with upper body lymphedema begins with moving or stretching the neck and shoulder areas. If a patient is still healing from breast cancer surgery, begin with pendulum arm swings. The arm is then moved and stretched in all directions, going across the chest and behind the head and back. Stretches that move the arms in shoulder flexion, extension, abduction, and adduction are added. Finally internal and external rotations are addressed. Patients suffering from fatigue can perform many of the stretches while in bed. An easy-to-follow DVD is Recovery Fitness Simple Stretching, which can be found on www.recoveryfitness.net.

All of the exercises incorporate abdominal breathing, which can stimulate lymphatic drainage. This intra-abdominal pressure may help move sluggish lymph fluid, stimulate lymph flow, and act as a lymphatic system pump. This type of breathing enables oxygen to get to the tissues. Abdominal breathing and relaxation breathing, along with the proper exercises can also reduce stress, a common cancer side effect. If weak, it may be best just to stretch and breathe deeply.

Strength training may help pump the lymph fluid away from the affected limb. Exercise helps the lymphatic fluid to April / June 2013 ~ NATIONAL LYMPHEDEMA NETWORK 13 move. Muscles pump and push the lymph fluid and can help move the lymph from the affected area. Strength training may also strengthen the arm so that it can handle those activities that may have otherwise led to swelling with a greater level of ease. Always wear a sleeve and stop if there is swelling or pain. Start with light weights and slowly increase repetitions and eventually weight.

Cancer survivors should follow a systematic and progressive plan. Exercise starts with a warm-up and cool down. Begin with deep breathing. Keeping a strong core should be emphasized. It is important to remember that following treatment the body may have become weaker. Even if a patient had exercised using 10 pound weights before surgery, if one is at risk for lymphedema they must start with a light weight. We teach patients to always listen to their bodies and to stop if they feel tired or if their limb aches or feels heavy. Patients must be aware of any changes in their body.

Exercising womanProgression of exercise should be gradual. A deconditioned person should start without using any weight and concentrate on proper technique. If 8-10 repetitions can not be executed, repetitions should be decreased or the weight lowered or resistance band used changed to less resistance. The exercise routines have to be adapted for the day-to-day changes that that can affect the ability to work out. Our program will start using a very light weight, with few repetitions, typically 10. In subsequent sessions, patients can add repetitions. After performing 2 sets of 10 repetitions with no problem then a small amount of weight may be added in 1 pound increments. We also alternate between a strength training exercises with a stretch for each muscle group and to alternate an upper body and lower body exercises. Pilates exercises are great way to incorporate deep breathing with strengthening the core. The deep breathing helps to pump lymphatic fluid and will also help reduce stress.

Every patient is unique. Many patients have pre-existing medical issues. The exercise program should be modified to accommodate all body types and needs. Some might need pillows for comport or postural problems. Also if osteoporosis is an issue, a cancer therapist should have experience working with this population. Always monitor the affected limb. Look for feelings of fullness or aching. We do not want to overwhelm the lymphatic system. Drink plenty of water and stop immediately if any pain. Lymphedema patients should elevate their limbs after a session.

Learn which aerobic exercises are considered safe. Walking, biking, and swimming are considered very safe. Hot tubs, pools, and warm lakes may increase risk of infection. In choosing an activity, consider the risk of injury, prior medical condition, and fitness level. Injuries can create further complications for those with lymphedema. It is still unclear whether certain sports can be safe. For example, tennis can put a lot of stress or repetitive activity on one’s limbs. It is important to know if the activity was something performed prior to lymphedema. If the patient wants to resume the activity in order to exercise, have fun, and to have good quality of life, a sports fitness program can be instituted. This should be performed under medical guidance. In a sports fitness program, the muscles used in the sport are progressively strengthened so that the sport can be resumed. Patients must use caution as they return to a sport.

One of the most important things that can be done to decrease the risk of lymphedema is to keep weight at a good level. Those individuals with whom I have worked who have had lymphedema typically see a marked reduction of swelling in conjunction with weight loss. My students who are successful in losing weight have the most success in lymphedema control. Proper nutrition is important and decrease salt intake. Evidence suggests numerous benefits of exercise: improved fitness level, physical performance, quality of life, and less depression and fatigue. Exercise is part of a healthy lifestyle and will help in weight control and emotional health. There are exercise programs that are targeted at cancer survivors but not all of them will meet the needs of someone at risk for lymphedema.

My goal is for cancer survivors to participate in individually structured and group exercise programs at all cancer centers or facilities close to their homes.

Article reprinted with permission from Carole J. Michaels.

Carol J. Michaels is the founder and creator of Recovery Fitness® LLC, located in Short Hills, New Jersey. Her programs are designed to help cancer survivors in recovery through exercise programs. Carol, an award winning fitness and exercise specialist, has over 17 years of experience as a fitness professional and as a cancer exercise specialist.


Exercise and Bladder, Thyroid and Prostate Cancers: The Impact of Staying Active

Part I: Bladder Cancer

There are many reasons why a cancer patient should stay as active as possible through cancer treatment and recovery. I will begin by pointing out a few studies that show how exercise can benefit cancer patients. These studies demonstrate how exercise can reduce certain side effects from treatment, increase energy, decrease stress, and improve quality of life. In the last article of this series, I will suggest ways to develop an exercise program that based on the individual’s needs and is safe and effective.


Research has shown that exercise can reduce the risk of getting some types of cancers. There are numerous published studies on the benefits of exercise for those with colon cancer, breast cancer, and endometrial cancer. An American Cancer Society’s newsletter stated: “Among breast cancer survivors, a recent analysis shows that getting exercise after diagnosis was associated with a 34% lowered risk of breast cancer death, a 41% lower risk of dying from all causes, and a 24% lowered risk of breast cancer recurrence. Among colon cancer, studies suggest exercise cuts death from colon cancer and all causes, and cuts the risk of the cancer coming back by up to 50%.”

The Journal of the American Medical Association reported that exercise lowers the risk of 13 types of cancers. Since there is limited research on exercise and bladder cancer, it is important to note that the results of the study showed that those who exercised the most had a 13 percent lower risk of bladder cancer. The JAMA study is empowering because it provides further ammunition as to the importance of exercise for additional types of cancers.

Studies suggest that exercise is safe and helpful for many people who are suffering from cancer and may lower the risk of some cancers. Other health benefits of exercise are weight control, cardiovascular health, increased bone density, and decreased fatigue, stress, anxiety and depression. Exercise can improve range of motion, improve endurance, and decrease the risk of lymphedema.

Exercise helps to control obesity, which is positively correlated with several cancers. Studies have shown that weight gain increases the risk of cancer and the risk of recurrence during and after treatment. Since exercise is a crucial component of weight control which effects cancer risk, exercise needs to be considered as part of the treatment plan.

How does exercise play a role in cancer prevention, control, and cancer outcomes?

  • During exercise, epinephrine is released which helps natural killer cell infiltration.
  • Exercise may restore normal gene function and may influence tumor-suppressing genes. There is a relationship between hypomethylation and hypermethylation and cancer cells.
  • Exercise can affect hormone levels
  • Exercise reduces insulin, increases IGF-1, and decreases leptin and may have an anti-inflammatory effect.

What does the research show for bladder cancer?

It has been observed that exercise can improve outcomes for those with bladder cancer. Research conducted by J. Vallance suggests that strength training and aerobic exercise can improve psychological and physical issues for those with bladder cancer and increases the chance of survival.

In May of 2007, “Associations between Exercise and Quality of Life in Bladder Cancer Survivors: A Population-Based Study” by Kristina H. Karvinen et al was published in Cancer Epidemiology and Biomarkers. The authors examined the association between exercise and quality of life in a sample of 525 bladder cancer survivors. They found exercise to be negatively associated with several aspects of fatigue. The study also suggested that active bladder cancer survivors have improved mood and energy and quality of life.

In 2016, “Lifestyle factors and health-related quality of life in bladder cancer survivors: a systematic review” by Gopalakrishna, reviewed the literature on the associations between lifestyle factors and quality of life in bladder cancer survivors. Their conclusion was that there is some evidence for a positive association between quality of life and physical activity.

Kellogg Parsons, MD, an associate professor of Surgery at the University of California, San Diego, discusses modifiable lifestyle factors associated with bladder cancer on onclive.com. Parsons and his team found that participants who had any amount of physical activity had improved survivorship compared to those with no physical activity.

A recent study in by Cannioto et al in Cancer Epidemiology reports an association between living a life with little to no recreational physical activity and an increased risk for bladder cancer. The study suggests a connection between being inactive and increased risk of cancer.

In summary, we know that physical activity reduces the risk of numerous diseases. Now we have additional evidence, that it may also reduce the risk of bladder cancer.

Physical Activity in Bladder Cancer Patients

The sooner the patient starts to exercise the better. Starting before surgery and treatments and continuing during treatment can lead to a better recovery with less complications and medications.

Survivorship can serve as a strong motivator to make positive lifestyle changes. Everyone’s situation is unique. Accordingly, exercise needs to be tailored to individual people, taking into account their overall fitness, diagnosis, and other factors that could affect safety.

Regular physical activity can help rebuild a patient’s strength and energy level and help manage other health related issues. Health issues like diabetes, and cardiovascular diseases are a leading cause of death in cancer survivors and those without cancer. Managing health related issues through exercise could increase survival.

Some cancers and cancer treatments may result in incontinence. A side effect of biologic treatment may include irritation of the bladder, an urgent need to urinate, frequent urination, or incontinence.

Incontinence can occur in men or women with bladder cancer and last for a short time or longer. There are different types of incontinence, ranging from mild to severe. Some examples are: stress incontinence can cause a person to leak urine during activities such as coughing, laughing, sneezing, or exercising, urge incontinence is a sudden, urgent need to urinate and continuous incontinence is not being able to control the bladder at all.

Kegel exercises strengthen your pelvic floor muscles to control urine flow. The pelvic floor muscles are comprised of the bladder, sphincter and the pubococcyges muscle. These muscles are used to stop the flow of urine. You can find your pelvic floor muscles by squeezing your sphincter and contracting the urethra to stop the flow of urine when using the bathroom.

Exercise can help control incontinence without medication or surgery. It is wise to start Kegel exercises before surgery and treatments and to work with a pelvic floor specialist.

Kegel Exercise

Perform the Kegel 10 times holding for 5 seconds each. Try to do this four times per day. Take a 5-second break between each repetition. It may take several weeks or months to be able to contract your muscles for 5 seconds at a time, or to repeat it 10 times. If you perform the Kegel several times per day, your pelvic floor strength should improve.


  • Try not to use the surrounding muscle groups in the buttocks, legs and abdomen.
  • Try to lift the pelvic floor upward.
  • You can perform this exercise in any position: standing, sitting, or lying in bed.
  • Kegels can be done at any time, such as while watching TV, waiting in line or driving.

Part 2 will focus on thyroid cancer. Contact me at caroljmichaels@gmail or go to www.CarolMichaelsFitness.com or https://www.nfpt.com/product/cancer-recovery-specialist to find out about cancer exercise programs in New Jersey and cancer continuing education courses.

Carol J. Michaels is the founder and creator of Recovery Fitness® LLC, located in Short Hills, New Jersey. Her programs are designed to help cancer survivors in recovery through exercise programs. Carol, an award winning fitness and exercise specialist, has over 17 years of experience as a fitness professional and as a cancer exercise specialist.


Steven C. Moore PhD, et al, Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults JAMA Intern Med2016; 176(6): 816-825.

Lynch B.M., Dunstan D.W., Vallance J.K., Owen N. Don’t take cancer sitting down: A new survivorship research agenda. Cancer. 2013, Jun 1; 119(11): 1928-35 Medicine

Kristina H. Karvinen, Kerry S. Courneya, Scott North and PeterVenner, Associations between Exercise and Quality of Life in Bladder Cancer Survivors: A Population-Based Study, Cancer Epidemiology and Biomarkers Prevention May 2007, 10.1158/1055-9965

Gopalakrishna et al, Lifestyle factors and health-related quality of life in bladder cancer survivors: a systematic review. Journal of Cancer Survivorship, 2016 (5): 874-82

Vallance, J., Spark, L., & Eakin, E.. Exercise behavior, motivation, and maintenance among cancer survivors. In Exercise, Energy Balance, and Cancer (2013) (pp. 215-231). Springer

Cannioto et al. The association of lifetime physical inactivity with bladder and renal cancer risk: A hospital-based case-control analysis, Cancer Epidemiology, Volume 49 August 2017

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Stephanie Cash et al, Recreational physical activity and risk of papillary thyroid cancer among women in the California Teachers Study. Cancer Epidemiology, Feb 2013,37(1): 46-53

Hwang, Yunji MS; Lee, Kyu Eun MD, PhD; Park, Young Joo

MD, PhD; et al, Annual Average Changes in Adult Obesity as a Risk Factor for Papillary Thyroid Cancer: A Large-Scale Case-Control Study, Medicine, March 2016, Mar; 95(9): e2893

Cao Y, Ma J. Body mass index, prostate cancer-specific mortality, and biochemical recurrence: a systematic review and meta-analysis. Cancer Prev Res (Phila). 2011; 4: 486-501.

Galvao, et al. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010 Jan 10; 28(2): 340-7.

Galvao, et al. Exercise can prevent and even reverse adverse effects of androgen suppression treatment in men with prostate cancer. Prostate Cancer Prostatic Dis. 2007; 10(4):340-6.

Winters-Stone KM, et al. Resistance training reduces disability in prostate cancer survivors on androgen deprivation therapy: evidence from a randomized controlled trial. Arch Phys Med Rehabil. 2015 Jan; 96(1): 7-14.

Giovannucci EL, Liu Y, Leitzmann MF, Stampfer MJ, Willett WC. A prospective study of physical activity and incident and fatal prostate cancer. Arch Intern Med. 2005; 165: 1005-1010.

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Focht, Brian C.; Lucas, Alexander R.; Grainger, Elizabeth; Simpson, Christina; Fairman, Ciaran M.; Thomas-Ahner, Jennifer; Clinton, Steven K., Effects of a Combined Exercise and Dietary Intervention on Mobility Performance in Prostate Cancer, Medicine & Science in Sports & Exercise. May 2016:48(5S): 51


Woman holding an x-ray image


According to the National Osteoporosis Foundation, 1 out of 2 women and 1 out of 4 men over 50 will have a wrist, hip, or spine fracture due to osteoporosis. If you have osteoporosis or osteopenia you should learn how to exercise properly and safely in order to decrease the risk the progression of this disease. Effective and safe exercise can improve your quality of life, overall health, and keep your osteoporosis under control.