Physical activity and sport, regardless of age, background, or location, enhances physical condition and offers numerous benefits for physical, mental, and social well-being. Regular physical activity offers numerous benefits for both adults and children, it strengthens the heart, improves blood circulation and sugar levels, builds muscle mass, bone density, joint flexibility, helps maintain a healthy weight, and boosts overall well-being and quality of life. Likewise, insufficient physical activity is a major risk factor for chronic conditions like cardiovascular disease, osteoporosis, etc.
The diagnosis of lymphedema doesn’t have to mean giving up exercises and sports, in fact, recreational activities have physical and emotional benefits for people with lymphatic dysfunction. In some cases they can even help slow the disease progression, even though there’s no normative guideline for exercise prescription from the perspective of reducing lymphatic dysfunction severity. The psychological Impact due to the visible swelling (disfigurement) and physical limitations associated with lymphedema (physical disability), can also lead to anxiety, depression, and social isolation. Impaired lymphatic function can pose certain risks, but with proper precautions, guidance, right adaptations or modifications, many sports and physical activities are accessible to people with different range of lymphedema stage levels.
WHAT ARE THE PHYSICAL LIMITATIONS AND RISKS IN LYMPHEDEMA?
Numerous scientific evidence regarding risk factors and injury complications in sport practice have been published, but there aren't studies specifically evaluating sport injuries in patients with impaired lymphatic function, therefore a “common-sense” approach should be adopted regarding sport injury preventative strategies and management in lymphatic vascular disease. Apart from the recognized risk of injuries related to various sport activities in the general population, it is clear that lymphedema carries an increased risk of developing severe complications, and therefore this fact should not be underestimated. Swelling in limbs due to lymphatic fluid build-up can cause pain, limited range of motion, and make individuals more susceptible to skin infections (infectious cellulitis). The physical limitations imposed by lymphatic dysfunction can make it difficult to engage in strenuous activities and maintain fitness levels. It is crucial to consult with a doctor or physical therapist before starting any exercise program to assess individual risks and benefits, as well as to monitor symptoms and adjust activity levels accordingly.
Lymphedema (Organic Lymphatic Vascular Disease) is due to impaired lymphatic drainage resulting in skin disease, characterized by persistent and progressive swelling, and abnormal thickening of the skin and subcutaneous connective tissue. lymphatic dysfunction is not just a localized swelling problem, but a condition that can affect multiple body systems, structures and functions, leading to a range of physical, physiological and psychosocial symptoms and complications. It is clear that no patient or their lymphedema is the same and neither is its progress. Some patients with limb lymphedema can easily do different degrees of physical activity, while others feel the strain and experience increased swelling with minimum effort. Research and planning are key to participating in physical activities, but it is essential to first consult with a healthcare provider to consider the sports and exercises options that can be done comfortably, safely, and with a limited risk and impact on the effected limbs.
WHAT ARE HIGH AND LOW IMPACT AND HIGH AND LOW CONTACT SPORTS
Depending on the amount of force exerted on the body, particularly the joints or the physical interaction between players, physical activity can be divided into high or low impact and contact sports and exercises.
High-Impact Sports are activities that put significant force on the body, involving running, jumping, landing, and rapid changes in speed and direction, and movements where both feet leave and then hit the ground, placing force and stress on the joints. This contributes significantly to a high risk of ankle sprains, knee injuries and falls, that can be harder to recover from. Even though proper technique and protective gear can help mitigate injuries, it doesn't eliminate all risks. Examples of intense high-impact physical activities are basketball, volleyball, tennis, etc. High-Contact Sports involve physical interaction between players, and potential high-impact collisions and increased risk of injury due to the nature of the sport. Examples of High-Contact physical activities are football, soccer, rugby, hockey, etc.
Low-Impact sports are activities that put less stress on the joints, as they keep at least one foot remaining on the ground during movement, making them suitable for people of all ages and fitness levels. When done safely and under guidance, they are good choices for maintaining cardiovascular health, improving range of motion and muscle strength, and promoting lymphatic flow without excessive strain or worsening lymphedema. Low-Contact sports minimize physical interaction between players. Examples of low-impact and contact sports and physical activities are walking, swimming, indoor/outdoor cycling, nordic walking, archery, bowling, golf, dancing, Pilates, aqua exercise , aerobics, gradual strength training, etc. There are also specific lymphedema exercises and activities (deep breathing exercises, posture work, gentle stretching and flexibility exercises, etc) that are designed to promote lymphatic drainage, which can be incorporated into a daily fitness routine.
WHAT ARE THE MAJOR INJURIES ASSOCIATED WITH SPORT?
All physical activity carries some risk of injury, although the risk varies greatly depending on the type, intensity, duration, environment, as well as individual pre-existing conditions. While most forms of exercise are generally safe, beneficial, and outweigh the risks, injuries can still occur, and it's important to be aware of potential risks and take steps to minimize them. The most common injuries associated with physical activity are musculoskeletal injuries, such as sprains, strains, and overuse injuries.
WHAT ARE THE MAJOR INJURIES IN HIGH-RISK SPORTS?
Different sports have different types of risks and injury patterns, some contact intensity sports directly correlate with a high rate of high-impact collisions and injuries. There are several sports injuries that are known for their complexity and potential for long-term consequences, such as ACL tears, lacerations, concussions, fractures (particularly those involving multiple bones, surrounding tissues, and nerve or blood vessel damage), spinal injuries, etc.
WHAT ARE THE COMPLICATIONS RELATED TO FRACTURES?
Complications from sports-related fractures occurring in a high functioning population include acute issues like nerve and blood vessel damage, compartment syndrome, infection from open fractures, as well as delayed problems such as malunion (improper healing), avascular necrosis, joint damage, and complex regional pain syndrome. High-risk stress fractures, common in athletes, have a higher chance of requiring surgical intervention, and can potentially lead to permanent damage.
WHAT ARE THE COMPLICATIONS RELATED TO FRACTURES IN LYMPHEDEMA?
If a fracture occurs in a limb affected by lymphedema, the situation can be complicated by the difficulty of lymphatic drainage. In lymphedema, the risk of infection is higher than in people without lymphatic dysfunction, and a fracture can complicate recovery and cause additional inflammation, which could delay proper healing of the fracture, both in the bones and soft tissues. It is important to avoid Cellulitis, characterized by redness, swelling, pain, and warmth in the affected area, which can spread quickly to more serious complications like sepsis. Although exercise is beneficial for lymphedema, scrapes, cuts, and burns, no matter how small, can take longer to heal and become an entry point for bacteria, potentially causing inflammation, pain, and even serious infections if not managed properly. It is crucial to seek immediate medical attention to treat both the fracture and lymphedema, and prevent complications.
By addressing lymphedema injuries early and effectively, it is possible to optimize fracture healing and improve outcomes for individuals with both a broken leg and lymphedema. Effective management often requires a team approach, involving physicians and certified lymphedema therapists. Treatment plans should be tailored to the individual's needs and the severity of the lymphatic dysfunction.
Before starting any exercise program or sport, it's crucial to always consult with a doctor specializing in lymphedema or a certified lymphedema therapist for personalized advice. Each case is different and the situation of each patient must be analysed individually. Patients also need to be educated about the importance of adhering to risk prevention strategies to prevent severe complications.
WHAT SPORTS SHOULD BE AVOIDED IN LYMPHEDEMA?
As with other diseases and the general population, certain types of physical activities should be approached with caution, modified, or avoided altogether. While exercise is generally encouraged for managing lymphedema, activities to be cautious with or avoided in lower and upper limb oedema, are those that can cause excessive strain, fatigue, pain, injury, and trauma to the affected limb and lymphatic system.
It is important to remember that lymphedema is a chronic condition and that proper skin care and infection prevention are essential to avoid complications. Accumulated lymphatic fluid (lymphatic stasis) can hinder the body's ability to fight infection, and wounds may take longer to heal. Specific concerns related to lymphedema are injuries, even minor ones can be problematic due to the impaired lymphatic system's reduced ability to manage fluid and fight infection. Skin infections like cellulitis (dermatolymphangioadenitis) are a common complication, as bacteria can easily enter through even small cuts or abrasions.
High-intensity, high-impact, and high-contact activities in the affected area can cause fluid to accumulate (Increased inflammation and swelling), and may exacerbate and worsen lymphedema, and should be done with supervision and appropriate precautions. Any activity that requires prolonged static positions, or that causes increased swelling, pain, and that can potentially cause infections, injuries, trauma, and lead to worsening symptoms should be avoided or modified.
WHAT ARE THE RECOMMENDATIONS TO MINIMIZING THE RISK OF INJURY?
- Consult and get clearance with a healthcare professional (specialist doctor or certified lymphedema therapist) before starting any new sport or exercise routine.
- Inform the healthcare provider to any signs of increased swelling, pain, or discomfort during or after exercise, to adjust the activity accordingly or stop the physical activity if needed.
- Inform the healthcare provider to any signs of injury (cuts, scratches, burns, trauma). Non-healing sores or wounds in lymphedema can become chronic and difficult to heal.
- Avoid contact sports or activities with high risk of injury and trauma that can lead to severe complications.
- Avoid prolonged static positions.
- Avoid overexertion that can strain muscles and potentially exacerbate lymphedema symptoms.
- Avoid extreme climatic temperatures (lymphedematous tissue has a thinner barrier),
- Avoid Skin breakdown due to swelling, and keep the oedematous skin clean and well-hydrated.
If recommended by your doctor, wear compression garments when practising physical activities to help manage swelling during exercise, use appropriate equipment (footwear and protective gear), practice proper warm-up and cool-down techniques, and gradual activity progression.
SUMMARY
Exercise and sports are healthy activities for the general population, and forms part of programs for the prevention and management of many diseases. People with lymphedema (Organic Lymphatic Vascular Disease) are encouraged to participate in sports and physical activities, particularly low-impact ones, so they can enjoy their benefits and maintain an active lifestyle. It is recommended to always consult with a healthcare professional (doctor or physical therapist specializing in lymphedema), before making choices and starting any new exercise program. The healthcare professional can assess the specific condition, and provide personalized recommendations and determine the appropriate and safe exercise plan. In this way, individuals with impaired lymphatic function can enjoy and safely participate in physical activities, minimize the risk of exacerbating their condition, and enhance their quality of life.
REFERENCES
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IMPORTANT NOTICE
Lymphedema is a serious chronic and progressive disease due to lymphatic dysfunction (Organic Lymphatic Vascular Disease). The clinical treatment of lymphedema is neither a cosmetic nor an aesthetic treatment. The treatment of lymphedema is to control its progression and alleviate the symptoms related to dysfunction of the lymphatic circulatory system.
To prevent and avoid serious complications associated with treatment, such as the possible displacement of edema to previously unaffected areas when compression therapy is applied for volume reduction, patients should use highly specialized and experienced therapists.
Professional qualification and instruction delivered remotely online are not the same as live hands-on practical instruction in the clinical training and certification of lymphedema therapists, similar to all other rehabilitation, medical, and surgical training programs, and especially for developing the necessary manual skills to treat a disease as complex as lymphedema.
Patients should also take special care when choosing a Multidisciplinary Center of Reference for Lymphedema, as not all countries and centers provide the same treatment options. The best choice is a center of reference that provides Complete Decongestive Therapy (CDT), which is recognized as the Gold Standard treatment for lymphedema.
- Read more about what is the best treatment option for Lymphedema HERE.
- Read about what are the principal functions of Manual Lymphatic Drainage HERE.
- Read about what are the main differences between the two principal lymphedema treatment protocols HERE.
- Read about what are the strategies for the implementation of low-cost treatment options for Lymphedema HERE.
REFERENCES
SCIENTIFIC SOCIETIES
PATHOPHYSIOLOGY
- lymphedema.
- Biology of Lymphedema
- Lymph vessels: the forgotten second circulation in health and disease
- Lymphatic Vessel Network Structure and Physiology
- Lymphatic System Flows
- Organ-specific lymphatic vasculature: From development to pathophysiology.
- The lymphatic vascular system: much more than just a sewer.
- The unresolved pathophysiology of lymphedema.
- Lymphedema: A Practical Approach and Clinical Update.
- Coagulation in Lymphatic System.
- Regulation of immune function by the lymphatic system in lymphedema.
- Oxidative stress in chronic lymphoedema.
- Regulatory T Cells Mediate Local Immunosuppression in Lymphedema.
- Hemostatic properties of the lymph: relationships with occlusion and thrombosis.
- Secondary lymphedema: Pathogenesis
- Gastrointestinal Lymphatics in Health and Disease
- Intestinal lymphangiectasia in adults
- Role of the lymphatic vasculature in cardiovascular medicine
- The lymphatic vasculature in disease
- Lymphoscintigraphic abnormalities in the contralateral lower limbs of patients with unilateral lymphedema.
- The Prevalence of Lower Limb and Genital Lymphedema after Prostate Cancer Treatment: A Systematic Review
- Peripheral Edema
- The lymphatic system and the skin. Classification, clinical aspects, and histology.
- Lymphedema and cutaneous diseases.
- Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae.
- Serum Immune Proteins in Limb Lymphedema Reflecting Tissue Processes Caused by Lymph Stasis and Chronic Dermato-lymphangio-adenitis (Cellulitis).
- Lymphatic Flow: A Potential Target in Sepsis.
- Infectious complications of lymphedema.
- Acute inflammatory exacerbations in lymphoedema.
- Inflammatory Manifestations of lymphedema.
- Cellulitis.
- Clinical features, microbiological epidemiology, and recommendations for the management of cellulitis in extremity lymphedema.
- Challenges of cellulitis in a lymphedematous extremity.
- Diagnosis and management of cellulitis.
- Cellulitis risk factors for patients with primary or secondary lymphedema.
- Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg.
- Prevention of dermatolymphangioadenitis by combined physiotherapy.
- Erysipelas: a common potentially dangerous infection.
- Malignant tumors as complications of lymphedema.
- Lymphedematous areas: Privileged sites for tumors, infections, and immune disorders.
- Lymphedema-related angiogenic tumors and other malignancies.
- Lymphedema: an immunologically vulnerable site for the development of neoplasms.
- Lymph stasis promotes tumor growth
- A retrospective analysis of Stewart-Treves syndrome in the context of chronic lymphedema.
- Stewart-Treves Syndrome
- Congenital lymphedema complicated by pain and psychological distress: case report
- Lymphatic Pain in Breast Cancer Survivors
- Does Manual Lymphatic Drainage Have Any Effect on Pain Threshold and Tolerance of Different Body Parts?
- Lymphedema therapy reduces the volume of edema and pain in patients with breast cancer
- Quality of life in patients with primary and secondary lymphedema in the community
TREATMENT
- Treatment of limbs lymphedema.
- Nonoperative treatment of lymphedema.
- Lymphedema: From diagnosis to treatment.
- Lymphedema-clinical picture and therapy.
- Physiotherapeutic rehabilitation of lymphedema: state-of-the-art.
- Diagnosis and management of lymphatic vascular disease
- Effective treatment of lymphedema of the extremities.
- Lymphoscintigraphic aspects of the effects of manual lymphatic drainage.
- Intensive Treatment of Lower-Limb Lymphedema and Variations in Volume.
- Effectiveness and safety of Complete Decongestive Therapy of Phase I.
- Therapeutic Efficacy of Complex Decongestive Therapy in the Treatment of Elephantiasis of the Lower Extremities.
- Effects of Phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer-related lymph edema.
- Does lymphoedema bandaging reduce the risk of toe ulceration?
- Study of 700 referrals to a Lymphedema Program.
- Worldwide assessment of healthcare personnel dealing with lymphoedema.
- Földi M, Földi E. Földi’s textbook of lymphology for physicians and Lymphoedema therapists.
- Fluid Shifts Induced by Physical Therapy in Lower Limb Lymphedema Patients
- Visualization of Accessory Lymphatic Pathways, before and after Manual Drainage, in Secondary Upper Limb Lymphedema Using Indocyanine Green Lymphography
- The risk of genital edema after external pump compression for lower limb lymphedema.
- The management of genital lymphoedema
- The management of deep vein thrombosis in lymphoedema: a review.
- Lymphedema-associated comorbidities and treatment gap.
- A study of the advantages of elastic stockings for leg lymphedema.
- Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement.
- Medical compression stockings for chronic venous diseases and lymphedema: Scientific evidence and results of a patient survey on quality of care.
- Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic edema: a randomized controlled trial protocol.
- Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema.
- Occupational leg edema-use of compression stockings.
DISABILITY
- Disability and lymphedema.
- Lymphedema and employability.
- Worse and worse off: the impact of lymphedema on work and career after breast cancer
- Functioning in lymphedema from the patient's perspective using the International Classification of Functioning, Disability and Health (ICF).
- Unilateral upper extremity lymphedema deteriorates the postural stability in breast cancer survivors
- Postural Stability in Patients with Lower Limb Lymphedema
- Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema
DISFIGUREMENT
- Adjusting to disfigurement: processes involved in dealing with being visibly different
- Quality of Life in Cancer Patients with Disfigurement due to Cancer and its Treatments
- Quality-of-life and body image impairments in patients with lymphedema
- Association of lower extremity lymphedema with pelvic floor functions, sleep quality, kinesiophobia, body image in patients with gynecological cancers
QUALITY OF LIFE
- The impact of lower limb chronic oedema on patients' quality of life
- Quality of life in patients with primary and secondary lymphedema in the community
- Evaluating the effect of upper-body morbidity on quality of life following breast cancer treatment.
- Functionality and quality of life of patients with unilateral lymphedema of a lower limb: a cross-sectional study
- The effect of complete decongestive therapy on the quality of life of patients with peripheral lymphedema
PSYCHOSOCIAL IMPACT
- Psychosocial Impact of Lymphedema.
- Associations between chronic disease, age and physical and mental health status
- A network analysis of psychological flexibility, coping, and stigma in dermatology patients
- 'Abandoned by medicine'? A qualitative study of women's experiences with lymphoedema secondary to cancer, and the implications for care
- People are neglected, not diseases.
- Chronic edema/lymphoedema: under-recognized and under‐treated.
- Lymphatic Medicine: Paradoxically and unnecessarily ignored.
- Medical education: a deficiency or a disgrace.
PEDIATRIC LYMPHEDEMA
- NORD: Rare Disease Database - Lymphedema
- Medical management of lymphedema.
- Primary lymphedema in childhood.
- An approach to familiar lymphedema
- Pediatric Children Lymphedema
- Primary Lymphedema French National Diagnosis and Care Protocol (PNDS).
- Lymphatic filariasis: an infection of childhood.
- Lymphatic filariasis in children: clinical features, infection burdens and future prospects for elimination.
- Podoconiosis: Clinical spectrum and microscopic presentations.
- Podoconiosis: A Possible Cause of Lymphedema in Micronesia.
- A cross-sectional study to evaluate depression and quality of life among patients with lymphoedema due to podoconiosis, lymphatic filariasis, and leprosy.
- The impact of acute adenolymphangitis in podoconiosis on caregivers.
- Neglected tropical diseases and disability-what is the link?
- Locomotor disability in bancroftian filarial lymphoedema patients.
- Neglected patients with a neglected disease?
- Neglected tropical diseases and mental health: a perspective on comorbidity.
- People are neglected, not diseases.
- Addressing Inequity: Neglected Tropical Diseases and Human Rights.
- Neglected Tropical Diseases, Conflict, and the Right To Health.
- Peripheral Edema
- Phlebolymphedema
- Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management
- Role of the lymphatic vasculature in cardiovascular medicine
- Communication between lymphatic and venous systems
- Phlebopathies and occupation
- Phlebopathies and workers
- Evidence of health risks associated with prolonged standing at work and intervention effectiveness
- Leg edema formation and venous blood flow velocity during a simulated long-haul flight
WHAT KIND OF DOCTOR TREATS LYMPHEDEMA/LYMPHOEDEMA - WHICH MEDICAL SPECIALITIES ARE RELATED TO LYMPHEDEMA?
WHAT IS THE BEST TREATMENT OPTION FOR PAEDIATRIC AND PRIMARY LYMPHOEDEMA?
WHAT ARE THE PRINCIPAL FUNCTIONS OF MANUAL LYMPHATIC DRAINAGE
WHAT ARE THE MAIN DIFFERENCES BETWEEN THE TWO PRINCIPAL LYMPHEDEMA TREATMENT PROTOCOLS
WHAT ARE THE STRATEGIES FOR THE IMPLEMENTATION OF LOW-COST TREATMENT OPTIONS FOR LYMPHEDEMA
WHY IS A BUTTERFLY THE SYMBOL OF LYMPHEDEMA?
WHAT DOES INTERMITTENT PNEUMATIC COMPRESSION PUMP THERAPY (IPC) DO, AND DOES NOT DO FOR LYMPHEDEMA?




