Written by: Kathleen Lisson is board certified in therapeutic massage and bodywork, a Lymphedema Therapist and a RYT200 Yoga Teacher. She has spoken at the AVLS, FDRS, MLD UK, S4OM and NLN conferences. She is a coauthor of the Standard of Care for Lipedema in the United States and the author of six books, including Stress Reduction for Lymphedema. She lives with her husband Arun and their dog in sunny San Diego, CA.
Learn more about Kathleen: KathleenHelenLisson.com
Can yoga really improve lymphatic drainage and benefit people with lymphedema? The answer is a resounding yes! Our lymphatic system transports water, fat, protein and waste products from all the cells in our body back into the circulatory system. Lymphedema is an accumulation of protein-rich fluid in the tissues as a result of damage or dysfunction of the lymphatic system. Most people acquire secondary lymphedema as a side effect of cancer treatment. The gentle movements and breathwork of yoga can help healthy lymphatic systems as well as lymphatics that need a little (or a lot of) extra help.
In this article, we will look at yoga as a stress reduction practice that affects the lymphatic system, learn why yoga is beneficial for people with a breast cancer history and review research that indicates that many people with lymphedema may already be using yoga as part of their self-care routine. We will also look at guidelines for adapting yoga asana for clients with upper or lower limb lymphedema and learn the specifics of what type of breathing may support lymphatic flow. At the end of the article, I will leave you with links to three research-based yoga protocols for people with lymphedema. Let’s start by looking at why yoga can be so beneficial for the lymphatic system.
Yoga is a Stress Reduction Practice
Stress management practices including yoga asana and meditation can create the relaxation response (Balasubramanian, 2015). The relaxation response is the counterpart to the body’s stress response, and the term was first described by Herbert Benson, founder of the Mind/Body Medical Institute at Massachusetts General Hospital in Boston. Benson found that regularly experiencing this state of rest created “anti-oxidation and anti-inflammatory changes that counteracted the effects of stress on the body” (Martin, 2008).
How can we tell that yoga is giving these stress reduction benefits? The person themselves can feel less stress, and their body can experience changes as well. The time between a calm, healthy person’s heartbeats fluctuate slightly – we call this heart rate variability (HRV). HRV is one measure of the effects of stressors on the body, and low HRV can indicate current or future medical issues. Researchers looked at the effects of mind-body exercises (tai chi / yoga) on HRV and perceived stress and found “significant reductions in perceived stress.” Additionally, they found “evidence for beneficial effects of Yoga on HRV is more robust than that for Tai-Chi” (Zou et al., 2018).
Researchers who conducted a clinical trial involving people with breast cancer-related lymphedema state that “as a holistic practice, yoga may be of benefit by reducing both the physical and psychosocial effects of lymphoedema” (Loudon et al., 2017). Let’s look at why yoga may be helpful for people with lymphedema.
How might yoga be helping the lymphatic system? Yoga can have an effect on our lymphatic system, if poses are comfortable and stimulate the parasympathetic nervous system. Terence Ryan from Oxford University states that “the lymphatic system, which is so dependent on body movements, benefits from yoga because of movement, but also yoga can control the autonomic stimuli causing the muscular walls of collecting lymphatics to contract” (Ryan, 2019).
Yoga is Used as Therapy During and After Breast Cancer Treatment
We just read that yoga has both physical and psychosocial benefits for women with breast cancer related lymphedema. What is the guidance for women who are still in treatment for breast cancer? In the ‘Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment,’ authors cite “high levels of evidence support the routine use of mind-body practices, such as yoga, meditation, relaxation techniques and passive music therapy to address common mental health concerns among breast cancer patients, including anxiety, stress, depression, and mood disturbances. Additionally, meditation has been shown to improve quality of life and physical functioning, and yoga has been found to improve quality of life and fatigue” (Greenlee et al., 2017).
In an article published in the journal BMC Cancer, researchers who conducted a systematic review of systematic reviews for interventions following treatment for breast cancer found that “exercise and yoga likewise have shown effects on anxiety, depression and [quality of life]” (Olsson et al., 2019). When practiced correctly, yoga has many benefits for both people undergoing cancer treatment and those with lymphedema.
People with Lymphedema May Already be Practicing Yoga
I share the journal articles above to show that many people with cancer may already have yoga in their self-care routines. Indeed, Australian researchers sent a survey to 247 members of the Lymphedema Association of Queensland and found that, in addition to using mainstream medicine treatments for lymphedema, half of the respondents reported using at least one of 22 complementary and alternative medicine (CAM) therapies to treat their lymphedema. CAM therapies including meditation and yoga (Finnane et al., 2011).
What about people with a cancer history in the United States? The Mayo Clinic sent questionnaires to over 800 breast cancer survivors and 63% stated that they included yoga in their self-care practices. Almost 90% of respondents stated that yoga helped improve their symptoms. The most common symptoms that prompted the use of yoga were breast/chest wall pain, lymphedema and anxiety (Patel, et al., 2021).
Disappointingly, fewer than 10% of breast cancer survivors said that they had been referred to yoga by a medical professional (Patel, et al., 2021). Hopefully, by bringing increased awareness to the research around yoga and lymphedema, we can improve that number.
How can Yoga be Adapted for People with Lymphedema?
The biggest misconception about yoga for lymphedema is that it has to be chair yoga. YES, your clients who would like a more active yoga practice can still practice on their mat safely. The Journal of Lymphoedema published an article featuring yoga guidelines for participants with breast cancer related lymphedema. Adaptations included:
Avoiding heavy loading of the affected arm
Restricting static postures
Encouraging continuous movement
Including breathing exercises
Adapting floor-based postures to offer a seated or standing option
Beginning with postures and movements that include clearing lymphatics of the trunk, then move distal to proximal in each arm
(Douglass et al., 2012).
Breathing During Yoga
Diaphragmatic breathing is used during lymphedema-focused yoga asana practice. Breathing during the The Institute of Applied Dermatology (IAD) yoga protocol asks participants to inhale during limb extension and exhale during flexion, with a longer exhalation than inhalation (Aggithaya et al., 2015). Pranayama practices like alternate nostril breathing and bhastrika are also included in the protocols listed below.
Yoga Protocols
I want to share three valuable resources with you. These researchers have given us three protocols and the reasoning behind their choice of pranayama and yoga asana as well as their session design. Sessions can begin with breathwork and positions to facilitate central lymph drainage, then asana to promote lymphatic drainage and reduction of symptoms caused by fibrosis. These protocols can be used to inform and inspire your own lymphedema-aware yoga classes.
Here are three Yoga Protocols for reference:
University of Dayton study’s yoga protocol is available at: https://ecommons.udayton.edu/cgi/viewcontent.cgi?article=1017&context=dpt_fac_pub
IAD Yoga protocol for lower limb lymphedema: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4278136/
IAD Yoga protocol for upper limb lymphedema: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959325/
In this article, we looked at research on the benefits of stress reduction for the lymphatic system and learned how yoga is beneficial for people with lymphedema. We explored ways to adapt yoga asana for clients with lymphedema and added three research-based yoga protocols to our toolbox. I hope you agree with me that, yes, people with lymphedema can safely practice yoga and experience its stress reduction benefits!
Resources:
Aggithaya MG, Narahari SR, Ryan TJ. Yoga for correction of lymphedema’s impairment of gait as an adjunct to lymphatic drainage: A pilot observational study. Int J Yoga. 2015 Jan;8(1):54-61. doi: 10.4103/0973-6131.146063. PMID: 25558134; PMCID: PMC4278136. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4278136/
Balasubramanian S, Janech MG, Warren GW. Alterations in Salivary Proteome following Single Twenty-Minute Session of Yogic Breathing. Evid Based Complement Alternat Med. 2015;2015:376029. doi: 10.1155/2015/376029. Epub 2015 Mar 19. PMID: 25873979; PMCID: PMC4383272. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4383272/
Douglass, Jan & Immink, Maarten & Piller, Neil & Ullah, Shahid. (2012). Yoga for women with breast cancer-related lymphoedema: A preliminary 6-month study. Journal of Lymphoedema. 7. 30-38. Retrieved from: https://www.researchgate.net/publication/257748548_Yoga_for_women_with_breast_cancer-related_lymphoedema_A_preliminary_6-month_study
Finnane A, Liu Y, Battistutta D, Janda M, Hayes SC. Lymphedema after breast or gynecological cancer: use and effectiveness of mainstream and complementary therapies. J Altern Complement Med. 2011 Sep;17(9):867-9. doi: 10.1089/acm.2010.0456. PMID: 21875352. Retrieved from: https://eprints.qut.edu.au/46303/1/46303.pdf
Greenlee H, DuPont-Reyes MJ, Balneaves LG, Carlson LE, Cohen MR, Deng G, Johnson JA, Mumber M, Seely D, Zick SM, Boyce LM, Tripathy D. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017 May 6;67(3):194-232. doi: 10.3322/caac.21397. Epub 2017 Apr 24. PMID: 28436999; PMCID: PMC5892208. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892208/
Loudon A, Barnett T, Williams A. Yoga, breast cancer-related lymphoedema and well-being: A descriptive report of women’s participation in a clinical trial. J Clin Nurs. 2017 Dec;26(23-24):4685-4695. doi: 10.1111/jocn.13819. Epub 2017 Jun 22. PMID: 28334470. Retrieved from: https://www.semanticscholar.org/paper/Yoga%2C-breast-cancer%E2%80%90related-lymphoedema-and-A-of-in-Loudon-Barnett/048764952dd0dd1d3fb8d99aa35fac812c03d7c7
Martin, S. (2008) The Power of the Relaxation Response. Retrieved from: https://www.apa.org/monitor/2008/10/relaxation
Olsson Möller U, Beck I, Rydén L, Malmström M. A comprehensive approach to rehabilitation interventions following breast cancer treatment – a systematic review of systematic reviews. BMC Cancer. 2019 May 20;19(1):472. doi: 10.1186/s12885-019-5648-7. PMID: 31109309; PMCID: PMC6528312. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528312/pdf/12885_2019_Article_5648.pdf
Patel SR, Zayas J, Medina-Inojosa JR, Loprinzi C, Cathcart-Rake EJ, Bhagra A, Olson JE, Couch FJ, Ruddy KJ. Real-World Experiences With Yoga on Cancer-Related Symptoms in Women With Breast Cancer. Glob Adv Health Med. 2021 Jan 8;10:2164956120984140. doi: 10.1177/2164956120984140. PMID: 33473331; PMCID: PMC7797571. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/33473331/
Ryan, T. (2019). The Nature of care in the management of Lymphoedema; not without laughter! Journal of Lymphoedema, 14(1), 54–55. Retrieved from: https://lymphoedemaeducation.com.au/wp-content/uploads/2019/08/11.-The-nature-of-care-in-the-management-of-lymphoedema-not-without-laughter.pdf
Zou L, Sasaki JE, Wei GX, Huang T, Yeung AS, Neto OB, Chen KW, Hui SS. Effects of Mind⁻Body Exercises (Tai Chi/Yoga) on Heart Rate Variability Parameters and Perceived Stress: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2018 Oct 31;7(11):404. doi: 10.3390/jcm7110404. PMID: 30384420; PMCID: PMC6262541. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262541/
