Yoga and BC in the news

Just a quick post today, I’m afraid.

A couple of events in the past few days:

Ontario, Canada: http://www.chch.com/breast-cancer-yoga/
Philadelphia, USA: http://www.philly.com/philly/blogs/sportsdoc/Yoga-On-The-Steps-Your-Love-Story.html

Peace and love.

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Yoga and the Endocrine System – Peace in the poses

A mandala

A mandala in shades of yellow

The practice of Hatha Yoga uses postures, breath and mental focus to bring about peace.  By peace, we refer to the physical peace derived from flexible muscle and joints, free of pain, good quality sleep, proper oxygenation brought about by correct breathing and mental restfulness, a state of alert calm, wakeful quiet.

There are scientific studies being done on the effects of yoga on the endocrine system – the hormones.  This is very promising work.   For a long time, people have tried to tie yoga nadis to the nervous system, and it is certain that some parallels can be drawn between nerve plexi and the chakras.  But this will never give the whole picture of just why a sustained hatha yoga practice, over years, brings about such overall good health and humour.

The Endocrine System

The endocrine system is composed of glands, organs and the substances they produce, known as hormones.   Hormones are secreted or excreted in miniscule quantities, but they have far-reaching effects.  Any woman who has ever taken hormonal birth control or even had a period knows this.

HPA Axis

Of great interest to those working with breast cancer is the so-called HPA axis, or Hypothalamo-Pituitary-Adrenal axis.  This is basically a cascade within the endocrine system in which one gland signals another.  The HPA helps control our reactions to stress, among other things.  The hypothalamus and the pituitary glands are nestled beside each other, and the link between the nervous system and the endocrine system is right here.  Basically, the hypothalamus secretes hormones that cause the pituitary to secrete hormones.  The hypothalamus receives information from the brain stem, that is, information from our body.  The anterior pituitary gland is where the hormones are secreted, and has been found to be activated by GABA.   Pituitary hormones then signal the adrenal glands, where cortisol is produced.

HPG Axis

There is yet another hormone axis called the HPG axis, or Hypothalamo-Pituitary-Gonad axis.  This axis signals and controls the sex organs.  The majority of breast cancer patients are menopausal or peri-menopausal at diagnosis, and those who are still menstruating have their periods suppressed in a bid to reduce oestrogen production.  The crux of the matter is the the Hypothalamus signals the Pituitary and this released two hormones, LH and FSH.  FSH does the final conversion of androgen to oestrogen, but LH helps produce the androgen, which coverts to oestrogen.  This process uses an enzyme called aromatase, and you may have heard of aromatase inhibitors, a class of drugs used in breast cancer patients with hormone-sensitive tumours.

Cortisol

One of the hormones that is of interest to yoga practitioners is cortisol.  Cortisol is produced in the adrenal glands and secreted into the blood.  Almost all cells of the body have cortisol receptors (these are like antenna or tunnels on the cell walls and they all the cells to transport the cortisol into the cell, where it can exert its effect.)  So, if you have high cortisol levels, you may see a wide range of effects in the body, including:

What is cortisol?  In it’s normal function, cortisol helps us meet life’s challenges by converting proteins into energy, releasing glycogen and counteracting inflammation. For a short time, that’s okay. But at sustained high levels, cortisol gradually tears your body down.  Cortisol is one essential we can’t live without.  But too much of a good thing is not healthy.

Sustained high cortisol levels destroy healthy muscle and bone, slow down healing and normal cell regeneration, co-opt biochemicals needed to make other vital hormones, impair digestion, metabolism and mental function, interfere with healthy endocrine function; and weaken your immune system.

Adrenal fatigue may be a factor in many related conditions, including fibromyalgia, hypothyroidism, chronic fatigue syndrome, arthritis, premature menopause and others. It may also produce a host of other unpleasant symptoms, from acne to hair loss.

(https://www.womentowomen.com/hormonal-health/the-destructive-effect-of-high-cortisol-levels/)

Here is a summary of the scientific studies substantiating the fact that the practice of Hatha Yoga reduces blood cortisol levels.

GABA

Another hormone of interest to yoga practitioners is GABA (Gamma-amino butyric acid). Low GABA levels in the brain are linked to anxiety and depression.  Anyone who has had cancer treatment knows that depression is rarely far away.  In my opinion, it is a very natural reaction to the physical trauma of treatment and the emotional trauma of facing your own mortality.  But depression cannot be allowed to continue unchecked, and the practice of Hatha Yoga helps regulate mood.  For example:

In a German study published in 2005, 24 women who described themselves as “emotionally distressed” took two 90-minute yoga classes a week for three months. Women in a control group maintained their normal activities and were asked not to begin an exercise or stress-reduction program during the study period.

Though not formally diagnosed with depression, all participants had experienced emotional distress for at least half of the previous 90 days. They were also one standard deviation above the population norm in scores for perceived stress (measured by the Cohen Perceived Stress Scale), anxiety (measured using the Spielberger State-Trait Anxiety Inventory), and depression (scored with the Profile of Mood States and the Center for Epidemiological Studies Depression Scale, or CES-D).

At the end of three months, women in the yoga group reported improvements in perceived stress, depression, anxiety, energy, fatigue, and well-being. Depression scores improved by 50%, anxiety scores by 30%, and overall well-being scores by 65%. Initial complaints of headaches, back pain, and poor sleep quality also resolved much more often in the yoga group than in the control group.

http://www.health.harvard.edu/mind-and-mood/yoga-for-anxiety-and-depression

Conclusion

I really could write all day, but my daughter will get mad at me, and Sunday is Sunday.  I will leave you to think about this:

Hatha yoga reduces blood cortisol, stimulates the vagus nerve and just darn well calms us down.  The brain stem recognises our altered physical state and sends this information to the Hypothalamus.  The Hypothalamus says to the Pituitary “all is good, settle down”.  The HPG and HPA axes find homeostasis and we establish a feedback loop of calm and settledness.  To any scientists reading this, I know it sounds facile.  But I think that your research – and our practice- will lead us to this conclusion.

In the meantime, keep practising.  We find peace in the poses.  Om.

Read on…

For your reading pleasure, a few curated links to articles discussing Yoga and the endocrine system.

http://www.bu.edu/news/2012/03/07/researchers-find-yoga-helps-ease-stress-related-medical-and-psychological-conditions/

http://www.studiodeeyoga.com/docs/MedicalHypothesisPaper-3.pdf

http://breastcanceryogablog.com/tag/gamma-aminobutyric-acid/

http://www.forbes.com/sites/alicegwalton/2011/06/16/penetrating-postures-the-science-of-yoga/

http://www.researchgate.net/profile/Vinod_Subramani/publication/23974308_Effects_of_a_yoga_program_on_cortisol_rhythm_and_mood_states_in_early_breast_cancer_patients_undergoing_adjuvant_radiotherapy_a_randomized_controlled_trial/links/549ad1da0cf2fedbc30e35a4.pdf

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A few links about yoga and breast cancer

I am out of town, so will just offer a brief Sunday update of a few links:

http://www.ibtimes.co.uk/yoga-reduces-fatigue-inflammation-breast-cancer-survivors-1434126

http://www.yogahealthfoundation.org/health_benefits_of_yoga_explained#breastcancer

http://www.yogajournal.com/article/practice-section/poses-for-breast-cancer-survivors/

http://www.lbbc.org/Learning-From-Others/Ask-the-Expert/2014-03-Yoga-and-Breast-Cancer

Happy reading!

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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.

  

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Child’s pose modifications for Yoga Therapy for Breast Cancer

We usually think of child’s pose, sometimes known as bheki, as a relaxation pose.  It figures in yin yoga and restorative sequences and is generally used as a counter-pose after more strenuous work.  However, what seems an easy pose actually represents certain challenges to the breast cancer patient.  

Firstly, the classic arm positions in child’s pose – arms alongside the legs or extended and next to the ears – can be challenging for these students.  To lay the arms alongside the legs suggests that the person is low enough into the pose (ie:  backside is sitting on the heels) so that the upper arm is on the floor.  My ladies aren’t all able to do this.  Also, anyone with serratus-flap reconstruction is going to find the required rounding of the shoulders hard on the affected side.  The extend the arms taxes both serratus anterior and trapezius.  There are some people who just can’t lift the extended arm that high.  This calls for a modification!  Read on…

The ankles can present a problem in ladies of a certain age.   If there is undue strain on the front of the ankles, the pose becomes unstable.  A simple solution is the prop the ankles on a tubular prop, or simply roll up the end of your mat and use that.

If there is a bit of belly – and let’s face it, with all the cortisone administered in chemo, most students arrive a bit on the heavy side – we need to make room for it.  Simply separating the legs helps the body settle comfortably into the deep forward bend.

In people who carry neck tension – and most mastectomized and reconstructed ladies do – you will see that the cervical curve persists in this pose.  Do your best to bring attention to the dorsal zone, instructing students to separate the shoulder blades on the inhale. Tell students to pull the chin down towards the sternum.  (For those who are comfortable on the pose, you can suggest a little breath retention after each exhale.)

Arm Modifications

Take the arms out to the side, just above shoulder height, with the elbows bent.  Keep a slight pressure between the forearms and  the floor.  Splay the fingers and keep a slight pressure on the fingertips.  Keep awareness at the fingertips.

Child's pose for breast cancer rehab

Child’s Pose- modified for breast cancer yogis

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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

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Muscles most affected by breast cancer and its treatment.

The skeletal muscles most affected by breast cancer and its treatment are:

  • pectoralis major:
  • serratus anterior
  • coraco-brachialis
  • trapezius.

(Don’t forget that chemo and radio-therapy affect the heart (cardiac) muscle. )

Why? and What to look for?

Pectoralis major:  The pec major suffers a lot.  Even conservative surgery leaves scars.  During wound healing, a protective arm position is logically adopted.  This may last for some weeks, leading to loss of muscle tone in the pectoral of the affected side. This muscle is frequently burnt by radiation.  Burn scars are deep and inelastic – the muscle loses stretchiness.   If an implant reconstruction has been performed, the expander and/or implant will likely be below the pectoral muscle.  This puts the muscle fibers under tension, leading the shoulder drop and poor arm abduction, extension and external rotation (difficulty taking arm back, outwards and palm up).

Serratus anterior: Watch for radiation burns (radio placement tattoos are often seen just around S.anterior digitations, on the side of the chest, below the armpit).  Often this muscle also suffers from the protective arm position post-surgery.  Poor shoulder position weakens S.anterior because the insertion fibers are under tension (sunken chest/rounded back posture). In re-constructed women, this muscle may be used for Serratus-flap reconstruction.  If this is the case, full arm rotation can probably never be re-established.  Watch for pain under the armpit and at the mid shoulder blade area.

Coraco-brachialis:  Usually loses elasticity due to inward rotation and adduction of the arm  (arm is pulled in towards the body, and rotated so that the back of the hand faces the front).  Majorly affected by axilliary web syndrome, or cording. Watch for pain in the inner arm, in the soft fleshy part, about two finger-widths down from the armpit).

Trapezius:  The trap is majorly affected by shoulder drop and poor posture post-therapy. Also, weakened S.anterior and P.major muscles mean the trap is unsupported.  Muscles work in pairs, that is, when one pulls the other gives.  If the pec is pulling down and forward, the upper fibers of the trap are being stretched.  After a while, they will get annoyed and pull back.  Then, watch for neck and shoulder pain, including headaches.

The shoulder capsule is frequently scarred as a result of radiation burns.

This list is not exhaustive. Each case is unique.  I have chosen to high-light these four major muscles because they are the ones that most often need rehabilitation.

Here are some oft-used postures, modified for yoga therapy for breast cancer.

Dvipâda-pitam or half-bridge pose:  Lying on the back, with legs bent and feet hip-width apart, heels towards buttocks without using the hands to adjust position.  Arms by the sides, palms down. Inhale, raise hips and lower back, at the same time, rotating the arms so that the palms face the ceiling (watch limitations).  Watch out for rotation from the elbow, protecting the shoulder joint.  If this is the case, advise that the student lift the forearm off the floor, bending the elbow, and while rotating the arm, see if she can place the back of the hand on the floor.

Dvipada-pitam or Half-bridge pose.

Dvipada-pitam or Half-bridge pose.

 

 

 

 

 

 

 

Virabhadrâsana or Warrior pose:  Stand, feet together at the back of your mat.  Turn your right foot out about 45º.  Step forward with the left.  Arms down by the side, back of the hand facing towards the front.  Exhale.  Inhale as the knee bends, and at the same time, rotate the palms forward and out, opening the chest and separating the arms from the trunk.  Exhaling, return to starting position.  Repeat six times.  Optionally, include 1-6 breaths in the warrior pose, holding static, deep breath, awareness chest and shoulderblades.

Warrior pose

Warrior pose – modified

Let us yog. Om.

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