PMPS: Post Mastectomy Pain Syndrome

Introduction  

om
om

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.

icbn skin innervation
Area of skin innervation 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.   

ICBN PMPS sequences
ICBN PMPS sequences

 References

Advertisements

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.

Fundamentals

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.

Movements

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.

Breathing

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.

Conclusion

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
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.

  

Twists in Yoga Therapy for Breast Cancer

Trikonasan mod 1
Trikonasana mod 1

image

At the beginning of the term last autumn, I decided to teach some twists.  Using the concept of vinyasa-krama, that is, work slowly into the postures, I taught some light standing, sitting and lying twists.  In general, if you keep the arm work light, the twist moves more into the lumbar spine.  Still, I was trying to work into the dorsal spine, so especially worked with the breath.  In sitting twists, one can add a krama in the exhale, as the students go into the pose.  In lying twists, one can do a dynamic phase followed by some breaths in the pose.

My experience was educational.  I discovered that this group is not yet ready for twists.    Two students experienced muscle pulls, one in the quadratus lumborum region after a trikonâsana (triangle pose) and one in the intercostal / serratus anterior region after a jatara parivritti (lying twist pose).  Another student fell out of trikonâsana.  This same student was later told to avoid practising twists after her expander/implant reconstruction.

Eight weeks into term, I stopped all but the lying twists, and these I did in their gentlest form.

So, be careful with twists in yoga therapy for breast cancer patients. Here is a workup (vinyasa krama) for the triangle pose (trikonâsana).

Legend:  

  • slight bend in the front leg, top arm bent with hand on hip, look down
  • slight bend in front leg, top arm bent, look up
  • slight bend in front leg, top arm stretched out and up, look down
  • slight bend in front leg, top arm stretched up and out, look up.

    trikonasana variations
    trikonasana variations

Into joint – healing the shoulders

The shoulder joint is the joint in the human body with the greatest range of motion. To keep the shoulder joint stable, we have the wonderful rotator cuff, a group of small muscles below the armpit and shoulderblade.  Sadly, these little muscles are ofter under-developed, leaving the shoulder unsupported and prone to pain and dislocation.  This little sequence is very healing for shoulders.  I learned it from Claude Maréchal, the head of the Viniyoga lineage in Europe. But, the shoulder-drop to the floor with the arms at vertical is pure Rachel…my little contribution to the sequence to make it more healing…Try to do this six times, twice a day.

Into Joint - healing the shoulders
Into Joint – healing the shoulders

Dvipada-pitâm

Earlier, I published a description of the yoga pose dvipada-pitâm.  Here are the photos to accompany that post.  Please refer to the description.  Please note:  keep the chin tucked in, make sure hands and feet are firmly on the floor.  Don’t pull the feet in towards the buttocks with your hands.  Let the natural flexibility of your leg joints determine the distance between bum and heel.

dvipada-pitâm
(breathe out) dvipada-pitâm
dvipada-pitâm
(breathe in) dvipada-pitâm