What exercises can help minimize lymphedema after Axillary Lymph Node Dissection (ALND)?

Exercise Recommendations for Lymphedema Prevention After ALND

Patients undergoing axillary lymph node dissection should be encouraged to begin early progressive resistance training and shoulder exercises without activity restrictions, as this approach is safe, does not increase lymphedema risk, and improves functional outcomes.

Early Mobilization and Exercise Initiation

Start shoulder exercises early in the postoperative period rather than delaying them, as early introduction of exercises prevents deterioration in shoulder range of motion without increasing lymphedema incidence 1. The timing of exercise initiation does not affect postoperative lymphedema rates, making early mobilization the preferred approach 1.

• Early exercise programs are valuable in avoiding deterioration in shoulder range of motion after ALND 1
• No evidence supports the outdated practice of restricting arm activity to prevent lymphedema 2, 3

Specific Exercise Components

Progressive Resistance Training

Supervised progressive resistance training is the cornerstone exercise intervention for patients at risk of lymphedema after ALND 4, 2. This approach has demonstrated safety and effectiveness in breast cancer survivors:

• Progressive resistance training can reduce the probability of arm swelling in survivors with high lymphedema risk (five or more lymph nodes removed) 2
• Patients should maintain physical activity in daily life without restrictions and without fear of developing lymphedema 3
• A no activity restrictions program combined with moderate resistance exercise shows equivalent or better outcomes compared to activity restriction programs 3

Shoulder Mobility Exercises

Shoulder exercises should be prescribed to address the most common postoperative complications including reduced range of motion, muscle weakness, and pain 1:

• Shoulder flexion and abduction exercises should target achieving >100° range of motion 5
• Gradual improvement in range of motion occurs from 1 to 18 months postoperatively with consistent exercise 5
• Upper limb exercises alone are effective for shoulder rehabilitation without requiring additional manual therapy 5

Complete Exercise Program Structure

The exercise component should be integrated into a comprehensive approach 4, 6:

• Intensive phase: Exercises combined with skin care, manual lymphatic drainage, and compression bandaging 6
• Maintenance phase: Continued exercises with skin care, compression sleeve wear, and manual lymphatic drainage as needed 6
• Exercises should be part of complete decongestive therapy, which has high-quality evidence and strong recommendations 4

Critical Clinical Considerations

Risk Factor Management

Weight management is essential for overweight/obese patients (BMI >30 kg/m²), as obesity is the only consistently identified risk factor for lymphedema development after ALND 2, 3:

• BMI >25 kg/m² is the primary risk factor for developing lymphedema 3
• Weight loss should be recommended for patients with elevated BMI 4, 2

Referral Pathway

Refer patients with clinical symptoms or swelling suggestive of lymphedema to specialized therapists (physical therapists, occupational therapists, or lymphedema specialists) 4, 2. Early referral prevents progression and complications 2.

Common Pitfalls to Avoid

• Do not advise activity restrictions: Historical recommendations to avoid physical activity and weight lifting with the affected arm are contraindicated by current evidence 2, 3
• Do not delay exercise initiation: Waiting to start exercises increases risk of shoulder mobility impairment without reducing lymphedema risk 1
• Do not rely on diuretics: Diuretics are ineffective for lymphedema management and physiologically unsound 4, 2
• Do not ignore infection: Cellulitis requires immediate antibiotic treatment as it can exacerbate lymphedema 4, 2

Expected Outcomes

Lymphedema incidence after ALND ranges up to 25-40% depending on additional risk factors such as radiation therapy 7, 8, 2. Exercise programs improve quality of life, reduce limitations in work and leisure activities, and enhance psychological wellbeing 4. Arm volume increases gradually over time in both affected and control arms, but appropriate exercise does not accelerate this process 3.