There are three phases of Pilates for breast cancer survivors. The goal of Phase 1, the Protective Phase, is to ensure tissue healing without sacrificing range of motion and flexibility of the chest and arm. In these exercises, only move your arms to shoulder height or 90° and during this phase try to use your affected arm normally to perform daily living tasks such as brushing your teeth, putting on deodorant on, or wiping up your kitchen table.

Below are two examples of Pilates exercises for breast cancer survivors that fall under the Protective Phase. Protective Phase exercises should have three to five repetitions each. This phase will last approximately 2 weeks, or until you feel comfortable progressing to more difficult exercises. The exercises should feel easier and there should be less and less discomfort as you progress.

Exercise 1: Scapula Protraction and Retraction

The scapula is another name for your shoulder blade. The purpose of this exercise (shown in the image below) is to warm up the shoulders in preparation for movement, as well as strengthen the scapular muscles, which are necessary for proper shoulder movement.

Contraindications: None

Equipment: Pad, small pillow, towel, or block under head if needed. Optional medium-sized ball (squeezing the ball between your knees will help to activate the pelvic floor and transverse abdominis muscles and prevent your knees from collapsing in).

Start:

• Lie on your back with both knees bent and feet on the ground, hip distance apart.
• Pelvis is level with the floor or slightly tilted toward your nose if you have back problems.
• Arms and fingertips are reaching toward the ceiling only to shoulder height.
• Optional: Squeeze ball between your knees.

Exercise:

• Inhale, and reach fingers tips toward the ceiling (shoulder blades will lift off the mat). This is protraction.
• Exhale, and bring your shoulder blades together (not too hard) as you imagine you are gently cracking a walnut between your shoulder blades. This is retraction.

Modification for an Added Challenge: Stretch a resistance band between your hands. If you are undergoing a breast implant expander program, TRAM, or DIEP flap reconstruction, do not use a resistance band until medically cleared.

Exercise 2: Bridging

The goal of bridging is to warm up the spine as well as your hamstrings and gluteal muscles. This exercise will help make it easier to put on your underwear and pants and reposition yourself in bed.

Contraindications: Check with your physician to make sure that this exercise is safe for you to do when recovering with drains in place.

Equipment: Pad, small pillow, towel, or block under head if needed. Optional medium-sized ball (squeezing the ball between your knees will help to activate the pelvic floor and transverse abdominis muscles and prevent your knees from collapsing in).

Start:

• Lie on your back with both knees bent and feet on the ground, hip distance apart.
• Pelvis is level with the floor or slightly tilted toward your nose if you have back problems.
• Arms are long at your sides.
• Optional: Squeeze ball between your knees.

Exercise:

• Inhale to start, and then exhale as you tilt your pelvis toward your nose to imprint your spine.
• Then push off through your heels, and lift your spine off the mat one vertebrae at a time. You will start moving the lower back, middle back, and then upper back off the mat.
• Inhale as you hold this position at the point where you can remain still, without any movement of your pelvis. Both the upper part of your shoulder blades should remain on the mat.
• Exhale as you return to the start position by gradually bringing the upper back, middle back, and lower back gently down to the mat, vertebrae by vertebrae to your neutral or imprinted pelvis. Think of rolling the spine slowly down to the floor.

NOTE: Be sure to… Keep both shoulder blades on the mat. Do not let the pelvis rock forward/back or side to side.

Modification for an Added Challenge: Hold a Magic Circle between your inner thighs for resistance as you lift your hips. Hold a Magic Circle between your palms with hands facing each other and fingertips toward the ceiling. Squeeze it when the hips are lifted.

Written by Naomi Aaronson and Ann Marie Turo. Reprinted with permission from Naomi Aaronson, MA, OTR/L, CHT; Also published on demosHEALTH; Images via demosHealth article.

Naomi Aaronson, MA, OTR/L, CHT can be reached at www.recovercisesforwellness.com.

For breast cancer survivors using Pilates, it is extremely important to pay attention to the Pilates principles. Getting physical exercise is essential to recovery, but overdoing it can cause more harm than good. Make sure you review the principles below before beginning Pilates for breast cancer recovery, and ask for help from a certified Pilates instructor if you need it.

The 9 Pilates Principles

These principles guide each Pilates exercise to ensure that they are done correctly and safely. In Pilates, less is more. The emphasis is on a correct starting position with proper execution of the exercises; there is no wasted movement in Pilates. No more than five to eight repetitions are completed (except for the Hundreds), and breathing during each exercise is very important. Concentrate on the correct movement patterns first and then add Pilates breathing.

If you’ve never done Pilates before, this may sound like a lot to think about. If possible, we recommend working with someone who is trained in Pilates first to get you on the right track.

1. Breathing: Breathing oxygenates the blood and connects the mind and body. Breathing during Pilates will enhance your relaxation, improve your focus, and help to activate your muscles. Pilates breathing is called “rib cage breathing” or costal breathing as the rib cage expands as you inhale and knits together as you exhale. Coordinating the breath with the movement is the goal. This may be difficult at first, but please stay with it. If you get confused, don’t hold your breath—keep breathing!
   • Inhale through the nose as if to smell the roses. Place your fingers on your rib cage and feel your rib cage expand.
   • Exhale through pursed lips as to blow out candles, drawing the belly in towards your spine. This activates the transverse abdominas muscle. The deeper the exhalation, the more this muscle is activated. Activation of this muscle should feel very gentle, as it is more like a subtle tightening of the abdomen. The lower back and pelvis should remain still. Buttocks and thighs should stay relaxed.
2. Concentration: You must place intentional focus on every movement. You will feel each exercise more if you close your eyes, once you become more familiar with the movements. After breast cancer surgery, you may lose the ability to feel if muscles are working properly. Closing your eyes will help in this process to listen to your body and refocus your mind upon proper body movement.
3. Control: To be in control means that you maintain the proper form, alignment, and effort during the exercise. You don’t want to throw your body around. If there is jerkiness, shaking, tightness and/or pain you are not in control. You can limit the movement and make it smaller if necessary to regain control.
4. Centering: In Pilates, all movements come from the “powerhouse,” or core abdominal muscles. Learning to use the powerhouse correctly will improve your posture, stabilize the spine, and improve your quality of movement. Thus, every exercise is an abdominal exercise. Visualizing a corset around the waist will help you to activate these muscles.
5. Precision: Every exercise should be performed with precision and an emphasis upon proper form. Therefore, proper starting position and posture is crucial as well as performing the exercises slowly without momentum.
6. Balanced Muscle Development: Everything that is done on one side of the body must also be done on the other side. For example, if you do an exercise with your right arm, you must also do it with your left.
7. Rhythm/Flow: All movements in Pilates are done with a sense of rhythm. The movements should be graceful and smooth.
8. Whole Body Movement: The whole body is engaged through breathing, engagement of the core, and use of the arms and legs (even though some exercises will not use the arms at all).
9. Relaxation: Breathing assists with the relaxation of muscles throughout the body. Unwanted tension should be released prior to beginning the exercises. You may work one body part and relax the others

Written by Naomi Aaronson and Ann Marie Turo. Reprinted with permission from Naomi Aaronson, MA, OTR/L, CHT; Also published on demosHEALTH.

Naomi Aaronson, MA, OTR/L, CHT can be reached at www.recovercisesforwellness.com.

Ann Marie Turo, occupational therapist, yoga and Pilates instructor and Reiki master, owns a thriving Pilates-based studio. When Turo was diagnosed with a breast cancer reoccurrence in 2002, she was devastated. Despite having limited range of motion, strength and endurance, as well as decreased ADL function, it was not recommended that she have any rehabilitation. This situation is not unusual.

After undergoing a self-described “meltdown,” she decided to take matters into her own hands. Turo designed her own rehabilitation program, which included visualization, Pilates, yoga and Reiki, along with traditional occupational therapy modalities.

Turo believes that an “integrated” approach is the best way to heal physically and psychologically from breast cancer. That is why she created Integrated Mind and Body in Boston.

Pilates is enjoying wide popularity throughout the United States as a form of exercise. It focuses on the whole person, uniting mind and body through a series of flowing movements that require both flexibility and strength. Recently, therapists have began incorporating Pilates as part of their general rehabilitation program for athletes, back injuries, hip/knee replacements and even autism.

Breast cancer survivors are starting to benefit from Pilates as well. A recent pilot study (Keays, 2007) found a modest effect in improving shoulder abduction and external rotation. However, further research is necessary to determine both the safety and efficacy of Pilates, as well as optimal exercise guidelines.

There are eight principles of Pilates: relaxation, concentration, control, centering, fluidity, precision, stamina and breathing. Joseph Pilates, who developed this movement method, believed that one must pay attention to each exercise and perform it with the utmost control to avoid injury. He believed that it is not the quantity that counts, but the quality of each repetition.

Pilates exercises initiate from the “powerhouse,” or core musculature. Therefore, every exercise is an abdominal exercise that initiates at the center and flows outward. This is in tune with developmental principles and ensures a proper base from which to perform more distal work.

Proper breathing is another cornerstone of this technique. Deep breathing is essential to activate the transverse abdominal muscles, which is why the exercises are coordinated with both inhalation and exhalation. Inhalation facilitates spinal extension and trunk stability while exhalation facilitates spinal flexion and scapular depression.

During upper extremity work there should be a sense of gliding the scapulae down the back to promote shoulder stability. Pilates can incorporate more than 500 exercises, which can be performed either on a mat or on special equipment, such as the Cadillac, Reformer and barrels. These exercises can be modified to meet the needs of patients through the use of springs to assist and mobilize the muscles, and provide resistance when patients are stronger.

Women who are diagnosed with breast cancer will have surgery, which can be followed by systemic treatment such as chemotherapy and/or hormone therapy and then, possibly, radiation. After undergoing breast cancer surgery and treatment, the body seems lost and out of control. Breast cancer survivors are faced with many issues including fatigue, loss of range of motion and strength in the affected arm, lymphedema risk, weight gain and poor posture.

Furthermore, there are psychological implications to being diagnosed with a life-threatening disease and breast removal. Pilates is one tool that can help one regain a sense of mastery and control over a body that seems foreign and lost.

How Does the Rehab Work?
Loss of range of motion and tightness in the axillary and pectoralis regions is common after breast cancer surgery, especially after axillary lymph node dissection and mastectomies. The more extensive the surgery, the greater the limitations secondary to greater tissue loss, pain and scar formation. Because many of the Pilates exercises are performed in the supine position, the neck and back can be comfortably supported. Active assisted exercises with a towel or band are used to improve mobility of the shoulder girdle while the spine is in a neutral position.

Pilates focuses on the scapula stabilizers including the rhomboids, latissmus dorsi, middle/lower trapezius and serratus anterior while performing active range of motion, which is different than a traditional rehabilitative approach. The use of imagery is often used to coordinate the mind and body, so one may be told to “place those wing bones in your back pocket.” Even some of the exercises can be done in side lying, which eliminates gravity, making the shoulder exercises easier to perform.

Pilates emphasizes proper alignment and posture which improves movement efficiency, opens up all the lymphatic channels and facilitates good breathing.

The risk of lymphedema, the buildup of protein-rich fluid in the chest, trunk and arms, is another concern for anyone who has received lymph node dissection and/or radiation. This is due to scarring of the lymphatic vessels that disrupts lymphatic flow, along with the loss of mobility. This can interfere with normal lymphatic or venous drainage from the arm.

Since diaphragmatic breathing is used in Pilates both to stabilize and mobilize the spine, this enhances trunk organization. Lymphatic fluid can be propelled through the body with this type of breathing, along with proximal to distal exercise. As one inhales and exhales, the pressure changes, stimulating lymphatic return. In addition, diaphragmatic breathing lowers heart rate and blood pressure, creating a relaxation response conducive to emotional healing.

Use of the deep stabilizer muscles, including the transverse rectus abdominas and multifidus, encourages pumping to the thoracic duct, the main area for lymphatic return. This in effect clears the trunk for fluid from the axillary region and pectoralis area where lymph flow may be impaired.

Once the trunk is cleared, one can exercise the arm at risk. Compression garments or bandages should be worn while exercising if at risk. Exercises should be progressed slowly and gradually to allow the lymphatic system to adjust to an increased lymphatic load.

There are usually few repetitions for each Pilates exercise, which is a natural fit for women at lymphedema risk.

Dealing with Fatigue
Fatigue both during and after cancer treatment is the most common side effect of the treatment. Many women feel unable to function and perform daily activities while undergoing chemotherapy or radiation treatments, and this fatigue can become overwhelming as treatments accumulate. However, many research studies have confirmed the advantages of both strength and aerobic conditioning even during treatment. Pilates offers a gentle introduction or re-introduction to regular exercise that can slowly help restore strength and endurance. One can gradually build up by performing the exercises at least twice a week. This should be combined with an aerobic conditioning program, such as walking, when able.

It is time to think about alternative approaches to meeting the needs of this population, along with individuals suffering from other chronic conditions. As one can readily see, Pilates offers many benefits to women recovering from cancer, especially since occupational therapists are well trained in the modification of such activities and exercises.

At Integrated Mind and Body, Turo works with breast cancer survivors as well as individuals who have had depression, total knee replacements and total hip replacements. She requires a signed physician’s release form, and does a full intake on clients that includes medical history, pain, postural analysis and ADL evaluation, as well as the standard occupational therapy assessments.

Clients pay out of pocket to receive Pilates and Reiki in conjunction with traditional therapy services. Turo demonstrates that therapists can balance an occupational therapy frame of reference along with other healing modalities to be successful.

Reprinted with permission from Naomi Aaronson, MA, OTR/L, CHT; Also published on Advance Healthcare Network.

Naomi Aaronson, MA, OTR/L, CHT can be reached at www.recovercisesforwellness.com.