EDITOR’S NOTE: This article is not intended as a substitute for medical advice. Clients with serious medical conditions should always consult their medical practitioners before beginning any exercise program.
Eve Gentry, one of the Pilates “elders,” was diagnosed with breast cancer in 1955. She underwent a radical mastectomy and was unable to lift her arm after the procedure. She discussed the situation with her mentor, Joseph Pilates. He told her, “Don’t worry, we fix.” Eve credited Joseph for helping her to regain her range of motion.
Today, radical mastectomies are rarely performed. Women still suffer from decreased range of motion, pain, altered body image, lymphedema and loss of function after breast cancer surgery and treatment. The purpose of this article is to learn about these treatments and how they impact mind and body. Pilates can be a valuable exercise modality to help breast cancer survivors regain mobility, strength and endurance. However, it is important to know the issues these women face if you are working as a Pilates instructor or use Pilates as part of an exercise program. Included below is a very brief summary of the implications of breast cancer surgery and treatment. Please remember that every woman is different, and the treatments can vary.
The first line of treatment for breast cancer is usually surgery to remove the cancerous tumor. There are some options, depending on the size of the tumor and whether there is lymph node involvement. The options include a simple mastectomy in which all of the breast tissue is removed. A modified radical mastectomy includes removal of the breast tissue as well as the lymph nodes. A lumpectomy is a procedure in which the tumor is excised with a margin of tissue around it. It is usually performed with an axillary dissection, which is a removal of lymph nodes, and then followed by radiation. Radiation is another type of local treatment involving high energy rays that damage cancer cells. A radical mastectomy is now only performed when the cancer has spread to the chest wall and includes removal of the breast tissue, pectoralis major/minor and all of the lymph nodes. This surgery caused many functional deficits and was severely disabling. The surgeries mentioned above can produce scars, limited range of motion, musculoskeletal pain, lymphedema and axillary web syndrome. In addition, many women must undergo systemic treatments, which can include chemotherapy, hormonal treatment and biological treatment. The biggest side effect that all of these treatments have in common is fatigue. However, chemotherapy can result in peripheral neuropathy,” chemo brain, sarcopenia, infection risk, weight gain, anemia and premature menopause leading to osteoporosis. In addition, hormonal treatment such as tamoxifen can cause weight gain, hot flashes and increased risk of uterine cancer. Other hormonal treatments such as the Aromatase Inhibitors can cause joint pain and osteoporosis. Biological treatments such as Herceptin can cause heart and lung problems. Finally, radiation can contribute to fatigue, lymphedema and brachial plexopathy. These side effects can last from 12 to 24 months or even years. Psychological issues such as changes in body image and fear of death can complicate the recovery process.
Benefits of Pilates
Pilates can help to restore mind and body integration because it is a low impact exercise regimen that strengthens the scapular, abdominal /back and pelvic core musculature while emphasizing deep breathing. If the core is strong, there is an improved ability to use more distal musculature.
Other benefits include the following:
- Improves lymphatic drainage by its focus upon deep rib cage breathing, which expands the chest and lungs along with activation of the transverse abdominas, which assists in pumping lymphatic fluid back towards the center of the body. In addition, this helps with stress management as deep breathing facilitates the parasympathetic nervous system. This system decreases our natural “fight” or “flight” reaction to a life threatening disease.
- It strengthens the middle back musculature such as the rhomboids and middle trapezius through exercises such as body extension, swan and diamond. This promotes better posture, which is often impaired after breast cancer surgery.
- If fatigue, anemia or infection risk is a factor, Pilates can be done in individual sessions. In addition, it can accommodate special needs and considerations as it can be performed standing, seated, prone, side lying or supine. For example, the supine position is excellent as it provides proprioceptive input to the scapula stabilizers. Proprioception is often decreased after injury or surgery.
- Pilates can improve scapula-humeral rhythm since so much emphasis is placed upon use of the scapula stabilizers including the latissimus dorsi, rhomboids and middle trapezius. Our upper trapezius muscles are often overworked, especially post surgery when pain is a factor.
- Since osteoporosis is a concern, many Pilates exercises can be modified, adapted or eliminated from the traditional Pilates repertoire. For example, keeping the head down during the “hundreds” instead of lifting it up or eliminating the roll up are some suggestions.
- One of the most prevalent issues faced after lymph node dissection and/or radiation is lymphedema. Lymphedema is the build up of protein-rich fluid in the chest, arm, back or hand. It would be advantageous to learn lymphedema risk reduction strategies for your clients. These include wearing a well fitting compression garment or sleeve while exercising. In addition, weights and repetitions should not be increased at the same time. Pilates is wonderful due to the fact that most exercises are performed with minimal repetitions. However, be prudent while increasing the weight or resistance of your equipment when working the arm.
Physical recovery after breast cancer surgery can take months or even years. The Pilates exercises that are recommended are part of the mat Pilates program. The goal here is to learn the correct Pilates principles while restoring range of motion and strength safely. The times provided are only approximations, as recovery must be individualized, and doctors’ recommendations can vary. Have clients perform three to five repetitions to start and then increase to eight to 10.
Phase 1 (protective phase with drain in place - see Figure 1) Days 1-10
Clients will be recovering from surgery and may be referred to rehabilitation, if needed. Pilates deep breathing can be used to assist in edema reduction and stress management. Pilates breathing is rib cage breathing. Place hands on ribcage (see Figure 2 below). As you inhale, you should feel fingers move away from belly button. Upon exhalation, fingers move towards the belly button.
Three Phase Recovery System
Start lying supine (see Figure 3 below), with knees bent and hip distance apart. Place heel of both hands on ASIS and make a triangle with fingers to pubic bone. Lift head off the floor and look at hands. Thumbs and index fingers should be on the same plane/level. If not, tilt pelvis to become level.
Place a pad under the head and a ball between knees. To start, lie supine with knees bent and arms reaching to ceiling with scapula at neutral (see Figure 4 below). Inhale and reach fingers toward ceiling as you protract. Exhale back to neutral scapula (not in retraction).
Figure 4 (Protraction)
Figure 5 (Neutral)
Phase 2 (drains removed) Day 10-24
This is when range of motion should be restored. Some clients may receive rehabilitation, while others may not. Some modifications as indicated in the Hints for Success section below can be helpful. Usually, you would not see clients at this phase but will need to take them through phase 1 and phase 2 to establish stability and master the Pilates principles.
Place a pad under head, ball under knees, feet hip width apart and arms at 90 degrees. Inhale and then exhale as one arm goes into flexion (see Figure 6 below). Inhale and hold. Exhale as you change arms. Raise one arm up and bring the other down. Keep the ribcage down.
Toning balls can be used for arm down at side. To start, side cross legged or in a chair. Inhale and reach the left arm up (see Figure 7 below). Exhale as you laterally flex to the opposite side (see Figure 8). Inhale and hold, and then exhale as you return your arm to the side and sit back up. Change sides.
Side Lying Shoulder Flexion/Extension
Start by lying on your side (line body up with edge of mat) with bottom knee bent for support (see Figure 9 below). Inhale, and move the top arm as tolerated into flexion. Inhale and hold at highest point (see Figure 10). Exhale and return to start. NOTE: Position other arm for comfort. Change sides.
Side Lying Chest Opener (Part 1)
Place a pad under your head. Start by lying on your side with shoulders flexed to 90 degrees and stacked palm/palm (see Figure 11 below). Inhale to start and stabilize. Exhale as you float arm up to ceiling (see Figure 12). Inhale, hold and then exhale and return to start. Change sides.
Place a towel or blanket under knees and buttocks. Start on your knees with buttocks to heels (see Figure 13 below). Spine is rounded. Arms touching ground near knees. Perform Pilates breathing. Move arms as far as possible to front (see Figure 14), then move arms to the left, hips to right. Change sides. Stretch for axillary area/back.
Phase 3 (strengthening begins Day 24 and beyond)
This is the use of toning balls, Therabands or increased repetitions to maximize strength and endurance, thus fostering function. Phase 2 exercises can be performed with resistance along with traditional Pilates exercises such as the swan, mermaid with toning balls, swimming, hundreds and criss cross. However, you must plan your program within the limitations of pain, range of motion and endurance along with the monitoring of side effects from treatment.
Scissors with Weights
Place a pad under the head and a ball between knees. Arms are at 90 degrees. Inhale to prepare and then exhale as you lift the left arm into flexion as you exhale (see Figure 15 below). Inhale and switch arms using the same procedure.
Side Lying Rotator Cuff Push
Place pad under the head with a ball between knees and a weight in top hand. Start lying on your side with both knees bent at 90 degrees, top arm adducted to waist. Hips are stacked (see Figure 17 below). Inhale to draw belly button to spine. Exhale and move top arm into ER. Hold and inhale. Exhale and return to neutral. Perform three to five repetitions (increase to eight to 10) and repeat on opposite side.
Side Lying Chest Opener (Part 2)
Place a pad under your head and a pillow under the non working arm, if necessary. Start lying on your side as in part 1 (see Figure 19 below). Inhale and then exhale as you lift the top arm into abduction (see Figure 20). Hold at point within tolerance and inhale. Eyes follow top arm. Be sure to rotate your ribcage. Exhale and return to start. Perform three to five repetitions (increase to eight to 10) and repeat on opposite side.
Swan (Traditional Exercise)
Equipment for this exercise includes a foam roller and toning balls. Start in a prone position with shoulders flexed in front and heels of the hands on toning balls (see Figure 21 below). Legs are abducted and externally rotated. Inhale and tighten glutes (to protect back). Exhale and press hands into balls. Draw balls toward you. Slide scapulae into a V as you extend spine (see Figure 22). Inhale and hold. Exhale and return to start position.
Hints for Success
- Be sure to work with a trained rehabilitation specialist who is familiar with the issues that can arise including peripheral neuropathy, lymphedema, axillary web syndrome and post mastectomy pain syndrome. Learn when to refer out to other medical professionals.
- Always secure a physician’s clearance for exercise, especially if women are undergoing treatment or have multiple health problems. Be sure to note any special precautions. Obtain a complete medical history with dates of surgery, radiation, chemotherapy and breast reconstruction. Find out about the side effects of any of the treatments. In addition, there are many protocols for breast reconstruction. It is advisable to work within the doctors’ guidelines, especially when beginning a strengthening program after breast reconstruction.
- If a client has osteoporosis/osteopenia in the spine, do not perform any exercises that involve spinal flexion, lateral flexion or spinal rotation. This includes the mermaid, saw and criss cross. If there is osteoporosis/osteopenia in the hip, do not perform exercises that involve hip external rotation and flexion such as leg circles or some of the side lying series.
- Prone position may be difficult after surgery. The use of towels, wedges or therapy balls can assist. If these props are not available, the exercise can be modified by performing it standing or seated. Pilates can always be changed to accommodate different bodies or needs.
- Progress your clients slowly and teach them to listen to their bodies.
- If client is at lymphedema risk, start with light resistance and monitor how the individual responds to the resistance before changing band strength and repetitions. Be alert to the signs and symptoms of lymphedema.
- Side lying can be difficult for some women after surgery. You may need to place a support under the head and arm and lower the arm for comfort.
To conclude, Pilates is an excellent exercise regimen to restore wellness. Many of my clients have found that it takes time to master Pilates, but the benefits are extremely rewarding. They report feeling stronger and more relaxed after participating in the exercises. I recommend you undergo further study before working with this population. This will ensure your clients receive maximum benefit from Pilates in a safe and effective manner.
Aaronson, N. and Touro, A.M. Breast Cancer Rehabilitation Using a Pilates Based Approach (2008) course manual
Betz, S. Modifying Pilates for Clients with Osteoporosis www.modifyingpilates.pdf
Clinical Pilates : The Art and Science of Pilates as a Rehab Approach www.sportsinjurybulletin.com/archive/clinical-pilates.com
Harris, S. et al. Upper Extremity Rehabilitation for Women who have been treated for Breast Cancer Physiotherapy Canada 2004;56:202-214
Keays, K. Harris, S. et al. Effects of Pilates Exercises on Shoulder Range of Motion, Pain, Mood and Upper Extremity Function in Women Living with Breast Cancer : A Pilot Study Physical Therapy 88: 494-510
Owsley, A. An Introduction to Clinical Pilates Athletic Therapy Today 2005;10(4) 6-10
Position Statement of the National Lymphedema Network Topic: Exercise 2008 www.lymphnet.org