Lymphedema, Lipedema, and Aquatic Therapy with Professional Yoga Therapy
Maureen Mason, MS PT WCS CCI PYT-C provides a guest blog for Professional Yoga Therapy Institute, highlighting how medical therapeutic yoga can be combined with aquatic therapy for lipedema and lymphedema. We extend our gratitude to Maureen for thinking outside the usual boundaries of health care, addressing a patient population that many may not be familiar with, and finally for sharing her wealth of experience.
Professional Yoga Therapy principles can be applied to complex client care. Do you know about Lipedema?
Lipedema is a condition of abnormal, excess adipose tissue deposition in the abdomen, hips, thighs and lower legs, yet it spares the feet below the ankles. It is viewed as a rare disease with frequent misdiagnosis as obesity or lymphedema. Lipedema's pathogenesis and management are a current area of research.
Onset of lipedema appearance classically begins at puberty. Lipedema may also occur post surgery, trauma, pregnancy, or peri-menopause. Lipedema may expand into the trunk and upper extremities over time in some individuals. Internet research will identify varied medical opinions regarding its treatment, from recommended liposuction, laser surgery, complex decongestive therapy, and other methods. Calorie restriction and other methods of dieting do not reduce the limb size or adipose deposition in lipedema. This condition affects an estimated 11% of women.
Individuals I have met have encountered shaming and other negative experiences as related to their appearance. Individuals with lipedema will have challenges in exercise performance due to large limb size. With aging and potential weight gain into higher BMI levels, physical performance and functional abilities will become challenged. The intent of this post is to educate other health care providers and professional yoga therapists about lipedema and offer yoga as a health care option for health and wellness.
Lipedema may be associated with a tendency to develop lymphedema over time. Lymphedema is most commonly recognized as a potential upper extremity complication post op breast cancer surgery, radiation and/or chemotherapy with lymph node treatment. Lower extremity lymphedema may occur following surgery as well, such as ovarian cancer intervention with inguinal lymph node removal.
Physical therapists commonly work as a team with the oncologist and other specialists to create a sustainable treatment plan for lymphedema. This includes addressing skin care guidelines and using compression garments and wraps, exercise, and complex decongestive therapy. Lymphedema has been extensively studied. Lymphedema has stages and associated treatment protocols, from prevention strategies, to treatment protocols for stage one, two, and three.
Pranayama as Therapy
Pranayama, or the regulation of the breath, may be a therapeutic adjunct in assisting lymphatic movement into the thoracic duct, cysterna chyli, and other transport sites. It has not been studied as a treatment or in combination with aquatics and yoga. (Personal note: I have measured 2 to 4 cm circumferential limb volume reduction pre/post pool therapy in a client with lipedema and Stage III lymphedema).
Individuals with lymphedema may encounter a decline in their quality of life over time, including the inability to exercise and to travel for local outings or extended trips with auto or air travel. Lymphedema also carries risk for infection and potential sepsis due to reduced skin, circulatory and lymphatic integrity in the affected tissues. In both lipedema and lymphedema we can consider application of Medical Therapeutic Yoga (MTY) for health and wellness of body, mind, and spirit.
The ayurvedic model of constitutional dosha physical attributes helps us consider the genetics and unfolding epigenetics that can present in the clinic or yoga studio, as pertains to lipedema and lymphedema. Larger, rounder bodies that are slower moving and tend to fluid and mucous congestion may be viewed from the lens of Kapha dosha, as having Kapha excess. Offering and guiding the Kapha excess client into balance includes encouraging positive Pitta elements such as heat and structured exercise formats, and positive Vata elements such as mobility, creativity, and flow.
Medical Therapeutic Yoga: for Body, Mind, and Spirit
MTY for exercise, pranayama, meditation, and use of sound and aromatherapy can be offered for the lipedma and lymphedema client to optimize health and wellness. MTY may utilize treatment tables that are elevated and larger in size, or recliner chairs, as needed. A 30 to 60 minute session may be provided and serve the client more therapeutically than conventional exercise classes or challenging personal training workouts.
Internalizing the Guiding Principles of Yoga
In order to optimize programming and address the mind, body and spirit, a client may be educated as to the guiding principles of yoga beyond the Asana (postures) and Pranayama (breath) training, which can include client education regarding:
- Yamas, Niyamas, Tapas: MTY uses application of these moral and spiritual paradigms that may promote feelings of peace, self-acceptance, and encourage discipline and focused effort to the client.
- The Yama of: Ahisma, non-violence, on the part of the client and therapist, serves as a safety factor to prevent injury. A gentle, repetitive, practice can build strength slowly for safety, and honors the principle of non-violence to self and others. (Current popular training methods such as “The biggest loser” as seen on T.V. promote an opposite approach, that of aggressive, forceful exercise programs which have a basis in military boot camp protocols for combat readiness, and are not appropriate for a client with lipedema or lymphedema, and often including shaming tactics to encourage compliance.)
- The Niyamas: Santosa, contentment, focus on the present moment.
- Tapas: perseverance of effort, with persistence, discipline.
Aquatic Therapy + MTY
Aquatic therapy can be a fun and creative therapeutic exercise method for MTY intervention for the lipedema and lymphedema client. Skin integrity must be considered for pool therapy and is beyond the topic of this blog; guidelines are available for aquatic therapists. Water immersion therapy for exercise can provide unique mobility and circulatory assistance and provide a successful platform for program development. Clients with lipedema and lymphedema may find a freedom of motion and joy of exercise in a pool program. Such a program can be uniquely tuned to their individual needs and concerns.
Sample Pool Program
Below is a MTY based pool program. An individualized program may also include adjunct use of a pool lift, pool noodles and floating aquatic barbells, and floatation vests and/or weight vests per client needs.
Small steps walking forward/ back 5 feet x 5
Small steps lateral to Left, Right, 5 feet x 5
Cervical rotation Left, Right. Small range trunk rotation Left, Right.
Aquatic MTY Asana Flow
Options to hold Asana pose or moving in and out of pose, and cue Pranayama method at the discretion of therapist per client needs.
1. Chest deep, modified cat-cow standing (Majaryasana, Bitilasana), cuing inhale with spine extension, and exhale with spine flexion.
2. Mountain pose with prayer hands. (Tadasana and Anjali Mudra)
3. Guided meditation in Tadasana on connection to earth, stability through bones, gratitude for toes, feet, ankles, knees, hips, pelvis and trunk and upper body areas that stabilize and also move us throughout the day. Gratitude for the fire of digestion, and for the lightness of the water and surrounding air.
4. Come out of Tadasana with hands reaching to the sky welcoming the day.
5. Move to Chair Pose (Utkatasana), engaging Shoulder Lock and TATD. Ujaii breaths in chair pose, and then back to TATD. Maintaining chair pose, heel lifts, and toe lifts.
6. Standing chair pose with twist (Parivtta Utkatasana) Hands in Anjali Mudra, gently turn to L hip, allowing expansion, opening of back ribs, spine, easy turn of the body, fingers pointing to pool surface. Repeat each side. (This is a modified version in a smaller ROM on the spine, hips, and avoiding head going under water).
7. Repeat Mountain, and add side bow Left, Right.
8. From Mountain, move into Warrior I cuing TATD breath (Viribhadrasana). Repeat each side.
9. From Mountain, move into Warrior II (Virabhadrasana), cuing posture locks from hip into TATD into arm spiral and scapulo-thoracic engagement, and slight chin tuck. Encourage client to notice body stacking and alignment sensations as pose is moved into, and held.
10. Repeat cat camel.
11. In pool, “seated” Forward Bend (Paschimotton) with feet on inside edge of pool, with T/S and L/S and Hip flex with knees extended, feet at neutral dorsiflexion, while holding stainless steel bar with hands, client is assisted with spine or hip soft tissue mobilization PRN.
12. AM program for Kapha balancing; finish session with TATD assisted breathing with transition to Ujaii breath. Use of Garuda mudra with hands over heart, cuing gratitude, pausing a few breaths to note those loved, and feeling self appreciation, then Garuda hands moving up to throat cuing breath, vital energy, and Garuda hands moving up to third eye and crown chakra. Mantra “Feel good (hands over heart), and see good” hands move up to over eyes, then open the hands and UE into abduction down then down to the sides, as if releasing birds, sensing lightness and air on fingertips. (Optional other techniques: 3 Part Breath standing, 3 cycles, or alternate nostril breath.)
13. Closing meditation. Return to Anjali mudra, in Tadasana. Hold a slight space between the palms and consider self -care, and gratitude during the day, noting moment-to-moment, seeing, sensing, warmth and energy, and mindfulness during the day.
Venus of Dolní Vestonice 29000-25000 BC
Finally, the Lipedema client physique has appeared in body shapes represented in art through out ancient history, commonly referred to as goddess figures or fertility figures as per anthropological interpretation. While current cultural standards promote and honor thinness and lean muscularity, there may have been benefits in ancient times for a greator body adiposity.
It is our role as professional yoga therapists to welcome and honor and guide all body types towards health and wellness, and now to recognize the genetics that may contribute to the larger body size that may need adaptive exercise for encouragement and goal attainment.
"Petr Novák, Wikipedia" guidance: Danny B. - che, CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php? curid=2682270
About the Author: Maureen Mason, MS PT WCS CCI PYT-C
Maureen is a board certified women’s health specialist who enjoys creative physical therapy programming blending Professional Yoga Therapy and MTY with traditional rehabilitation protocols. She strives to optimize client health with the big wheel of mind, body, and spirit care. Maureen offers clients meditation and mindfulness training, and attention to the application of breath awareness throughout the day. She offers guidance to best practices for nutritional healing, and a lifestyle application of exercise for integration into daily routines for health. She has a passion for helping women over the perinatal and menopausal transition times, educating clients in bladder, bowel, GI, pain management, and sexual health and pelvic self -care.
Maureen has served as a research therapist on two randomized controlled trials; ”Journal of Urology 187:6:2012, Randomized multicenter clinical trial of Myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome”, and “Postpartum Diastasis Rectus Abdominus Interventions” with San Diego State University, which is an upcoming poster presentation at combined sections meeting American Physical Therapy Association (APTA).
Maureen serves as a teaching assistant for Herman and Wallace Pelvic Rehab courses, and she is developing courses for trauma recovery, and health care practitioner self care and resilience. She is a member of the APTA, sections on aquatics, women’s health, and geriatrics, and she is a credentialed clinical instructor who has developed in house training in pelvic rehab at Comprehensive Therapy Associates San Diego. She is the proud parent of two adult daughters who both practice yoga, and she and her husband share a canyon side home with an organic orchard, chickens, and a dog and cat.
Contact Maureen at: email@example.com
The following references cover a diverse array of rehabilitation interventions, and offer clues to our scientific validation of certain approaches, yet mostly point towards the need for more research. The combination of therapeutic, integrative approaches that do no harm to the client follows the PYT model of safety, program adaptability, and specificity to individual client needs.
Broach, Ellen and McKenney, Alexis. Social Fun and Enjoyment: Viable Outcomes in Aquatics for Individuals with Physical Disabilities. International Journal of Aquatic Research and Education: Vol. 6: No. 2, Article 8, 2012. http://scholarworks.bgsu.edu/ijare/vol6/iss2/8
Tidhar, D, and Katz-Leurer, M. Aqua lymphatic therapy in women who suffer from breast cancer related lymphedema: a randomized controlled study. Supportive Care in Cancer, 2010; 18: 383-392. http://link.springer.com/article/10.1007/s00520-009-0669-4
Vécseyné, Magdolna, et. al. Effects of Pilates and aqua fitness training on older adults’ physical functioning and quality of life. Biomedical Human Kinetics, 2013; 5, 22–27. http://www.degruyter.com/view/j/bhk.2013.5.issue-1/bhk-2013-0005/bhk-2013-0005.pdf
Shin BW, Sim Y-J, Jeong HJ, Kim GC. Lipedema, a Rare Disease. Ann Rehabil Med Annals of Rehabilitation Medicine. 2011 Dec; 35(6): 922–927. doi:10.5535/arm.2011.35.6.922 www.ncbi.nlm.nih.gov/pmc/articles/PMC3309375/
Fife, Caroline, Maus, Erik , Carter, Marissa, Lipedema: A frequently Misdiagnosed and Misunderstood Fatty Deposition Syndrome, Advances in Skin and Wound Care. Feb 2010;23(2), 81-92. doi:10.1097/01.asw.0000363503.92360.91
Forner-Cordero, I, Szolnoky,G, Forner-Cordera, A, Kemeny, L. Lipedema:an overview of its clinical manifestations, diagnosis and treatment of the disproportional fatty deposition syndrome-a systematic review, Clinical Obesity. 2012;2(3-4):86-95. doi:10.1111/j.1758-8111.2012.00045.x
Okhovat JP, Alavi A. Lipedema: A Review of the Literature. Int J Low Extrem Wounds. 2015 Sep;14(3):262-7. doi: 10.1177/1534734614554284. Epub 2014 Oct 17.
Rudkin G, Miller T, Lipedema: A Clinical Entity Distinct from Lymphedema. Plastic and Reconstructive Surgery. 1994; 94 (6). doi:10.1097/00006534-199411000-00014 http://journals.lww.com/plasreconsurg/Abstract/1994/11000/Lipedema__A_Clinical_Entity_Distinct_from.14.aspx
Kwan, Marilyn, Cohn, Joy, Armer, Jane, et al. Exercise in patients with lymphedema: a systematic review of the contemporary literature. J Cancer Surviv. 2011; 5:320-336, DOI 10.1007/s 1174-0111-0203-9.
Rodrick JR, Poage E, Wanchai A, Stewart BR, Cormier JN, Armer JM. Complementary, Alternative, and Other Noncomplete Decongestive Therapy Treatment Methods in the Management of Lymphedema: A Systematic Search and Review. Pm&r. 2014;6(3):250-274. doi:10.1016/j.pmrj.2013.09.008 http://www.pmrjournal.org/article/S1934-1482(13)01082-4/abstract
Saravu R. Narahari, Madhur Guruprasad Aggithaya, Kodimoole S. Prasanna, and Kuthaje S. Bose. An Integrative Treatment for Lower Limb Lymphedema (Elephantiasis). The Journal of Alternative and Complementary Medicine. February 2010, 16(2): 145-149. doi:10.1089/acm.2008.0546 http://online.liebertpub.com/doi/abs/10.1089/acm.2008.0546?journalCode=acm
Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA: A Cancer Journal for Clinicians. 2000;50(5):292-307. doi:10.3322/canjclin.50.5.292
Narahari SR, Ryan TJ, Bose KS, Prasanna KS, Aggithaya GM. Integrating modern dermatology and Ayurveda in the treatment of vitiligo and lymphedema in India. International Journal of Dermatology. 2011;50(3):310-334. doi:10.1111/j.1365-4632.2010.04744.x
Tiwari A, Cheng KS, Button M, et al. Differential Diagnosis, Investigation, and Current Treatment of Lower Limb Lymphedema. Archives of Surgery. 2003; 138 (2): 152-161. doi:10.1001/archsurg.138.2.152
Narahari SR, Ryan TJ, and Aggithaya MG. How Does Yoga Work in Lymphedema? J Yoga Phys Ther. 2013; 03 (02):135. doi:10.4172/2157-7595.1000135
Kwan ML, Cohn JC, Armer JM, Stewart BR, Cormier JN. Exercise in patients with lymphedema: a systematic review of the contemporary literature. Journal of Cancer Survivorship. 2011;5(4):320-336. doi:10.1007/s11764-011-0203-9