Joshua Trock, DPT, RVT, CLT-LANA, is the Doctor of Physical Therapy and Lymphedema Specialist at San Antonio’s leading vein treatment center, Medical Vein Clinic. He has more than a decade of experience caring for patients suffering from various forms of lymphatic disease. He is passionate about creating novel and adaptive plans of care that positively impact the socioeconomic, emotional and relational outcomes for lymphedema and lipedema patients, as well as their caregivers. Joshua recognizes the importance exercise plays in positive patient outcomes and improved quality of life. We asked him to explain why physical activity is imperative and share how he approaches this topic with his patients.
Q. Why did you decide to become a lymphedema therapist?
A. It was extremely serendipitous. I truly feel like this specialty chose me. Coming out of physical therapy school I had very little exposure to the lymphatic system and lymphedema as a diagnosis. This is unfortunately the case regardless of what practitioner school is attended (MD, NP, PA, etc). My plan when I graduated was to start a home-based primary care physical therapy practice where I would treat individuals with balance, strength and mobility problems, along with aftercare for surgeries and acute injuries. Soon after graduating, I was contacted by a podiatrist asking if I could treat one of her patients with lymphedema. I told her “no,” but the question stuck with me.
I don’t like letting people down, so I started doing some research. The more I thought about it, the more I realized I would start running into patients with lymphedema, and I wanted to be fully equipped to help them. I found a training school online that was hosting a certified lymphedema therapist (CLT) training course in San Antonio at the hospital where I did all of my clinical training. I signed up and immediately fell in love and the rest, as they say, is history.
Q. What is your role in patient care at your clinic?
A. Primarily, it is to uncover the genesis of our patients’ major symptoms and then triage accordingly. Once I’ve established things in the order of importance, I can direct them into interventions that will give the biggest return on investment in the shortest amount of time. Many times, I run into patients that have never truly had their limbs examined and explained why things are occurring. We spend a large amount of time educating patients on why things are happening and why certain interventions will work. In addition, being certified in vascular ultrasound has given me another vantage point to assess how much of the symptom equation is being impacted by the venous and arterial system.
Q. Why do you “prescribe” exercise to your patients?
A. I typically don’t use the word “exercise,” since that word carries with it a ton of definitions and experiences from person to person. I like to start the conversation using neutral terms such as “movement” and “function.” As I outline to my patients, movement is a basic criteria for human flourishing. So much of our inherent physiology is based around movement and this is almost no more apparent than in our vein and lymphatic system.
I usually then transition to talking about function because we all want to be able to move in a safe and productive way, which would be the goal of achieving greater levels of function. Once we understand these two ideas as our primary goal then exercise makes much more sense and can easily be tailored to achieve those two things.
Q. Exercise can be difficult, or even painful, for lymphedema and lipedema patients. How do you motivate someone to start a plan, despite fear of initial discomfort?Everyone is different, which is why guidance from a qualified professional is key. It’s essential to set realistic expectations while understanding that the overall goal is permanent life change and not four weeks of effort to only regress back to the start.
A. I completely understand the fear or apprehension associated with beginning something new like exercise. It can be scary and intimidating, especially if you’ve had bad experiences in the past. The first step is identifying what is possible and reasonable. It could be something as simple as breathing differently or practicing a different sitting or standing posture—or setting a walking goal based upon time, frequency, distance or duration. Finally, starting a simple bodyweight exercise regimen with 10 repetitions for one set can be extremely effective for the right person.
Q. Ideally, how much physical activity should people with lymphatics disorders work into their day?
A. Let’s start with basic guidelines for all people and then fine tune for those with lymphatic disorders. The text book guidelines would be a minimum of three hours of cardiovascular exercise per week. Typically, this is exercise at an intensity of 60-80% of the person’s maximum heart rate for 30 minutes, six days a week. You can event split the 30 minutes up throughout the day.
There are many variations to this guideline out there, but I find this to be the most simplistic. The initial focus is cardiovascular exercise since it requires the least amount of muscle strength, flexibility and coordination. Once this is achieved, fine tuning specifically for disease management, such as lymphatic dysfunction, becomes slightly more nuanced. First, it obviously matters where the lymphedema is located and how severe it is. Lymphedema in the legs vs. arms vs. face will be slightly different in terms of how to manage.
We start where they all intersect…breathing. Yes, surprisingly breathing is a HUGE aspect of the initial focus since it actually impacts lymphatic flow directly. From there, basic range of motion exercises through simple movements such as squats, lunges, arm elevation, etc. These are movements that should be practiced daily and the amount will be based upon the severity of the condition.
Q. Are there any tips on ways to work in exercise without it feeling overwhelming?
A. I’m going to go back to ground zero. It all starts with movement and function. We all have to do this to a certain degree, so initially it is about aligning it with our motivation and interests. Start with your “why.” Why do you want to be better? What do you want to achieve? Is it less pain? More time with family? More independence? Less reliance on others? Figure out what you motivation is, and make it a bold reminder daily.
Once you’ve established your why, try and set a consistent regimen. For me, I have to exercise first thing in the morning. No one is up, and there is nothing else vying for my attention. I can be very consistent at it and now it is an automatic part of my routine. Next, figure out what interests you. Maybe you like audio books and podcasts so exercise is a great time to engage your mind and body. Possibly find a group of individuals that share your interests and goals. Working together in a group that will encourage you and keep you accountable is one of the best ways to turn exercise into a habit.
Finally, draw on your past. Maybe you were a former athlete and need that competitive edge. Find a new sport like pickle ball, swimming or online exercise classes. Find what engages the basic parts about you, as this will enhance your ability to stick to it.
Q. What are some common exercises you suggest?
A. When I start an exercise program for patients, I first have them start with a movement audit, writing down how much movement they do throughout the day. Sometimes, I correlate this with a fitness tracker and see how many steps they take on average. This gives me an idea of the starting point. Next, I do a function audit. What are some things the person wants to do but can’t and what are the probable roadblocks to doing those things?
These two aspects give us both an idea of how to map out the next steps. My initial goal for an individual would be to improve their breathing and posture (you can’t do anything without these dialed in) and then focus on achieving the minimal requisite amount of cardiovascular exercise per week. For most people this would be a walking program.
In regards to a specific exercise, you cannot beat a squat. This could be a true barbell back squat at a gym or getting on and off a commode. They are both squats, and it is the most basic movement there is. My initial test is how many body-weight squats a person can do in 30 seconds. We build out a program from there.
Q. We’re excited to share that you’re partnering with Juzo on the “Freedom in Motion Exercise Series.” What videos do you plan to share with us?
A. I am absolutely elated to partner with Juzo to combine my love of fitness, function and the lymphedema community to help others achieve a better, healthy life. My series will start with the fundamental basics I’ve already alluded to: breathing and posture. From there, we will expand the series on how to achieve the minimal amount of daily movement to be a healthy adult, along with a guideline for starting a cardiovascular fitness program. We will end the series on basic functional movement to include strength, balance, coordination, flexibility and finally, optimal fitness. Each series will build on each other so you will want to stay up to date as they come out.
Disclaimer: Do not disregard medical advice you have received, nor delay getting such advice, because of something you learn in this blog, on the Juzo website or in our videos.
In addition to exercise, there are other lifestyle considerations you can implement to help manage swelling. Read more. Be sure to follow us on Instagram, @JuzoCompression and Facebook for more content on exercise and the benefits of compression therapy.