PMPS: Post Mastectomy Pain Syndrome

Introduction

Among breast cancer patients, a common complaint is numbness or tingling in the upper-inner arm. This is called neuropathy and is often down to damage to one particular nerve: the intercostobrachial nerve.

ICBN

The intercostobrachial nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and anterior chest wall. The brachial plexus is a group of nerves that originate in the neck and whose basic function is to move the arms. (plexus definition: a network of nerves or vessels in the body. an intricate network or web-like formation.)
It is well known that many breast cancer survivors have problems with mobility, strength and sensation in the arm of the affected side. Today, we are going to talk about the specific complaint of tingling, numbness, pain and loss of sensation in the armpit and the inner arm. Here is an image, lifted from the pdf whose link is in the references section, that illustrates perfectly the areas of skin that are innervated by the ICBN.

PMPS

Intercostobrachial neuralgia, also known as Post-mastectomy Pain Syndrome (PMPS) is estimated to occur in about 33% of breast cancer survivors. I can’t find reference to whether these are 5-year remissions, or longer or shorter intervals, but 33% seems to be the agreed upon figure, and this is for PMPS that persists for longer than three months after the breast surgery. There are other nerves involved in PMPS, but it appears that the the ICBN is the main nerve affected in most cases. Thus, some people say it is more correct to refer to Intercostobrachial neuralgia. However, as that doesn’t exactly roll off the tongue, let’s stick to PMPS and try not to think about PMS (ouch!).

Why does it hurt?

axilla dissection — Axilliary lymph node dissection.

The origin of the pain is either:

nerve damage during surgery, or
scar tissue around the nerve.

Surgery in the axilla is usually to remove lymph nodes, and these are deep to the ICBN. Here is an image of the technique that is used to remove lymph nodes. I lifted it from the medscape article that is cited in the references section. Radiation therapy (RT) tends to damage nerve tissue and promote the formation of fibrosis, is also a cause of the PMPS.
Here is a wonderfully concise description of the surgical reasons for PMPS:

“The most commonly cited theory of chronic postoperative pain in breast cancer patients is the intentional sacrificing of the intercostobrachial nerves. These sensory nerves exit through the muscles of the chest wall, and provide sensation predominantly to the shoulder and upper arm. Because these nerves usually run through the packet of lymph nodes in the armpit, they are commonly cut by the surgeon in the process of removing the lymph nodes.” (http://www.cancersupportivecare.com/surgerypain.html)

I tried to understand what a “lymph node packet” might be, as this isn’t a term that we use in MLD speak. I think that it is a surgical term for the bundle of lymph nodes that is excised. [An article unrelated to PMPS and ICBN contained this phrase “We prospectively assessed 61 pelvic lymph node dissection specimens (packets) in 14 consecutive patients undergoing radical cystectomy.” ]

What to do?

As usual, when we use yoga therapy for breast cancer rehabilitation, we must respect limitations. Firstly, PMPS won’t be cured by practising yoga. But, it can be helped. Secondly, there is variability in the extent and severity of pain and impairment to range of motion. So, adopt a personalised approach and be patient. Use simple, slow movements with breath synchronisation to achieve optimum results. If you are a yoga teacher, you probably believe in prana. I certainly do, and no matter how scientific the tone of my posts, I will absolutely vouch for the healing effects of good prana circulation. So, when teaching, keep your students focused on the practice, not on the results. Also, use your own healing energy and direct it towards them. Wish them well. Ask for guidance and the blessing of whatever guiding energy you believe in.
Here are a few suggestions for sequences that you can integrate into your own practice and bring some flexibility and mobility to the chest and inner arm region. Note that all sequences mobilise the brachial plexus in general.

References

June 2, 2013

El método y la meta

Ayer, tuve el placer de dar una clase en una Jornada de Bienestar y Salud, en Dénia. Habían unos 20 personas. Entre ellos, algunos novatos, y algunos que ya practican hatha yoga.
Es curioso como los que ya practican yoga piden casi siempre clases y posturas avanzadas. De un lado, lo puedo entender, este deseo de reproducir las posturas tipo espaghettis que nos venden en las revistas de yoga. En un momento dado, yo también tenía muchas ganas de hacer el Escorpión. Incluso, me caí de cabeza intentando bajarme las piernas desde sirshasana (el escorpión no se toma desde sirshasana…pero como era bastante neofita y sin profe, bueno…)
Pero luego, encontré el Viniyoga y, estudiando con asiduidad, llegué a entender que las posturas no son el fin de la práctica del yoga. El fin es tranquilizarnos la mente para encontrar la felicidad.
La posturas forman parte de método del yoga. La paz mental es la meta. Importante no confundir el método por la meta.
En Yoga Sutras Libro II, el sábio Patanjali describe el camino del yoga. Consiste en ocho partes, ó miembros. Las primeras cinco – yama, niyama, âsana, pranayâma y pratyahara – son el método. Es la receta para preparar la mente para la medtación. El sabio cierre el segundo libro con pratyahara, el retiro de los sentidos. Parafraseando, Patanjali dice:

Bueno, alumnos, ahora que, a través de nuestros buen comportamientos hacia los demás y hacía nosotros mismos (yama, niyama), a través de la práctica contínua y al largo plazo de las posturas y respiraciones (âsana, pranayama), habeis llegado al momento para sentaros, retirar vuestra atención del entorno (pratyahara) y contemplar.

Patanjali continua en Yoga Sutras Libro III describiendo el camino del yogi. Ahora, abordamos la contemplación meditativa. Dharana, dhyana, samadhi….concentración, meditación, liberación. Estos tres son la meta del yoga, Tambíen forman parte del camino, pero son realmente los frutos de la práctica. Repito: importante no confundir le método por la meta.

¿Y, de estos que te demandan las posturas avanzadas? Bueno, en el contexto de una clase general y grupal, no las vamos a abordar. Y punto. Iguál en una clase avanzada ó MasterClass se podría trabajar equilibrios avanzados. Con la preparación y actitud adecuadas son perfectamente asequibles.
Pero,¿como una profe puede satisfacer a la necesidad de esa gente de profundizar en su práctica? Porque, en su esencia, cuando te piden posturas avanzadas, lo que realmente te estan pidiendo es profundizar en su práctica. “He llegado a tal punto, me encuentro bien, por donde voy ahora?” Puede ser impaciencia (ojo!). Pero, puede ser la sed de él que busque pidiendo limosna. “Por favor, enseñame el camino que me lleva desde la miseria hacía la paz”, te imploran.
El Viniyoga dispone de muchas herramientas para esa gente. Nosotros los viniyoguis abordamos la respiración con una lucidez y coherencia que no se encuentra en otros lineajes (admito que no conzco de primera mano el método Iyengar. Lo aprecio como un método muy sano y coherente. Igual allí también dan a la respiración la importancia que merezca…). Las técnicas respiratorias son nuestras semillas. Vamos plantando semillas en las cabezas de estos yoguis sedientos. De que colores serán sus flores?
Como profes de Viniyoga, sabemos muy bien poner pautas respiratorias a posturas sencillas, dandolas el enfoque mental completo y absorbiente tán característico de una buena práctica de hatha yoga. Pausas (krama), retenciones (kumbhaka), y ritmos. Bandhas (cierres musculares), mudras (apretones), dristi (la mirada) y bhavana (enfoques mentales). Todas estas cosas aportan una dmiensión energética a la práctica, saciando a la más hambriente mente. Cuando las inquietudes mentales se suavizan, entonces, el alumno está prácticando yoga de verdad. Hemos relizado la meta, empleando las herramientas del método.
Sencillo, ¿no?
The guru is in you. Let us yog.

April 7, 2013

Musings: The unsung note

I had the great pleasure of returning to the stage this Thursday past. Yes, dear yogis, in my spare time I am a singer-songwriter.
I began this odyssey years ago. In fact, I could say that I have always been a musician. As child I played the oboe, and the recorder. I used to sit there with my tape recorder, registering a harmony to then play the melody on top. Too bad I only had one track! I gave up classical music, as most teens do, only to then buy a red Yamaha bass at the age of 18. I played in a band, and enjoyed mild local success, before shyness and nerves forced me off the stage. Life continued apace. I began writing more and more, diaries, poetry, laments, and soon, songs. It took me 10 years to buy a guitar and another four before I could tune by ear and play with some fluency. At this point, I bought my lovely Taylor 414CE cutaway and began composing the songs that I still play today.

How does this relate to yoga?

Vishuddah chakra and overcoming fear.

Singing is related to the throat (vishuddha) chakra. Mine was most definitely blocked. I used to speak in a whisper and was plagued by the sensation of something in my throat. (In TCM, this is called plum-pit throat and is related to the Liver Qi). I bought a couple of books (Finding Your Voice, Zen Guitar), took a workshop (The Healing Voice with Jill Purce), but, mostly, I just sang. Over and over, through smiles and tears. Overcoming my incredible fear, I took to stage in open mic nights and small gigs in and around London. It was terrifying but I knew it did me good. Still, the fear was being pushed down, not truly overcome. But, I think that in yoga we have to push past our fear, be brave and have great faith, in order to grow. So, that was one phase of my growth.

Control of the diaphragm

Another phase of my work was taking control of my diaphragm muscle. The diaphragm is fundamental to the singer. My yoga teacher gave me a short personalized practice in which I did krama in the exhale. This means, the exhale was broken up into two or more parts, and then the breath retained with the lungs empty. For the first time in my life, I could actually locate my own diaphragm. My colleague Santi, a fantastic osteopath, adjusted my diaphragm and pericardium, loosening the tendons and leaving my breath much freer.

Control of the perineum

By now, my voice was vibrating nicely in my chest and abdomen. It was mellower and sweeter and easier to control. But, still, on the high notes, something was missing. In my ongoing reading – I am voracious, and practically only read on theme – I came across a few lines in The Anatomy of Hatha Yoga by H. David Coulter.

A famous conductor…once shouted…”No! No! Squeeze it in – push it up!” He may not have known it, but he was telling them to seal off and control the anatomical perineum – the base of the pelvis -and thereby cultivate what we have been calling abdominopelvic energy. All trained singers have learned that the purest and richest sound originates from this region. In the language of singers, the base of the body “supports” the voice.

Wa-hey! that’s the secret. On the high notes, all that perineum work I’d been doing in yoga would pay in by holding my voice up in a clean, sweet note. Hallelujah!

Believing in myself

Yoga teaches us that within each and every human being there is a tiny spark of Divinity. We don’t need any mediators when we talk to God because God is within. When we first learn, then internalize this, our faith in ourselves grows and grows and we begin to value ourselves for who we are instead of what we do. Through yoga, I realized that my music, my words, my beliefs and my message are not only valid but beautiful and even Divine. And having that behind me, I take the stage with courage and honesty, and never try to emulate the music or sound of anyone else. This is freedom. And now, the fear is not being suppressed. It is no longer there. I offer it all to God with the simple mantra, Ishvara Pranidanah.
There is karmic cleansing here. My grandfather went down to London in the 1920’s and played his clarinet in the earliest SoHo jazz clubs. From my limited research, there was only a handful of jazz clubs in the UK at that time, so both he and my grandmother – they met on the jazz scene – were well ahead of their time. They married, and moved up to Yorkshire where dreams of jazz music were replaced by granite houses and the family woolens mill. A frustrated musician to the end of his days, Grandsir, as well called him, would get drunk on G&Ts and pull out the clarinet at Christmas, even as his dentures popped from his gums. My mum sang. In the choir, in Gilbert and Sullivan productions, in the singalong Messiah every Ottawa Christmas. My father was the greatest music fan. He wept and danced and collected music. His LP collection filled the basement of a huge Saskatchewan house by the time he died. I come by it in honestly. Music is in my blood. But yoga helped – and helps – me realise it in a sane and safe way.
When our karma (work) and our dharma (lifepath) unite, we find liberation (Kaivalya). Let yoga guide you towards Self-realization. And don’t think for a moment that Self-realization means isolation in an ashram. For some, maybe, but not for everyone. Sri Aurobindo’s contribution to modern yogic thought was the idea that liberation can be found here and now, in daily life, not only when the soul leaves the body. Be happy here and now. Bless y’all.

March 27, 2013

Well woman massage

I have spent the past 11 years of my life as a professional massage therapist, and 8 of those dedicating myself to the gentle art of Manual Lymphatic Drainage (MLD). MLD is a very gentle and highly specific massage technique that is used in cancer rehabilitation. Many who opt for allopathic cancer treatments such as radiotherapy and surgery are left with impaired lymphatic drainage in the affected area. This manifests as swelling known as lymphedema (sometimes lymphoedema).
In massage training, touching of the breast is generally verboten. In MLD it is an integral part of the treatment, especially in women who have had lumpectomies, mastectomies, radiotherapy, reconstruction (implant or TRAM). I consider myself an expert in the treatment of breast conditions.
Drawing from my massage training, I have always emphasized the importance of the abdominal massage. Deep abdominal massage is used in many healing modalities including, but not limited to, Tui-Na, Mayan massage, modern Osteopathy, Ayurvedic massage, and Swedish massage. MLD includes very important abdominal work, but the touch is light, as it is in all aspects of the technique.
In hatha yoga, we learn and teach techniques to release the diaphragm muscle, deepen the breath and connect with the muscles of the pelvic floor.
I propose to you a Well Woman Massage:

Hatha yoga to stretch the body and deepen the breath, connecting with the perineum and diaphragm.
Deep abdominal massage, back massage (lest we forget that the abdominal obliques and the hip flexors originate in the spine)
MLD for abdomen and breast.

Women have special physical needs not seen in men – hormones and hot flashes and pregnancy and childbirth and breastfeeding and, and, and…If you feel it’s time to care for yourself the way you’ve always wanted to, please feel free to drop me a line. Treatments available in Altea, Benidorm and Teulada. For treatments booked in April 2013, I offer a 5% discount on the normal price of €60. This is a two-hour program.

March 12, 2013

Musings on Meditation

In Patanjali’s Yoga Sutras, the path of yoga is very clearly laid out. Book 1 talks about the kind of person who undertakes to stay on the path, and the pitfalls that may arise whilst there. Book 2 talks about the practical part of yoga. It is here that you will find the first mention of hatha yoga – the postural part that we are now familiar with – and the other 7 branches of Astanga Yoga (there are eight limbs in total).
We start with character-building, as Swami Radha calls it in her brilliant book “Kundalini Yoga for the West”. These are the yamas and niyamas. Once this is established, the yogi can then confidently practice asana (postures) and pranayama, (breathwork) leading to pratyahara, or retraction of the senses. I found the concept of pratyahara difficult to understand before directly experiencing its effects. Your path and my path of yoga are each distinct and unique, so I won’t elaborate too much here. But, in my case, pratyahara meant a softening of the impact of external influences – loud noises make me jump less, bright lights don’t annoy, strong smells…well strong smells still bug me. Okay, but you might get the point.
The next limb of Astanga Yoga is dharana, or concentration. This is not, note, meditation, which is dhyana. Dharana is the ability to focus the mind on a single object for increasingly long periods of time. Eventually, one become “one” with the object, and enters into samana with it. This is the beginning of Book 3 of the sutras. The object can be something external like an icon or candle, or it can be more subtle, like the breath or the heartbeat.
Still, the point I want to make here is that dharana, and eventually dhyana, are the fruits of previous practice. I was a terribly meditator. For years I fidgeted on my zafu, wondering where all the mental peace was. Well, the answer is it’s coming…be patient. Practice and all is coming, said Sri Pattabhi Jois. I use the spinal breathing method described in the book “Advanced Yoga Practices”. (http://www.aypsite.org/)
My advice is: don’t jump straight into meditation without toning the body and breath first. Some people can – hey, we’re all different – but many people can’t. And don’t give up. Propel yourself forward on wings of faith. Look up at the sky and realise that the Universe is boundless and you are a speck and rejoice in all the incredible freedom that gives you. OM.

February 16, 2013

Tending the Fire

There is much talk of fire in most Yoga texts and teachings. Fire is one of the 5 elements, the others being Air, Water, Earth and Ether/Space. Fire is felt to transform matter from one state to another. Its sinuous flames remind us nearly of liquid, so despite its “hot” quality, it is also intimately associated with Water, Water being its equal and opposite.
The path of yoga is one of transformation. We learn new ways to move, think, breathe and be still, and thus we transform ourselves from one type of person into another. We are still ourselves, but we have changed, shed a skin or grown a new one. Thus, stoking the fire of transformation is of utmost importance.
In hatha yoga, we do this mainly through postures associated with the abdominal region. We also practise breathing techniques that emphasize the inhale and breath retention with lungs full. Other lineages may follow other methods, and these are all legitimate. You are always in control of your yoga practice, and are free to choose the branch of yoga that most satisfies your heart and soul.
This winter, I have learned to tend the hearth. I have never before lived in a house with a working fireplace, let alone relied upon it as my main heat source! But, I am open to change. I had call to be the sole firelighter for a period of nearly two weeks. I struggled mightily at first, sitting near it, blowing desperately on rapidly dwindling sticks and leaves and bits of paper. Once, I managed a roaring inferno on the first go, but most nights heard me cursing the whole rustic life and yearning to go back to the city and central heating.
But I persisted.
I discovered that the paper I use on my massage couch serves perfectly as a recycled firelighter. Light, and slightly oil-streaked, it takes immediately and burns hot. I learnt the value of the small bits of kindling that my partner lovingly chops, and how to tell if wood if green or dry. I am now a one-match woman. I can set and light a fire in about ten minutes, and tend it carefully for hours. I watch it and poke it and generally feel it to be a living presence in my home.
I think that our inner Fire is the same. It needs the right material to start it up, and the right material and rhythm to keep it burning brightly. We need to pay attention to it, feeding it more when it needs it, and leaving it to rest when it doesn´t. Cared for properly, our inner Fire helps us efficiently transform our food into healthy tissue and keeps us energetic and motivated.
Weak Fire leaves us sluggish, uninspired and waterlogged. We feel like we are walking in soaked through clothing. A Fire burning too brightly manifests in a flushed face, quick temper and impatience. Remember, a person may have imbalance of one Element in the physical body, while having a completely different Elemental layout in the realm of the Mind.
So, tend your Fire, dear souls.

June 20, 2011

A few days away

Namasté. I went this weekend with my yoga group to the Sierra de Mariola, near Alcoy. A lovely break, it was. We stayed at a lovely casa rural called “Casa Bons Aires.” If you should chance to visit the Font Roja region of Alicante, I highly recommend a visit.
The theme of our studies was pranayama, but the unintentional theme was sound. We chanted the Gayatri mantra in the vedic form as a group. We sang some bhakti mantras together, with yours truly on guitar. We laughed our asses off over supper. The rooster crowed us awake in the morning. Claudia the donkey brayed. Water flowed and gushed. Gases erupted unexpectedly in down dog (adho mukha svanasana). We practiced bhramhari pranayama. We had fun…ananda! Santosha!
There really is nothing like a few days away to recharge your batteries. “Cambiar el aire” as the Spanish say. Although I arrived home tired, I feel like I’ve had a month of holidays!
Meanwhile. have a listen to Wade Imre Morrissette sing the Tara Mantra. I went to High School with this fellow. I must admit that I would not have imagined him ending up chanting sanskrit mantras! Wahey Guru!!