Inner IDEA: A two-phase Pilates program helps breast cancer survivors regain function.
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
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.
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
- 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.
- 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.
- Rotator Cuff. Breast cancer surgeries affect the rotator cuff muscles, resulting in faulty shoulder girdle mechanics, poor posture, increased stiffness, decreased mobility and pain.
- 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.
- 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.
- 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
Kaelin, C., et al. 2007. The Breast Cancer Survivor’s Fitness Plan. New York: McGraw-Hill.
- 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.
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