Tidhar – Pool Exercises

It is tragic, that some people do die because of the complications of lymphoedema. These can include a number of things including chylothorax, (a build-up of fluid in the lungs), which can cause death and Stewart-Treve’s Syndrome, which is a lethal angio-sarcoma for which the prognosis is very poor. This occurs particularly in chronic, untreated lymphoedematous limbs.

We are very privileged to have had an article written especially for us by Dr. Attilio Cavezzi, MD on “Varicose Vein Surgery and Lymphoedema”. This is a problem that we are frequently asked about. We know that it will be of particular value to our members who are Health Care Professionals, and for patients to take to their specialists if this problem arises.


This first part of the newsletter comes from many sources and discusses the benefits of many different forms of exercises and sports. Many of these are not only enjoyable, but enhance the breathing, the exercise of the arm and stimulate normal nodes, to which any overload of the lymphatics can drain. Water in itself provides extra pressure. This is approximately 22.5 mm Hg pressure for every foot of water that you go down, so that both for lymphoedema of either arms or legs, submersion and exercise, (even just walking in the water) can together make an excellent and enjoyable combination of treatment and management.

I cannot stress how much both deep breathing as well as relaxation plays a very important role in the well-being of patients. I have changed the order of the L.A.A. exercises a little in that I now start with the breathing. Firstly, I suggest you take a deep breath and pull your stomach in. Secondly rest your elbows on the bed, breathe in. As you breathe out, cross your arms over your chest and lift your head. Make these breaths as strong as possible. Repeat these two sequences three times. Then do the relaxation sequence in stages, concentrating on each part of the body in turn. Make sure that during the day, you relax your shoulders!

Many of the following sports and exercises stimulate the normal existant nodes and areas of the body, especially in the inguinal and axillary areas. This occurs both by movement and is aided by deep breathing. Flow through superficial collateral drainage is increased as is pumping of the deep lymphatics.

Lymphoedema often requires intense, long and costly treatment. The following article is courtesy of Dorit Tidhar from Israel, who has had real success with hydrotherapy exercises as well as self and partner massage. They were practised first thing in the morning, immediately after the pool had been cleaned, to minimise any risk of infection. No patient with any infection was allowed in the pool. The pool was 1.3 metres in depth with a temperature of 32.4°C, and monitored for chlorine concentration with a ph of 7.02. The women practiced for 45 minutes, once or twice per week during the summer season for two months. You will see, that overall the limbs decreased in size, but some increased at several points due to extreme outside temperatures. I thank Dorit for this excellent piece of work and her initiative in organising this treatment regime for this group.



Tidhar, Dorit, PT, ISRAEL

Women that undergo an operation for the treatment of breast cancer are at risk of developing lymphoedema. Those who don’t develop lymphoedema suffer to some extent, from other consequences of the operation: seroma under the armpit, reduced shoulder range of motion, and loss of sensation etc.

The conventional treatment of lymphoedema as for today is, Complex  Physical Therapy (C.P.T.). The treatment achieves very good results after an intensive treatment and then, when the woman enters the maintenance phase, it is hard to keep a high motivation for self on-going  treatment at home.

The method that is presented here, has been used for the last six months, here in Ashkelon – a city by the sea in Israel – by women with different levels of lymphoedema. The core of the group contains women who have been exercising in the water before, but the swelling was not in as much control as they wanted it to be, and in one woman it even got worse. They all have a passion for the water, but a few didn’t know about it until they joined our group. Two, didn’t know how to swim and were afraid of the water. The range of ages was 42-73. Some of them work, 3 are nurses, there was a secretary, and an artist. Half of these women are on a pension. In this period, they are on a one in a month follow up by their therapists. Before we started exercising, we had gathered one Saturday evening for a lecture about self treatment of lymphoedema. These sessions are their choice and I don’t judge them about their self treatment at home. Some wear garments, and some don’t. I only let them have reliable feedback about their situation so this is what I call self controlling of their lymphoedema. This experience is a pilot study and is not statistically proven.

The principles of this method are based, on one hand on the physical forces of the water – buoyancy, resistance, hydrostatic pressure, and on the other hand on the basic principles of the massage technique which are – working first from central to distal, light touch, slow rhythm, and direction based on lymphatic anatomy, existence of scar tissue etc.

When combining everything together, you have a group of eight women that are “dancing” in the water, at first working without pressure on their central areas and gradually achieving maximum pressure with movement on their arm combining with very deep breathing and diving – like the “frog” or “dolphin” exercises.

It is important to emphasize, that this way, the women are not passively lying on the therapist’s bed. This way, the women are controlling their lymphoedema.

The water is relaxing, allowing greater range of motion, reducing the weight of the limb and helping the movement being lighter and easier.

This group is actually a support group, with all the characteristics – exchanging knowledge about bathing suits, recipes for cakes, and friendship that goes beyond classes.

An average reduction of 15.2% for the whole group after class  

After 2 months of exercising in a very hot summer, in which, not all of the women were “good girls” and bandaged their arms, the results of this pilot were above my expectations. Not only did the women maintain their status but the swelling was even reduced. Measurements of both the affected and healthy limb of each participant were taken weekly before and after class. The results were analysed and recorded on follow-up charts, giving each woman a feedback on her progress. No woman with an active infection was allowed to enter the pool until receiving physician clearance. Volume reduction of the affected arm was noticed in measurements for all participants. During the first two months, the range of swelling reduction after each class, for the group unit, was 6%-72.5% (30.9%+/-26.5% figure 1). The mean swelling reduction was 40.1%+/-15.38% after the whole period. After two months, the group started changing: two got sick, two went abroad for a vacation, and 3 new women joined. (Figure 2 (see p.6) shows the results of the 5 women that participated for the whole period of six months).

My conclusion was, that in a one hour class, in which a woman does lymphatic exercises, massaging her own body and her fellows’ bodies, the results are like one session of C.P.T. on a massage table. They are not, however, bandaging their arms, so they don’t maintain the result to the next class. But in the summer, when you sweat, and you suffer so much under the garment, making some fun in the pool is a great way to prevent your arm from swelling. (see following page for the volume of the affected limb over a six month period).


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