Yoga therapy for the pericardium

a grey and purple mandala
Harlequin Mandala

Radiation therapy (RT) has improved life expectancy for many cancer patients.   However, it is well known that RT has long-lasting side effects that can range from mild to severe. Breast cancer patients treated with RT are at risk of damage to any of the structures near to the breast.  This includes the heart, lungs, pericardium, skin, lymphatic vessels and nodes, and skeletal muscles.  Today we are going to talk about the pericardium, what it is, how it may be affected/damaged in yoga therapy students, and how we can present a hatha yoga class to benefit and rehabilitate the pericardium.

What is the pericardium?

The pericardium is “a fibrous sac that attaches to the central tendon of the diaphragm and fuses with the adventitia of the great vessels superiorly.”  The great vessels are the large blood vessels that carry blood to a from the heart.  The adventitia is the outermost layer of the wall of a blood vessel.  So, the pericardium is:

  • A fibrous sac (two-walled, in fact, with fluid in the space between).
  • Attached to the central tendon of the diaphragm (the main muscle of breathing).
  • Fused with the outermost walls of the big blood vessels of the heart.

What does the pericardium do?

The pericardium has four functions.

  • It protects the heart from infections,
  • It protects the heart from knocks and jolts (this due to the fluid in the space between the two sacs),
  • It lubricates the heart and
  • It prevents excessive swelling of the heart in the case of a sudden increase in blood volume, which is usually associated with other illnesses or problems with sodium levels in the blood.

Unsurprisingly, given its roles, in Traditional Chinese Medicine, the pericardium is also referred to as the heart protector.  The pericardium meridian runs down the inner arms, between the two tendons of the inner forearm, crosses the palm and then runs along the middle finger, terminating at its tip.  Anyone who has treated secondary lymphoedema of breast cancer will observe that the affected areas coincide spectacularly with the pericardium meridian…

What happens to the pericardium during cancer treatment?

Fibrosis is the thickening and scarring of connective tissue usually as a result of injury.  The injury in this case is a radiation burn. Bear in mind that there are diseases that cause a primary fibrosis (cystic fibrosis, for example).  We are not talking about yoga therapy for such diseases here, although some of the underlying theory may be applicable.  We are discussing yoga therapy for breast cancer patients who may have pericardium fibrosis caused by RT.  This would be a secondary fibrosis, just at the lymphoedema seen in breast cancer patients is secondary to lymph node excision or what have you.
RT has a tendency to burn the surrounding tissue as well as the tumour.  The pericardium is already defined as a “fibrous sac” and the fibrosity that can develop as a result of radiation burns is our main concern here.  Bear in mind that different RT techniques will have greater or lesser probability of damaging the pericardium.  I observe that women with deep tumours often have RT tattoos on the other side of the chest, meaning that at least one ray had to cross the chest the get to the tumour.  Shudder.  Indeed, this article (from 2010) says that 20% of oncology patients who have had RT in the chest develop constrictive pericarditis.  This is called “radiation-induced constrictive pericarditis.” Constrictive pericarditis is a medical condition characterized by a thickened, fibrotic pericardium, limiting the hearts ability to function normally.
Let’s also take a moment to recall that chemotherapy often damages the heart.

Yoga poses for the pericardium.

Spinal extensions, backbends, outwards arm rotations, held inhales, arm raises with inhales and basically anything that stretches the chest and moves the diaphragm will be therapeutic for the pericardium.  However, as usual, there are limitations and contraindications that must be considered.  A glance at this page is useful in that it demonstrates a number of poses that quite frankly could not be used in the classes that I give.
Firstly, recall that fibrosis is not reversible.  It can be improved and loosened, but under normal circumstances, it is chronic.  I mention this to help you pace your program and not expect miracles.  I also warn strongly that overwork and tears are not desirable.  So, work within your students’ limits.
Referring back to the last page I mentioned, the “puppy dog pose” could be modified to a cat-cow sequence, breathing out with rounding the back and in when arching.  Another typical viniyoga sequence is moving slowly between cat pose and child’s pose.

cat-child's pose sequence
cat-child’s pose sequence

Another typical sequence is alternating between standing on the tiptoes with the arms reaching up (keep to shoulder height in some cases, elbows may also need to bend, ideal is palms facing at the top) and a half-squat with a spinal twist.  If you alternate sides and breathe in when you go up and out when you go down, you get a really nice loosening effect in the mid-trunk without really running risk of injury.
twist utkatasana - tiptoes sequence
twist utkatasana – tiptoes sequence

What can be interesting is using breath retentions to increase the lung volume and mobilise the intercostal and the serratus anterior muscles.  Next week I will post a sequence that I use and love.  Right now, I have to go.  It’s been a long post and I think that I have communicated what I set out to.
To yog is to live.  Keep at it!!!

Yoga vs Pilates: What's the difference?

“Should I do yoga or Pilates?”

I hear this question a lot.  As a yoga teacher, I am naturally inclined to say yoga.  However, I recognise the usefulness and appropriateness of both systems, depending on the person and their circumstances. 

Let’s explore the similarities and differences between Yoga and Pilates.


Yoga is an ancient system of healthcare and spiritual inquiry.  What most of us consider yoga is really only a fraction of the entire body of Ayurvedic medicine.  Hatha yoga consists of specifically applied breathing and postures.  There are many branches of hatha yoga, including  Astanga and flow styles (vigourous, stimulating), Kundalini and tantric lineages (spiritual),  and everything in between.   The objective of yoga is to heal the physical body and prepare body and mind to sit in contemplation and, eventually,  meditate profoundly.  The stilling of the mind is paramount in yoga.

Pilates, is a system of exercise developed in Germany by Josef Pilates.   Setting out to align and strengthen the body, Mr. Pilates believed that the mind, when properly oriented towards the physical endeavour, could completely dominate the body, bringing it into harmony through force of will, as it were.  Thus, as in yoga, there is mental focus required, but the objectives are quite different.  In our modern world, we tend to believe the the intellect reigns supreme and human ingenuity can solve any problem.  For this reason, the Pilates philosophy may be more comprehensible for the beginner.  It is hard to imagine what “stilling the mind” might entail until we have experienced it.  When choosing between Yoga and Pilates, review your belief system:  are you more materially or spiritually oriented?  While yoga doesn’t have to be spiritual, I could not deny the spiritual underpinnings of the practice.


Yoga can be both dynamic or static, depending on the style.  Dynamic yoga places poses in a sequence and one moves smoothly from one to the other.  This can be used for warming up – the famous Sun Salutation, for example – or the whole series can be built around flowing vinyasa-s.   More static styles work on holding poses.  The time can be measured in number of breaths or in seconds/minutes.  Yin yoga, for example, holds poses for five minutes or more, allowing deep work into the connective tissue.  Some styles combine the two:  Viniyoga usually takes each pose through a dynamic phase before holding the pose for a certain number of breaths.  The idea behind yoga is that the subtle energy needs to flow in all parts of the body, so a practice could focus on one area (hips, chest) or indeed a whole season could be dedicated to working slowly towards a certain key pose.  Again, depending on the style, because the flow styles are more “full body” and some systems work with a set series of poses that work the entire body.

PIlates is always a full body workout, but you may use certain props such as balls, stretchy bands and magic rings to focus a class.  There is also simply mat Pilates which perhaps looks more like yoga.  Notwithstanding, some yoga styles, such as Iyengar, use props.  Pilates is focused on aligning the joints, toning the muscles and strengthening the core abdominal musculature.


Correct breathing is important in both systems.  In Yoga, breath and movement are co-ordinated and interdependent.  Inhaling for opening movements (extensions, lifts), we exhale to close (flexions, lowering).  The breath brackets the movement.  That is, the breath is longer than the movement, beginning before and finishing after.  Most Yoga classes involve a component of “pranayama” or breathwork.  This can be done during the practice, or in special gentle sequences.   More often, we close the class by sitting with a straight back and breathing through one or both nostrils following a pattern and rhythm designed by the teacher.

Pilates also has specific breathing patterns, but they are distinct.  Inhaling to open and exhaling the close is usually observed, but this pattern is reversed in some exercises.  In strength work, we are taught to exhale when applying force (think of a weightlifter’s grunt when squatting).  Pilates uses this technique for its strength component.  In Pilates,  the navel is usually held in.  However, with tensed abs, we can produce “paradoxical breathing” as we draw breath, .  Paradoxical breathing is a breathing pattern in which the pressure in the lungs increases due to intake of air, but the lung volume does not increase (the lungs can’t expand because the tensed abs limit diaphragm movement).  Paradoxical breathing is the hallmark of anxiety and even trying it for a few seconds brings on quite a nervous feeling.  Try it yourself:  pull your abs in then breathe deeply a few times. That heady feeling?  The brain’s response the the increased lung pressure.  So, while Pilates will produce more toning and strengthening than yoga might, it can have undesired secondary effects due to the breathing.  When deciding between Yoga and Pilates, review your personality and challenges:  are you nervous, anxious and looking for mental peace?  Or are you more interested in toning and firming?

Adaptations for Breast Cancer Survivors

A yoga teacher with a good training will know how to adapt yoga poses (and flows) to minimise their potential harmfulness to irradiated and/or post-operative areas.  Bear in mind that this somewhat eliminates styles in which a set of poses “has to” be practised as a sequence.   If these sequence is what the teacher CAN teach – and many 200-hour trainings teach their teachers only set sequences, not how to sequence postures – then a practitioner who “cannot” do the equence will put pressure on herself, the teacher and the class.  We need a therapeutic style for breast cancer work, so make sure your teacher knows how to adapt both postures and sequences.  Bear in mind that yoga teaching is economically unrewarding and some teachers will be under pressure to fill their classes at any cost.  Bear in mind, also, that some teachers might be unaware of their limitations.  By reading this post, you are gaining the knowledge necessary to assess your potential teacher and decide.

Astanga-style flows are awesome for the fit body, but tend to include quite a few arm balances.  Bear in mind that even the ever-famous Downward Dog (Adho-mukha-svanâsana) is an arm balance.  This seemingly simple pose puts pressure on wrists and arms, requires full range of motion in the shoulder joint and requires that Serratus anterior be stretched.  All of these factors make Downward dog a tough pose for breast cancer patients.  I am not saying “Don’t do it”.  I am saying – assess carefully just how important this pose is to the final objective of yoga – stilling the mind through body and breath work – and decide if a class that involves a lot of Downward dog is the BEST option.

Kundalini classes also tend to work set kriyas – sequences – but are probably easier on the breast cancer survivor as the âsana element is less important.  There tend to be poses that work pretty intensly the abdominal region, so those with shoulder drop might find this imbalance makes some kundalini poses more challenging.

Bikram is out because of the heat.  Too dangerous for lymphedema.

I practice and teach Viniyoga.  It covers all the bases when it comes to adaptation of postures and sequences.  The therapeutic aspect of Viniyoga also makes it more useful when working with the very personal journey each breast cancer survivor is coursing.

Pilates is subject to the same general contra-indications I mentioned about Astanga and flow styles.  It may be difficult for a teacher to adapt a class to one single student.  Arm balances for core work may be unavoidable.  It may be left to the student to adapt the poses, rather than receive specific instructions about how to do so.  Pilates will be great for bringing the shoulders back into alignment and keeping the shoulders joint stable, but again, interview your teacher and decide if they are the person best able to help you.


Gentle physical exercise is a must for breast cancer patients.   How tough you want to go is up to you, but it also depends on where you were when you were diagnosed.  Did you have a good level of physical fitness, or had you been making excuses for too long?  How old are you?  Have you any extenuating circumstances like injuries or co-pathologies?   Answering these questions helps you to decide what your goal is.  But, really, I urge you to go slow at first, and keep a steady pace over time.  This will bring greater rewards, over time, than plunging in and risking injury and setbacks.  Either yoga or Pilates will do you a great service.  Find a teacher who knows and inspires confidence, a class that is nearby and at a time that you can manage.   Consider taking a private class, just to give the teacher time to know your history, your limitations, and to teach you how to modify the postures that you will find in the group class.  Most important of all is to stick with it! 

a green mandala

If you can’t find a group class in your area, why not start one yourself?  Find three other breast cancer patients – not too hard, sadly – and contact a teacher.  Be pro-active and believe that this is a fundamental part of your healing journey.  Om.


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

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.