March 2014 Ask the Expert: Yoga and Breast Cancer
Many people say that practicing yoga brings them strength and peace of mind, whether or not they have breast cancer. But the unique qualities of yoga also may help you cope with the stress of diagnosis and treatment while improving your quality of life.
During the month of March, LBBC expert Jnani Chapman, RN, BSN, E-RYT 500 answered your questions answered about yoga and breast cancer, how practicing yoga during and after breast cancer treatment can improve your everyday life, how to safely practice, and how to find yoga teachers trained to help you.
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I had radiation to the armpit and an axillary lymph node dissection as part of my treatment. I know because of that I am at high risk for developing lymphedema. What poses should I avoid? Downward Facing Dog? Others?
I work with a client with healed spinal fractures. She has osteoporosis. Her concern with practicing yoga is she is unwilling to do any forward bending; she worries she will re-fracture her thoracic spine. Do you have any advice?
Question: I had radiation to the armpit and an axillary lymph node dissection as part of my treatment. I know because of that I am at high risk for developing lymphedema. What poses should I avoid? Downward Facing Dog? Others?
Ms. Chapman: Dear One: Your question reminds me why I am so passionate about teaching Yoga instructors to adapt Yoga practices for people in cancer treatment and recovery. I frequently default to physiological nursing in teaching Yoga teachers, because I want them to understand the underlying dynamics that are at play in the physical body.
I personally can’t say, “These poses are counter-indicated and these poses are therapeutic,” in your situation. I would need to know a whole lot more: Was it left- or right-sided breast cancer? Can you show me your range of motion in that arm and shoulder and the places of any discomfort or pain? How long have you been out of treatment? We need to look at all the factors and variables at play in each circumstance, with each person individually, to suggest poses that will support healing and poses that will tax the body’s fluid dynamics.
Even while I say that, there are some generalities to offer you: Arms held overhead or at shoulder height while activating muscles (like wiggling fingers, squeezing and releasing fists) will help support lymphatic drainage and healing. Muscle actions with the arms below shoulder height can force fluids away from the drainage field and cause undue fluid pressures. If you love Downward Facing Dog, plant the affected arm without pressing weight into it, so that it is resting there for balance while most of the weight is pressing on the opposite arm.
Exercise, when performed carefully, may benefit those with lymphedema. The lymphatic system hugs the muscles and muscle action moves the lymph, which has to fight gravity to drain into the blood supply below the collarbones. There is a lot of teaching that can be given about lymphedema, but, it cannot be said in a few sentences. I wish you all the best in your healing and recovery and I hope that all cancer patients and survivors receive adequate teaching about lymphedema.
Ms. Chapman: It sounds as if you are new to Yoga. For me, this means that I need to extend a deep caution your way: Please do not ever surrender your own intuitions, judgments and perceptions to another in the context of learning and practicing Yoga. Listen to your body and allow it to tell you what is right in movement. It will feel right, it will feel good and that will tell you this movement or position is okay. It is the body’s permission, not any teacher that should tell you to go there.
Many Yoga teachers are trained only in Asana. Asana means pose or posture. In modern usage the word’s meaning extends to all aspects of the physical Yoga practices, even though originally it was meant as a vertical seated position maintained in stillness to allow for meditation.
Much of today’s Yoga asana training includes vigorous postures and movements that are directed appropriately for the young and fit, the flexible and the athletic. The muscle exertion and energy expenditure in these styles of practice are not, however, suited for most people who are still in cancer treatment or more recently in recovery post-treatment. Whether recovering from cancer or any other chronic illnesses, the body is working so much harder inside to heal than it is for that honed athlete or even the average couch potato.
As you gain stamina and health, you need to be more protected in your energy expenditures. Think of energy as a limited commodity that you need to spend wisely. The adjectives used to describe the approach to asana in the Yoga Sutras of Patanjali (one of the two great texts that bring Yoga to us from ancient times) are: easy, steady and comfortable. Please use these words to guide you in practice.
Seek out a teacher and class that is gentler so you come away energized and not depleted. It may take some trial and error to find the right fit for you, but if you trust your body's innate wisdom you will indeed find the style of Yoga that best suits your healing and recovery.
Question: I had a double mastectomy in June 2013 followed by chemo. I currently have tissue expanders in while awaiting the final implant surgery. I've heard that certain movements could cause my implants to shift. Once I get back to yoga, what kind should I avoid?
Ms. Chapman: Dear One: I have never been asked this question before, so I had to do some research. What I found in my reading is that, yes, indeed, while it is not common, implants can shift out of place to the sides or center, to the top or bottom, and the resulting shifts can be unsightly: breasts can pucker and wrinkle or worse.
Implants shifting is attributed to many things, but the most frequent reasons that I found were either because the implant was not securely positioned into the breast pocket or the size of the implant was larger than the space it fit into. To avoid size of implant as a cause, many plastic surgeons recommend keeping the implant volume less than 500cc. While I do understand the cultural imperative toward large breasts, I hope that you will choose a size that fits your body. This will reduce your need for concern.
While I learned a lot in my research, I recommend that you also do your own research to learn as much as you can to reduce any risks. For example, one article suggested not sleeping on the belly to prevent hours of pressure on the chest as a precaution. I did not find a single article that said that a person’s movement choices in exercise (or Yoga) caused implant displacement.
Implants can be placed either above or below the pectoral muscles and there are benefits and risks associated with either choice. For some women, placing the implant below the pectoral muscles, while reducing the likelihood of contractures, can increase the chance of muscle flexion issues such that any action of the pectoral muscles can move the implants around. One website actually featured a video of a woman demonstrating the implants moving as she flexed her pecs prior to her corrective surgery. Please discuss your concerns with your plastic surgeon and the practice nurse.
It is not wise to be fearful or project worry forward for yourself. Remember, you are choosing to invite these implants into your body to become the new you. An important aspect of Yoga that does not get enough airtime in generic Yoga classes is consciously using the mind and directing the mind with intention toward desired outcomes. I suggest that you actually talk to the body to remind it to welcome these new guests. Once the implants are in place, speak to them with loving kindness, welcoming them as a new part of you, incorporating them, so to speak. It takes time for bodies to adjust when things change. This is a huge change, so please be slow and attentive in all your movements, not just in Yoga movements. Awareness in all your actions will go a long way in preventing unwanted consequences. May your presence in your practice bring you deep healing.
Question: I am 60 years old and signed up for introductory yoga classes in the hopes of diminishing my ongoing anxiety-caused health issues. I found even the intro classes too difficult and was struggling to keep up. I became more stressed than ever before. Are some people just not physically suited to practice yoga?
Ms. Chapman: Dear questioner: You will notice right away that I always capitalize the word Yoga wherever it appears in sentences. I am not surprised that even an introductory Yoga class had you struggling to keep up and I am really glad that you are bringing up this question.
You ask if some people are just not physically suited to practice Yoga. My answer is a strong, resounding NO! Do not think that the problem is with you or your present physical conditioning. The problem is that Yoga is now so popular and many people use it as a cross-training discipline for exercise, with the focus on muscle exertion and energy expenditure.
It is the job of the Yoga teacher to adapt the practices appropriately for each student by honoring the student’s current physical limitations and abilities. If you start by accepting where you are in your physical capacity, then each practice will allow you to slowly gain range of motion, flexibility and stamina. If you try to push beyond your capacities it is possible that harm will result. Experienced Yoga teachers know this and will meet you appropriately with adaptations that feel good to you so that you can feel consistent progress.
It may be a challenge to find a class or a teacher that is right for you, but please know that such classes and such teachers exist. If you live in a rural area you may have to travel some distance to find one, but most cities these days have many Yoga studios and centers that offer adaptive Yoga classes. They may be listed as “gentle Yoga” or “adaptive Yoga” or “medical Yoga” or even as “chair Yoga.”
I recommend that people who have no former Yoga experience call the studio ahead to ask a lot of questions about the classes and teachers to find what is right for them. I also recommend you find a class that includes the non-physical practices of Yoga like a gentle Integral Yoga class. Integral Yoga was introduced in the U.S. by Swami Satchidananda in 1966. In this lineage, Yoga class includes breathing practices, deep relaxation techniques and meditation training as well as the Yoga postures and movements.
I honestly think that the breathing practices, the relaxation techniques and the meditation training will go a lot further in reducing your anxiety than the stretches and postures alone ever can. As an RN I specialize in communicating the physiological benefits of the Yoga practices and these non-physical practices have many significant benefits substantiated in research.
Integral Yoga was the Yoga chosen as an hour-a-day prescription for stress management in Dr. Dean Ornish, MD’s heart disease reversal program research, for which I was one of the teachers. I taught also for his post-research clinical program for over a decade; his program is now a Medicare-covered benefit. I hope you will not give up and that you will find the teacher and the class that brings you a sense of deep peace and inner healing.
Question: I work with a client with healed spinal fractures. She has osteoporosis. Her concern with practicing yoga is she is unwilling to do any forward bending; she worries she will re-fracture her thoracic spine. Do you have any advice?
Ms. Chapman: Personally, you will never find me encouraging anyone to move in ways that feel uncomfortable to them, even if the discomfort is emotional and not physical. In my earlier responses I make a distinction between Yoga asana practiced for fitness or cross-training in exercise and Yoga asana that is appropriate for people dealing with chronic illness and debilities who are working to restore health in survivorship.
If you did not work with this client during the time her osteoporosis lesions were healing, you may not be aware of the pain that was most likely associated with any movement she made with her body. Of course, when it hurts to stand from sitting or to sit from lying, it is easy to develop an aversion to any movement. Even though the pain goes away as the lesions heal, she may still have the memory of that pain imprinted in her psyche.
Swami Satchidananda used to say, “Do not disturb another person’s faith.” I take this to mean that wherever there is an aversion, accept it, respect it and do not try to change it. As Yoga therapists we need to think outside the box. There are many useful education pieces to communicate to her.
Especially communicate how essential weight-bearing exercise is to bone density and bone health. It is never too late to become physically active. One of the easiest weight-bearing exercises is to climb stairs. I worked as a Yoga therapist in an assisted living center in San Francisco and walked with clients up a flight of stairs one step at a time, resting as needed, with me on one side (or even behind some people) and the client holding the stair rail on the other side. You would be amazed how quickly clients gain stamina and endurance: We would take the elevator down to repeat the process for an easy bone-strengthening workout. Please know that walking up (and down) stairs or hills doubles the weight bearing impact on the bones compared with walking along the flats.
On another note, your client’s fear of forward bending is quite legitimate in my opinion. Forward bends and twists can produce torque at potentially vulnerable places and ought not be taught until the client is embodied and aware of how individual planes of movement feel in the body. While encouraging weight-bearing, I would also provide the physiological rationales for shifting away from sedentary behavior by suggesting regular hourly movement.
Think of time with your client as mutual exploration and work together to find movement she is comfortable with. As she feels secure in the movements and learns to trust her body again, she will delight in her progress with Yoga asana. Our YCat Yoga therapy curriculum teaches an adaptive forward bend that eliminates any torque from the lower spine. Someone could say, “Is that really a Yoga pose?” and I would reply that there is evidence that most of the Yoga poses we know today did not come to us from ancient times, but from the 1800-1900’s.
Ms. Chapman: I am very sorry to acknowledge to you that I do not pay any attention to marketed Yoga products like DVDs, so I am not able to advise you on this. Instead, I am going to encourage you to find a Yoga teacher or therapist who specializes in working with people in cancer treatment and post-treatment and either join a class or seek private sessions. It is much safer to practice with an experienced teacher than to try to copy something you see on a video. With personalized attention you also get immediate feedback, which will allow you to continue progressing and healing in your practice.
Ms. Chapman: I addressed this question in my answer to a previous inquiry. Please do take a look at my comments there. Every suggestion a Yoga therapist makes for movement sequences people should practice or avoid needs to come from a very thorough intake process. The Yoga teacher/therapist gets to know you very well, including your limitations, discomforts and places of pain. This is not just at the physical body level, but at the emotional, mental, spiritual and energetic levels as well.
If you came to a YCat Yoga therapist, I expect that she would communicate significant pieces of information to you about, for example, the lymphatic system and safe practices for those with lymphedema. Being aware as you go forward in life—in your Yoga practice, your exercise routines and in the activities of your daily living—can keep you healthy and free from harm. Understanding physiological systems and mechanisms in the body and their dynamic interplays can empower you to make conscious choices in movement that support your health.
Bottom line: We most often learn by trial and error. Listen to your body and do not force it or push it. Respect it and honor it with all of its quirks and limitations. Only choose movements that feel good. May your focused presence and loving attention in movement keep you safe and free from harm as you and your body learn and grow together in healing.
Question: Is there a network of yoga teachers who offer reduced prices to cancer patients and if so, how can I encourage local yoga studios to participate? Classes are $15 each and monthly membership is $99 to $150. I was the main breadwinner for my family of four before cancer, and I can’t begin to afford those rates on disability.
Ms. Chapman: Integral Yoga is the original style of Yoga that I am trained in through Swami Satchidananda. It offers a non-competitive form which tends to be gentler and more appropriate for people in treatment and recovery.
These classes will frequently be the least expensive offered in many locations and can be found both nationally and internationally. They often also offer work exchange programs so that people can exchange some service to their institutes and teaching centers for taking classes. Here is their on-line teacher directory site.
You can also check a website called yogabear.org. This organization encourages Yoga studios to offer free or by-donation-only classes to people with cancer and may list a studio near you. My caution is that most videos on that site show people who are well past cancer treatment, in full survivorship, and doing poses I would not recommend for people in active cancer treatment.
Standing pose Yoga is so popular in our culture as an exercise regimen and a workout. While exercise research shows a strong correlation between exercise and reducing cancer recurrences and mortalities, the exercise in most of this research is mild to moderate and not physically exhausting. Much of this research shows that being active, as compared to sedentary, on a daily basis is enough.
Even if you find a local Yoga center that will let you come for free, do not give your power to the teacher, thinking that teacher knows more about your body than you do. Please read my past responses about this. Expecting oneself to keep up with a popular regimen of standing poses in Yoga is unrealistic for people in treatment and can leave a person feeling deflated and depressed.
The former Lance Armstrong (now LiveStrong) Foundation also offers financial support to many classes that operate through Ys that allows them to waive fees for people with cancer. Even when someone offers a class that advertises itself for people in cancer treatment, I recommend you ensure you are practicing adapted poses that are safe for people with cancer.
Please be proactive and communicate with your local studios and teachers, especially those you believe will be able to guide you safely in developing your healing Yoga practice. Let them know of your financial limitations and ask what they can offer you in the way of scholarships and grants for attendance. A happy client does wonders for providing free advertising and generating other clients, so do not think yourself beholden when offered free classes!