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Child's pose modifications for Yoga Therapy for Breast Cancer

We usually think of child’s pose, sometimes known as bheki, as a relaxation pose.  It figures in yin yoga and restorative sequences and is generally used as a counter-pose after more strenuous work.  However, what seems an easy pose actually represents certain challenges to the breast cancer patient.  
Firstly, the classic arm positions in child’s pose – arms alongside the legs or extended and next to the ears – can be challenging for these students.  To lay the arms alongside the legs suggests that the person is low enough into the pose (ie:  backside is sitting on the heels) so that the upper arm is on the floor.  My ladies aren’t all able to do this.  Also, anyone with serratus-flap reconstruction is going to find the required rounding of the shoulders hard on the affected side.  The extend the arms taxes both serratus anterior and trapezius.  There are some people who just can’t lift the extended arm that high.  This calls for a modification!  Read on…
The ankles can present a problem in ladies of a certain age.   If there is undue strain on the front of the ankles, the pose becomes unstable.  A simple solution is the prop the ankles on a tubular prop, or simply roll up the end of your mat and use that.
If there is a bit of belly – and let’s face it, with all the cortisone administered in chemo, most students arrive a bit on the heavy side – we need to make room for it.  Simply separating the legs helps the body settle comfortably into the deep forward bend.
In people who carry neck tension – and most mastectomized and reconstructed ladies do – you will see that the cervical curve persists in this pose.  Do your best to bring attention to the dorsal zone, instructing students to separate the shoulder blades on the inhale. Tell students to pull the chin down towards the sternum.  (For those who are comfortable on the pose, you can suggest a little breath retention after each exhale.)

Arm Modifications

Take the arms out to the side, just above shoulder height, with the elbows bent.  Keep a slight pressure between the forearms and  the floor.  Splay the fingers and keep a slight pressure on the fingertips.  Keep awareness at the fingertips.

Child's pose for breast cancer rehab
Child’s Pose- modified for breast cancer yogis

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Twists in Yoga Therapy for Breast Cancer

Trikonasan mod 1
Trikonasana mod 1

image
At the beginning of the term last autumn, I decided to teach some twists.  Using the concept of vinyasa-krama, that is, work slowly into the postures, I taught some light standing, sitting and lying twists.  In general, if you keep the arm work light, the twist moves more into the lumbar spine.  Still, I was trying to work into the dorsal spine, so especially worked with the breath.  In sitting twists, one can add a krama in the exhale, as the students go into the pose.  In lying twists, one can do a dynamic phase followed by some breaths in the pose.
My experience was educational.  I discovered that this group is not yet ready for twists.    Two students experienced muscle pulls, one in the quadratus lumborum region after a trikonâsana (triangle pose) and one in the intercostal / serratus anterior region after a jatara parivritti (lying twist pose).  Another student fell out of trikonâsana.  This same student was later told to avoid practising twists after her expander/implant reconstruction.
Eight weeks into term, I stopped all but the lying twists, and these I did in their gentlest form.
So, be careful with twists in yoga therapy for breast cancer patients. Here is a workup (vinyasa krama) for the triangle pose (trikonâsana).
Legend:  

  • slight bend in the front leg, top arm bent with hand on hip, look down
  • slight bend in front leg, top arm bent, look up
  • slight bend in front leg, top arm stretched out and up, look down
  • slight bend in front leg, top arm stretched up and out, look up.
    trikonasana variations
    trikonasana variations
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Muscles most affected by breast cancer and its treatment.

The skeletal muscles most affected by breast cancer and its treatment are:

  • pectoralis major:
  • serratus anterior
  • coraco-brachialis
  • trapezius.

(Don’t forget that chemo and radio-therapy affect the heart (cardiac) muscle. )

Why? and What to look for?

Pectoralis major:  The pec major suffers a lot.  Even conservative surgery leaves scars.  During wound healing, a protective arm position is logically adopted.  This may last for some weeks, leading to loss of muscle tone in the pectoral of the affected side. This muscle is frequently burnt by radiation.  Burn scars are deep and inelastic – the muscle loses stretchiness.   If an implant reconstruction has been performed, the expander and/or implant will likely be below the pectoral muscle.  This puts the muscle fibers under tension, leading the shoulder drop and poor arm abduction, extension and external rotation (difficulty taking arm back, outwards and palm up).
Serratus anterior: Watch for radiation burns (radio placement tattoos are often seen just around S.anterior digitations, on the side of the chest, below the armpit).  Often this muscle also suffers from the protective arm position post-surgery.  Poor shoulder position weakens S.anterior because the insertion fibers are under tension (sunken chest/rounded back posture). In re-constructed women, this muscle may be used for Serratus-flap reconstruction.  If this is the case, full arm rotation can probably never be re-established.  Watch for pain under the armpit and at the mid shoulder blade area.
Coraco-brachialis:  Usually loses elasticity due to inward rotation and adduction of the arm  (arm is pulled in towards the body, and rotated so that the back of the hand faces the front).  Majorly affected by axilliary web syndrome, or cording. Watch for pain in the inner arm, in the soft fleshy part, about two finger-widths down from the armpit).
Trapezius:  The trap is majorly affected by shoulder drop and poor posture post-therapy. Also, weakened S.anterior and P.major muscles mean the trap is unsupported.  Muscles work in pairs, that is, when one pulls the other gives.  If the pec is pulling down and forward, the upper fibers of the trap are being stretched.  After a while, they will get annoyed and pull back.  Then, watch for neck and shoulder pain, including headaches.
The shoulder capsule is frequently scarred as a result of radiation burns.
This list is not exhaustive. Each case is unique.  I have chosen to high-light these four major muscles because they are the ones that most often need rehabilitation.
Here are some oft-used postures, modified for yoga therapy for breast cancer.
Dvipâda-pitam or half-bridge pose:  Lying on the back, with legs bent and feet hip-width apart, heels towards buttocks without using the hands to adjust position.  Arms by the sides, palms down. Inhale, raise hips and lower back, at the same time, rotating the arms so that the palms face the ceiling (watch limitations).  Watch out for rotation from the elbow, protecting the shoulder joint.  If this is the case, advise that the student lift the forearm off the floor, bending the elbow, and while rotating the arm, see if she can place the back of the hand on the floor.

Dvipada-pitam or Half-bridge pose.
Dvipada-pitam or Half-bridge pose.

 
 
 
 
 
 
 
Virabhadrâsana or Warrior pose:  Stand, feet together at the back of your mat.  Turn your right foot out about 45º.  Step forward with the left.  Arms down by the side, back of the hand facing towards the front.  Exhale.  Inhale as the knee bends, and at the same time, rotate the palms forward and out, opening the chest and separating the arms from the trunk.  Exhaling, return to starting position.  Repeat six times.  Optionally, include 1-6 breaths in the warrior pose, holding static, deep breath, awareness chest and shoulderblades.
Warrior pose
Warrior pose – modified

Let us yog. Om.

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Yoga for breast cancer

My path until here, from here on…

Weaving the strings of our lives together into a coherent pattern, our unique tissue, might be the best objective we can strive for in this life.
I am a Gemini.  I have a lot of interests.  At times, it seemed as if they might pull me to pieces.  Yoga.  Guitar.  Nutrition. Travel. Family life. Tattoos.  Bodywork.  Sexuality.  Languages. Crochet. Technology. Parties. Books. Clothes. Shall I continue to list?
In the language of yoga, tapas is the burning up of impurities.  In practical terms, it is the shedding of that which distracts us from the path.  This can include things like divesting oneself of excessive possessions, losing excess body weight, severing ties with people who do us harm, and shedding activities that only serve to distract.  Tapas comes along quite naturally, when practice is continuous and conscientious.
I have written of tapas before in this blog.  It is something that has occupied my mind for some time.  I was quite certain that some of my, uh, stuff, needed to be bidden goodbye.  But, when the process is motivated by rajas – the energetic guna, the one that I tend to have in excess – the shedding is likely to be excessive, and possibly lead later to regret (a swing into the opposite of rajas, tamas, the heavy guna).  When the process of tapas is sattvic – sattva being the balanced, calm guna – then it is filled with gratitude, awe, thankfulness and joy.  (btw:  the gunas are the three qualities of matter, as postulated in the yoga theory that I have studied.  rajas-tamas-sattva are found in matter and mind, only pure spirit is nirguna, without these qualities.  It is a bit hard to explain in few words.  If you don’t get it right now, don’t worry, there is plenty of time to learn.)
I think, I believe, that  I have reached the point in which the strands of my various interests begin to weave together to form a special tissue.

Yoga therapy for breast cancer rehabilitation.

I began working in breast cancer rehab in 2005.  I had qualified in Manual Lymphatic Drainage and, with some trepidation, began treating oedema.  Then, later, lymphoedema.  It was scary.  The first scars, the first radiation burns, the first time a patient developed metastasis, the first patient to die.  It was a path that demanded a lot of me both as a therapist and as a person.  To stand in front on one person after another and reflect back their fears, doubts, triumphs, to stop getting angry at intransigence and inability to change, to understand that an experience of facing death does not automatically change a person, that the fear of changing habits that are ingrained is stronger than the fear of dying.
I feel that MLD therapists have a different relationship to our patients than do oncologists or radiologists or plastic surgeons.  We all share a therapeutic role, but the fact that MLD is usually applied outside of the hospital setting and the therapy lasts at least an hour and may be ongoing for years means that we develop a true relationship with our patients.  This can be taxing, especially when they relapse, or die.  But it is also rewarding in the sense that friendship is always rewarding.  People are interesting, their stories are interesting.  I have learned more about modern European history by listening to my patients than I ever could have studying in University.
The ongoing tête-a-tête with death stimulates a need for answers, for ways to reflect back to these women some ideas about what the bloody hell is going on here, anyway???  I was already contemplating all this, and from a young age.  Death and dying fascinate me in the way that only a person with a huge zest for life can be interested in them.  Without fear.   I am a Gemini.  I like opposites.  I have fit three lifetimes into my first 42 years. I can’t wait to see what the next 80 years bring!
Yoga is the path I chose in my quest to find the answers.  I has helped me enormously.
And so, I chose to teach yoga to my breast cancer patients.  Simple as that.
So, from now on, instead of blogging about this and that, I choose to blog about yoga therapy for breast cancer rehabilitation.  Sounds pretty good, eh?
I ought to get organising my categories then, yes?  If you have any suggestions for a blogroll, would you please be so kind as to comment?  Many thanks and a big, fat om.

Angel in a Circle
Angel in a Circle

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Yoga teaches to listen to my body

Yoga teaches me that the body has needs, wants and desires.  These are communicated to the mind through pain, pleasure and longing.
Yoga teaches me that male and female – and everything in between – practitioners can come to respect the needs and signals of their bodies, overcoming the dominance of the mind.
Yoga teaches me that until we come to yog, we are necessarily involved in a submissive or dominant mind-body relationship.  When the mind commands the body to move-make-do-act constantly, incessantly, the body is obliged to do so, until it collapses in a foetal heap in need of sleep.  Sometimes, the abuse is so severe that the body rebels completely and starts to run the show.  But, the body does so through a passive-aggressive kind of submission.  “Oh, how I ache, it cries, I cannot wake I cannot sleep.  Help me!”
Does the mind listen?  Maybe, maybe not.  I suspect that quantities of pain killers are usually consumed before any listening begins.
Yoga teaches me that the dominant mind will first chastise the body, bending it to its will.  The body will oblige, but again, only for so long.
Yoga teaches me that true yoga begins to happen when the mind and body listen to one another, establish a mutually co-operative, symbiotic relationship.  Like a settled old couple, the mind asks for booze, the liver says perhaps not, the mind concurs, then perhaps has a small nip before bed, and the body happily settles into a comfortable sleep.  Or the body asks for magnesium, the mind is listening attentively and selects appropriate foods, the body is satisfied and the cravings cease.
Yoga teaches me that this is possible.  Yoga relies on an ancient body of knowledge in which a reproducible formula for self-realisation is laid out.  I have trod this path for 16 years.  I have lived these changes. I would not bother to blog about things I did not experience myself.
Yoga teaches me that we can heal the mind-body relationship.  Abhyasa-vairagya, discipline and detachment.  Yoga teaches me to keep at it.

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Bonds, not things.

Yoga teaches me that the process of purification – tapas – is necessary and useful.  Yoga teaches me that the time for tapas arrives just when it should. Yoga teaches me to recognise the disordered perceptions handed down by our families and to modify them as needed.  My parents were both hoarders.  Not hard to justify if you grew up in Depression-era Toronto or WW2-time Leeds, as they did.  In the age of plenty, collections of yogurt pots and old socks are unnecessary. Yoga teaches me to discern between detachment and spurning.  I have spent the past year emptying my closets of clothes, books, cables, tat and trash.  The end result is a spectacular spaciousness where once there was clutter.  The elation at seeing emptiness outstrips the flea market triumph of the find that brought most of this stuff into my life.   Yoga teaches me that I could have ejected these things from my life much earlier, but the process would have been aggressive and unconscious.  I could have become angry at the clutter – this has happened – and rid myself of things that are useful or treasured.  Instead, I found myself one day in a place where I truly appreciated the things, gave them thanks, even embraced them, then happily let them leave my life.  It is a nice, comfortable process. Yoga teaches me that the space we empty of things can fill with other things, but they are not likely to be material.  We moved to a larger house in order to have more space for, well, everything.  Hobbies, art material, instruments, cooking implements.  But the only space that love needs is a corner in the heart.  The heart is infinitely big, its capacity untested in most cases. I don’t need a bigger house to house more things.  I need a bigger heart to hold more people, to make the bonds that tie stronger and stretchier.  But, caution, with detachment.  I hold you in my heart, but I never aim to own you. Yoga teaches me to lighten my home and open my heart.  Yoga teaches me, patiently and carefully, that our wholeness is something felt from deep within.

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We need love, not splits

Yoga teaches me that what this world needs is more love, not more flexible bodies.
Yoga teaches me that postures linked to breath are part of a path, but the path leads to compassion and comprehension, not contortion or competition.
Yoga teaches me that when we undo the knots and become soft, we can learn to love without asking to be loved in kind. Yoga teaches me that we don’t lose anything by doing this – it is a safe practice, once we truly arrive at the place where this is possible, rather than forcing the practice by spiritual bypass.
Yoga teaches me to know myself deeply, profoundly, intimately.  Yoga teaches me to let go of the shame I feel about showing who I really am.  Yoga teaches me that when I do so, the anger also evaporates because it no longer serves.  It was just the tool I used to protect myself from the shame of showing my true self.  On guard!
Yoga teaches me that there are many people who are on the path who may be bendy but are still angry and/or ashamed.  Yoga teaches me that this is okay, that I may be one of these people and not know it, but if I am lucky enough not to be, then I can shine that good fortune out and be patient and encouraging, not critical.

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Yoga teaches me that arm balances improve shoulder alignment

Thoracic outlet syndrome.  TMJ.  Frozen shoulder.  Tingling fingers.  All these conditions, and many more, have to do with the shoulder joint.  Yoga teaches me that using arm balances helps bring the shoulder joint into alignment. There is a group of muscles known as the rotator cuff.  Put simply, these muscles stabilise the shoulder.  They are usually pretty weak.  Modern life doesn’t encourage us to develop them.  Most people can’t even detect the rotator cuff muscles, when prompted. Arm balances can be symmetric or asymmetric postures.  Symmetric postures, like plank or downward dog, or handstand are more easily maintained because it’s easier to balance.  Beware bad habits, like rotating the shoulders upwards and inwards, hyperextending the shoulder and/or elbow joints.  The feeling I seek is like rolling the arms down and inwards from beneath the armpits.  If you aren’t feeling that, you are not engaging the rotator cuff.  Yoga teaches me to ignore the rotator cuff at my peril.  I will only get neck ache and head ache. Asymmetric arm balances are harder, but as with all asymmetric postures, they teach me about imbalances between the two hemispheres of my body.  Yoga teaches me to ask why I balance better on my right arm than my left?  Why do I rotate more on the left than the right?  Why does one shoulder click and the other lock or hurt.  I watch my imbalances, keep practising, and over time they correct.  Or they are less pronounced. Yoga teaches me to love my body anyway, just cuz. My osteopath adjusts my diaphragm, pericardium and hyoid and reminds me that seeking help is good.  When the yoga gets deep, things shift around.  Professionals are there to help keep us aligned and to reflect back at us what we are projecting.  I tend to overwork spinal extensions.  My osteopath reminds me that this tends to put my T10-T12 out of alignment.  So, I hold back.  Yoga teaches me to listen to the opinions of others, to let go of my egotistical all-knowing and to surrender. Yoga suggests to me that when I finally align my shoulders, my heart will feel freer.  All I want to do in this world is learn to love.  My armour comes off piece by piece.  Yoga teaches me not to fear my nakedness.