Pilates and Breast Cancer: Rebuilding the Foundation

Fashion designer and breast cancer
survivor Sigrid Olsen began a Pilates program with me just months after her
surgery. “I had no physical strength in my upper body,” she says. “I had lost
the endurance to hold myself up straight. The Pilates program got me feeling my
body again and gave me the strength to keep my shoulders back and down. I had a
sense of self again.”

According to the National Cancer Institute, approximately 2.4
million women living in the United States in 2004 had been treated for breast cancer
(American Cancer Society 2007). For­tunately, thanks to early detection and
advancements in treatment, many more women will survive breast cancer and go on
to live out their natural life expectancy. Despite this good news, cancer
treatments take an enormous toll: in just a year of treatment, the body can age
a decade. Between the inherent weight gain, muscle atrophy and premature bone
loss, women are left weak and physically challenged even by normal day-to-day
activities.

Pilates is a gentle restorative exercise regimen perfectly suited
for women as they recover and work to rebuild their bodies. (The benefits also
extend to the very small minority of breast cancer patients who are men.) Many
people considered Joseph Pilates a master of rehabilitation during his
lifetime. His approach emphasized precision and control. Combine those
qualities with current exercise science and you have a recipe for success.

In this article we will briefly review breast cancer treatments
and then provide specific Pilates programming ideas and exercise guidelines for
breast cancer survivors.

Treatments and Side Effects

Breast cancer treatments aim both to rid
the body of disease and to minimize the possibility of the cancer returning.
Breast Cancer treatments are either local or systemic, with patients receiving one form or a
combination of forms, based on individual needs. Local treatments are
used to remove or destroy damaged tissue at and around the cancer site; they
include operations such as lumpectomy, mastectomy, breast-conserving surgery
and axillary (underarm) lymph node removal. Systemic treatments
are used to destroy or control cancer cells throughout the entire body rather
than at a specific site; these methods include chemotherapy, hormone therapy
and biological therapy.

Side effects to breast cancer treatments—such as pain; temporary swelling;
tenderness; infection; increased stiffness in joints; hardness due to scar
tissue that forms at the surgical site; and very high levels of fatigue from
surgery, radiation and chemotherapy—may impact patients’ ability and/or desire
to exercise. Weight gain and low self-esteem are also common challenges. The
sidebar “Program Design: 5 Key Concerns” describes more conditions that all
exercise professionals must
be aware of when designing programs for breast cancer survivors.

Why Pilates?

Although medical research specific to
Pilates and breast cancer is nonexistent to date, a growing body of research
strongly suggests that exercise can greatly reduce the risk of breast cancer
recurrence as well as enhance functionality and quality of life (Kaelin et al.
2007; Mutrie et al. 2007; Sprague et al. 2007). Given that the essential aims
of Pilates are to build a strong core, facilitate effortless movement and
repattern musculature, it seems a natural exercise choice for those recovering
from breast cancer and its side effects. See the sidebar “Pilates Benefits for
Breast Cancer Survivors” for an overview of how Pilates can help.

The key to the success of a Pilates program is to proceed slowly,
consistently checking with the client to see how she feels. Developing a
continual dialogue will ensure that the client is not taking on more than she
can handle. Since there is very specific work to be done in each case, it is
important to stick to the program. This is not a time to take risks or be
creative, which might exacerbate the client’s condition. Just as crucial is
your bedside manner; there is a strong emotional element when working with
breast cancer survivors, and positive reinforcement from the wellness professional
is vital in all phases. Pilates strengthens the body-mind connection, which is
essential through the recovery phase.

Occupational therapist, two-time breast cancer survivor and STOTT
PILATES^® certified instructor
Ann Marie Turo owns Integrated Mind & Body, located in Boston. In
rehabilitating breast cancer patients, she uses Pilates as the primary exercise
method and has had great success. “I find the breathing techniques especially
beneficial to encourage proper lymphatic drainage,” says Turo, who reports that
her clients feel better, both physically and emotionally, with each session.

Pilates Programming and Exercise Recommendations

Organize your Pilates program in two
phases.

Phase
One. This phase begins once the medical team has given your
client the okay to exercise. First, conduct a comprehensive health history
session. The information you gather determines where you begin. Second,
introduce the basic biomechanical movement principles used in Pilates,
including breathing; pelvic placement; rib cage placement; scapula mobility and
dynamic stabilization; and head and cervical placement. The exercises in this
phase are foundational and can be part of the client’s daily exercise regimen
forever. These moves are considered the essentials:

• breathing; sitting, supine or four-point
  kneeling
• pelvic rocking; imprint and release
• scapula protraction and retraction
• hip release
• scapula elevation and depression
• spinal rotation and hip rolls
• butterflies
• side-lying arm circles
• cervical nods

It’s critical in this phase that you avoid taxing or overdoing
any one area of the body. Select one or two exercises for the upper body and
then one or two for the lower body. Have the client perform only 3–5
repetitions at a time. Let the weaker side determine the amount of resistance
and number of repetitions. Always support the affected limbs with pillows or
cushions, and only work in a comfortable range of motion. Never work through
pain. Pain is an indicator that you must refer the client back to her medical
team.

Phase
Two. Along with building on the basic principles, phase two
slowly incorporates low-load exercises to strengthen the local stabilizers,
promote joint stability and enhance neuromuscular control. Use a layering
effect as you add each new exercise, and keep a record of what you have added.
This will help you determine which exercises the client can withstand and which
may be overly challenging. If you add too many new exercises at once, you won’t
know which move is problematic. Use Pilates props for support or extra
resistance. Weighted balls (no more than 1–2 pounds), Flex-Bands^® and Fitness Circles^® are ideal for providing light load
and for supporting the limbs in exercises such as leg circles or spinal
rotation. Phase two exercises can include the following:

• cervical and thoracic flexion
• one-leg circles
• cervical and thoracic extension
• hip rolls
• swimming preps done in four-point kneeling
• spinal rotation; four-point kneeling, supine,
  side-lying
• side-lying leg lifts, with small circles
• side-lying shoulder circumduction

Be very mindful of these phase-two contraindications:

• progressing too quickly
• using too heavy a load and potentially
  stressing the joints
• not adhering to clients’ needs and physician
  recommendations
• overworking the limbs, especially in the
  affected areas
• not allowing for adequate rest and recovery
  between sessions

A strong component of body-mind exercise is empowering the client
by increasing her kinesthetic awareness. As this happens, the client becomes
more familiar with her own body from one day to the next and can recognize when
things aren’t quite right.

(Editor’s Note:
See the April issue of the e-newsletter Inner
IDEA Body-Mind-Spirit Review for a detailed description of some of
these exercises.)

Tools for Life

Sigrid Olsen continues to practice
Pilates today. Together we have created a program she can take on the road with
her while traveling. And when a workout just isn’t possible, she says, “I
really miss my Pilates!” The success of clients like Sigrid is what keeps me
inspired to spread the word about Pilates.

By arming our clients with simple, effective exercises, we
provide them with the tools they need to become self-reliant, to enjoy a higher
quality of life and to be more functional in everyday activities. Whether it
means picking up groceries, doing laundry, taking a walk, catching a plane or
dancing at a daughter’s wedding—we all want our clients to live their lives to
the fullest.

SIDEBAR: Program Design: 5 Key Concerns

According to Carolyn Kaelin, MD, MPH, it is imperative
that Pilates instructors and other wellness professionals understand that
clients recovering from breast cancer differ from those healing from an injury.
Kaelin is founding director of the Comprehensive Breast Health Center at
Brigham and Women’s Hospital in Boston, a surgical oncologist at the
Dana-Farber Cancer Institute, also in Boston, and herself a breast cancer
survivor.

She outlines five seminal
concerns that all professionals should consider when designing exercise
programs for breast cancer survivors.

1. Lymphedema. This condition relates specifically to axillary
   lymph node dissection, axillary radiation or surgical infection (swelling of
   the arm). The swelling occurs when the lymph channels are altered and no longer
   able to properly drain lymph fluid from the arm back into the body’s general
   cir­culation.
2. Rotator
   Cuff. Breast cancer surgeries affect the
   rotator cuff muscles, resulting in faulty shoulder girdle mechanics, poor
   posture, increased stiffness, decreased mobility and pain.
3. Sarcopenia. This condition results in a simultaneous loss of
   muscle and gain in fat tissue. Inactivity during treatment, chemotherapy,
   premature menopause and other hormonal changes brought on by breast cancer
   treatments may lead to sarcopenia.
4. Premature
   Osteo­porosis. Women who undergo
   chemotherapy or take certain breast cancer medications are often pushed into
   early meno­pause. This can increase bone loss and lead to osteoporosis.
5. Physiological
   Muscular Imbal­ances. After a mastectomy a
   woman may opt to have the surgeon reconstruct her breast(s) using an artificial
   implant or her own tissue, referred to as an autologous tissue flap. Flap
   surgery takes tissue from the abdomen, back or buttocks and uses it to
   reconstruct the breast. The procedure creates significant muscular imbalances,
   and compensation patterns occur.

Loss of function in prime movers, such as the rectus abdominis and
latissimus dorsi, puts greater demand on synergistic muscles, such as the
obliques, rhomboids and mid and lower trapezius.

SIDEBAR: Pilates Benefits for Breast Cancer Survivors

• improves
  lymphatic drainage with proper breathing techniques (Jordan 2007)
• improves
  shoulder girdle mechanics, specifically scapula-humeral rhythm, to aid in the
  breakdown of scar tissue and frozen shoulder
• restores
  overall range of motion, flexibility, strength and endurance
• restores
  upright postural alignment and balance
• increases
  strength of local and global stabilizing muscles
• enhances
  core strength and endurance
• improves
  overall kinesthetic awareness
• re-establishes
  proper muscular firing patterns
• reduces
  both physiological and emotional stress
• improves
  appearance
• increases
  self-confidence and overall well-being

SIDEBAR: Pilates and Breast Cancer Resources

Book

Kaelin,
C., et al. 2007. The Breast Cancer Survivor’s Fitness Plan. New York: McGraw-Hill.

Websites

• Breastcancer.org,
  www.breastcancer.org
• National
  Cancer Institute, www.cancer.gov
• Susan
  G. Komen for the Cure, www.komen.org

PJ O’Clair has been a fitness industry
leader for 25 years. She was a finalist for the 2007 IDEA Program Director of
the Year award and has been nominated again for 2008. Her clientele ranges from
professional athletes and celebrities to everyday people. O’Clair is a master
instructor trainer for STOTT PILATES and has appeared in numerous fit­-ness
DVDs. Her website is www.northeastpilates.com.

Special thanks to Josie Gardiner for her
professional encouragement and Carol Burnham and Kerri Lee Brown for their
creative guidance.

American Cancer Society. 2007. Breast cancer facts &
figures 2007–2008. www.cancer.org/downloads/STT/BCFF-Final.pdf; retrieved Feb.
14, 2008.

Jordan, S. 2007. The lymph system.
www.copypastearticles.com/article/7081/the-lymph-system; retrieved Feb. 14,
2008.

Kaelin, C., et al. 2007. The
Breast Cancer Survivor’s Fitness Plan. New York: McGraw-Hill.

Mutrie, N., et al. 2007. Benefits of supervised group
exercise programme for women being treated for early stage breast cancer:
pragmatic randomised controlled trial. BMJ
Online First, 334, 517.

Sprague, B., et al. 2007. Lifetime recreational and
occupational physical activity and risk of in
situ and invasive breast cancer. Cancer
Epidemiology Biomarkers & Prevention, 16, 236–43.