Finding My Lost Dog: Yoga After a Mastectomy

by Shanna Nasche

I was diagnosed with breast cancer and in February 2014 I had a double mastectomy. At age 54, the mastectomies were my first major surgery. As any of us yogis know, our breath—including basic breath awareness and simple, calming forms of pranayama—is the practice we can always turn to, so my breath was my regular companion during the various tests and while waiting in pre-op. As a yogi, who temporarily on medical leave, one flame that flickered within me was the desire to return to my physical practice. I mentally visualized Adho Mukha Svanasana (Downward-Facing Dog pose) as my goal. For me, finding my lost dog meant an open chest, shoulders, armpits, and straight arms, none of which I could access after surgery. I couldn’t even shrug my shoulders! I’ve never been motivated by the repetitious nature of lifting weights or the thought of 100 sit-ups to tone my muscles. But Vinyasa yoga offers me creativity, freedom of movement, and a spiritual aspect to taking care of my body. 

For those of you going through a similar journey (or who are teaching people recovering from this surgery), I’ve recreated a summary of my physical journey with recommendations for initial poses after the breast surgery. As you practice, you should not feel pain but might notice a pulling or stretching sensation. Please review this or any other plan for exercise with your surgeon, especially if you’ve experienced complications, began reconstruction using tissue expanders, or had lymph nodes affected by surgery. 

First Things First

While drains remain, walk at a comfortable pace as much as an hour a day (less if you did not exercise regularly prior to surgery). Moving helps the body heal, increasing blood flow and oxygen. Don’t do any weight bearing or lifting with the arms but reach outward (with the remote!), upward (to wash your hair), or behind you to put on a jacket. Avoid letting others do what you can do for yourself, even if it takes longer. Use deep breathing to reduce physical tension and to gently expand the chest muscles. Practice engaging the muscles used to shrug your shoulders, possibly rolling them up and back several times a day. As you release the shoulders, imagine your shoulder blades pulling down toward your waist. 

Approximately 10-14 Days After Surgery

Begin light stretches at this time (even if drains remain). Walking your hands up a wall is the best post-surgery “asana,” and officially recommended by all experts. 

Stand with your arm on the effected side at a 90 degree angle to the wall. Walk your hand upward and hold for about five breaths (3-5 sets). Repeat about 3 times day. As your shoulder opens, move your hand above your head along the wall and inch the outer edge of your foot closer. A fully extended arm with hip touching the wall is the final pose, which may take several months to achieve. Ask permission to move your arm higher than your shoulder from your surgeon, often approved around two weeks. Use breath awareness or an extended exhalation for each of the stretches with the goal of releasing tension in your body as you hold the stretch. 

The next stretch requires reaching your elbow behind your body. You can grasp a strap (or a towel) in one hand and take it behind your back (arm straight or slightly bended). The other hand reaches behind to grab the other end of the strap. Walk the hands toward each other along the strap. Allow your shoulder blades to move toward each other. Don’t arch your back, and allow your tailbone to move toward your heels. Turn your palms away from the body. Over time, you may be able to interlace your fingers behind your back. 

This photo shows an advanced version with heels standing on the strap (looped), hands grasping the top of the strap (palms out). Elbows move toward each other as your chest opens over time. As your body allows, your elbows may bend slightly, pointing straight behind. 

The third stretch uses a strap or towel in both hands (try gripping with palms up and down). Reach your arms in front, in line with your shoulders or lower if needed (review video). 

Raise your hands (arms straight or slightly bent) upward toward ceiling until you reach the edge of your flexibility. Keep your arms no higher than shoulder height until the drains are removed. Keep your spine long with your tailbone pointing toward your heels and your lower ribs stacked below the others. 

You can also do these lifts on your back with knees bent and soles of feet on the floor. Arms above your head can be helpful to reduce swelling if lymphedema is a concern. Another option for this stretch is to face the wall and walk your hands upward, inching closer to the wall as your body allows. These stretches are pre-cursors to Child’s pose (Balasana) and Downward-Facing Dog pose.

End with a restorative pose with the arms out to the side and your elbows bent in Cactus arms (in line with shoulders) or in the shape of a “W” if your elbows need to move lower (toward your hips).

This photo shows elbows touching the ground but that is unlikely in the beginning. If they don’t easily touch the ground, support your elbows and hands with blocks, blankets, or pillows, and allow gravity to open your chest instead of force. Relax in this pose at the end of your stretches, reducing the height of the props over time as your body allows. Once you can easily rest your elbows on the floor, another option to further open the heart and shoulder areas is to place a rolled blanket under your spine (keeping the back of your pelvis—the sacrum—on the floor) As you regain your range of motion, continue these or similar stretches at least once time a day to help reduce scar tissue around the incisions. 

In the Classroom

Each body heals at its own rate. Complications will likely extend your healing “schedule.” I returned to an official class (specific to cancer patients) about three weeks after surgery. I started with chair yoga. Without the ability to place much weight on the arms, I felt clumsy trying to move around on the mat. Stay with gentle versions of the stretches outlined above. My surgeon released me for physical activity five weeks after surgery, encouraging moving and stretching to reduce scar tissue. My first attempt at Downward-Facing Dog was around that five-week mark. My spine resembled an old gray mare, curving like a “U” in the middle to accommodate the tightness in my shoulders and chest. It helped to bend my knees, but my arms tired quickly, keeping me from holding the pose more than a few breaths. But despite my limitations, it was healing to return to my mat. I was thrilled! The photo at the beginning of this post shows my latest version, which I estimate at four to six months to achieve. 

In addition to the overall goal to regain range of motion, consider Downward-Facing Dog pose as a yoga “carrot” to visualize your healing after breast cancer surgery. 

Shanna Nasche, RYT-200 is a Yoga Bridge instructor and a student at Yoga Bridge. Yoga Bridge is a 501(c)(3) nonprofit that provides evidence-based coping strategies to complement medical treatment for cancer and recovery. They offer free and low-cost yoga programs to all people affected by cancer. Students are part of a nurturing community where they find relief from fatigue, muscle weakness, and stress. Yoga Bridge also offers teacher trainings in yoga for cancer twice a year. Email yogabridge@hotmail.com for more information.

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Yoga for Cancer: An Interview with a Nurse and Cancer Survivor

Butterfly by Melina Meza

Two of our readers, Susan Reeves and Pam Ryan, are co-founders and teachers at Yoga Bridge - Yoga for Cancer in Denton, Texas. When they offered to interview one of their students for the blog about her personal experience practicing yoga as a cancer survivor, we jumped at the chance. The student they chose to interview was Judie Craven, RN, who, as both a nurse and a breast cancer survivor, has a special perspective. —Nina 

Susan/Pam: Why don't you start by telling us a bit about yourself, Judie.  

Judie: I've worked in the medical field for over 23 years in all clinical aspects of nursing: oncology nurse, physician's nurse, medical nurse, radiation nurse, and now as a practice administrator. I also work to promote awareness and raise funds for breast cancer research and patient support with other organizations in my community.

In the fall of 2009 I was diagnosed with early stage breast cancer, which was found on a routine mammogram. I recall sitting in my car in the parking lot of my doctor’s office when I got the call that my biopsy was positive. Here I was, three months after the traumatic end of my 30-year marriage, alone and hearing that I had breast cancer. It was surreal. I thought, “God, why me?” Then I realized that I thought I knew what it was like to hear those words (by that time I had treated thousands of cancer patients at my facility), but my understanding pre-diagnosis wasn’t even close to this new reality.

Susan/Pam: So why did you start practicing yoga and how have you found it personally helpful?

Judie: I started with the Yoga Bridge group in 2012. I decided to attend the class because I thought to myself, "These nice ladies are donating their time. I am a cancer survivor so I should go to set a good example for my patients and staff." Little did I realize how this program would enrich my life! I was immediately embraced by a group of compassionate, understanding friends who knew exactly how I felt and we quickly became a source of support for each other, forming sincere and supportive friendships. Even surrounded by your own family and friends, cancer is a lonely disease that can leave you feeling that you have failed and/or that your body has failed you. To be among your peers is comforting beyond description. 

Susan/Pam: How about the yoga asanas—do you have a favorite pose that you've found particularly helpful?

Judie: Downward-Facing Dog. My job can be pretty stressful! Down Dog helps to release tension better than any other pose for me. It stretches my whole body and makes me feel strong—like I can accomplish anything.

Susan/Pam: That pose is a great choice for someone who has returned to full health after a diagnosis. So, have there been any challenges in your yoga practice because of your cancer diagnosis or treatment?

Judie: One issue I had was scar tissue at my surgery site—I had some limitations with movement there. My teachers at Yoga Bridge taught me specific movements and stretches that  helped improve my range of motion. I previously tried yoga classes at my gym, but Yoga Bridge offers smaller classes and assistant teachers who are knowledgeable enough to help students customize postures to their specific needs. That way, everyone has a successful practice.

Susan/Pam: In general, why do you think yoga is such a good fit for someone with cancer?

Judie: One of the most important things a cancer patient can do is learn to manage their energy levels. For many, the diagnosis and treatments can cause extreme levels of fatigue. In general, exercise can greatly help to manage that. What sets yoga apart is that you can go at your own pace and choose from a seemingly never-ending list of exercises for the mind and body. Once you’re taught how to modify, you can adapt according to your own level of energy in almost any class,. Yoga is a good overall fitness plan for both those who need something gentle and also for those who are ready to rebuild strength and balance.

I've also noticed how yoga helps with my own stress levels. It makes me feel grounded and centered, and I sleep better. It works for many of my patients, too. Linda has been in and out of treatment for metastatic breast cancer for almost nine years. She says yoga gives her “me” time to meditate and relax through rhythmic breathing, stretching, smooth flowing poses and Savasana, which let her body rest and be in a calm state for 75 minutes. Away from the family, appointments, errands, the endless to-do list, intrusive stressful and often depressive thoughts, she finally can be one with the space she is in. It can be a very spiritual experience.

The breathing exercises are tools we can use to calm or energize ourselves inside and outside of class, especially simple techniques like even count breath or mental alternate nostril breath. It’s usually the first thing new students latch onto. They come to class and tell how they were able to make it through scans, lab visits, and infusions with remarkably greater ease. These are easy exercises to remember and can be done anywhere at any time. Combining breath with wonderful guided imagery meditations is a special treat. Over the last three years I have been able to observe my progress by recognizing I am better able to quiet my normally very busy mind. Amazing.

I also love Nadi Shodhana at the beginning of hatha class. At first I was a little anxious when retaining my breath, but my stamina increased, as did my overall energy level. It’s so invigorating!

Personally I enjoy both hatha and restorative classes; however, restorative yoga is particularly appropriate for patients as they go through chemo and radiation. It's so gentle and accessible. It allows a person to be still and quiet the anxious mind while stretching and supporting the tender in-treatment body. 

Susan/Pam: As yoga teachers, we’ve noticed that, at first, many of our students are afraid to practice yoga—they don't think they are flexible enough, physically strong enough...many reasons. What would you tell someone with a recent cancer diagnosis about Yoga for Cancer classes?

Judie: I think that most people have not been exposed to this type of yoga. My own first experience was in a local health club and, although I consider myself to be physically fit, I was completely lost! It seemed everyone around me already knew what to do and I was so intimidated. But with smaller classes and specially trained teachers, I’ve learned how and when to modify poses, and I know that yoga can accommodate anyone, no matter their fitness level, with or without a cancer diagnosis. It's important to find the right teacher who knows specifically how cancer diagnosis and treatment changes the mind and body. I recommend looking for teachers who have had specialized training in yoga for cancer and restorative yoga, as well as someone who focuses on breathing exercises and meditation. Smaller classes are crucial, too. 

Susan/Pam: For yoga teachers out there, can you tell us how to approach the medical community about teaching a class for their patients?

 Judie: You need to impress upon the medical community that yoga designed specifically for the cancer patient is safe. Focus on all the benefits it provides: stress reduction, community, strength, and confidence. Explain how it is taught with modifications to the standard poses to fit the individual. 

Susan/Pam: Judie, thank you so much for sharing your story. You are such a positive force and we especially appreciate your candor. It is our hope that your words will inspire people with cancer to reach out and find the yoga community that is ready and willing to support them.  

Susan Reeves and Pamela Ryan are E-RYT yoga teachers and co-founders of Yoga Bridge. Yoga Bridge is a 501(c)(3) nonprofit that provides evidence-based coping strategies to complement medical treatment for cancer and recovery. They offer free and low-cost yoga programs to all people affected by cancer. Students are part of a nurturing community where they find relief from fatigue, muscle weakness, and stress. Yoga Bridge also offers teacher trainings in yoga for cancer twice a year. Email yogabridge@hotmail.com for more information.

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Yoga's Healing Powers

by Ram

Morning Glory by Melina Meza

Undoubtedly, all of us who do yoga as part of our daily routine have experienced its benefits, either at the physical, mental, or emotional level or at all levels. We all agree that it is relaxing, it is calming, and above all it has helped us in our flexibility and strength. Additionally, for some of us, yoga has helped in the healing of the heart, brain, gut, colon, kidney, hips, spine, and so forth. And all the anecdotal reports of the benefits that people have raved about are now being proved by empirical findings. In one of the largest studies of health benefits of yoga, it appears that yoga can reduce inflammation, the body's attempt at self-protection. Before I describe the study, let me briefly discuss inflammation and its positive versus negative health effects.

Inflammation is part of your body's defense response; the objective is to remove damaged cells, harmful irritants, or toxic pathogens from the body and initiate a healing response. While inflammation is not infection, an infection itself caused by bacteria, virus, or fungus can trigger an inflammatory process. Inflammation has a high beneficial value. For example, if you develop a viral infection or if your back sustains a severe blow, inflammation sets in to care and protect the injured tissue. The classical signs of inflammation are pain, heat, redness, and fluid accumulation (swelling). Other signs include: fever, chills, fatigue/loss of energy, muscle aches, headaches, and loss of appetite. All these signs are the body’s defensive strategies were activated to ward off the damage and heal the injured area. These defensive strategies are carried out by an arsenal of molecules that fight the invaders. The molecules include but are not limited to: leukocytes, macrophages, dendritic cells, mast cells, bradykinin, histamine, interleukins, and TNF, among others. Thus, the inflammatory process is akin to a country’s defense system involving several units of entities of increasing specificity that culminate in the removal of invaders and promote healing of any damaged tissue. In a perfect setting, the inflammatory process occurs just as it should: releasing defense/pro-inflammatory molecules when needed and then turning them off when the threat has been sufficiently addressed.

Now imagine if this body’s strong defense system turns awry and the defending molecules take on their own body’s system (akin to a coup). That would be the negative aspects seen in chronic inflammation, which are characterized by a defense response that is aberrant, out of control, and not completely turned off. Just like a constant, slow-burning fire, in chronic inflammation the defense/pro-inflammatory molecules continue to be present in the body even when they are not needed and the body operates as if it is constantly under attack. Thus, chronic inflammation draws on your body’s energy and resources, which can with time result in bodily damage. Additionally, when this system goes out of control, it self-perpetuates and triggers disease conditions, such as, atherosclerosis (inflammation in blood vessels), diabetes (inflammation in pancreatic tissue), arthritis (inflammation in bones and joints), celiac disease (inflammation in digestive system), fibromyalgia, and neuralgia (inflammation in limbs, muscles and nerves), among others. It is as though the body’s defense system fails to distinguish its own self, making the body vulnerable to attacks from its own defense team. The causes of chronic inflammation are numerous and include age, genetic predisposition, smoking, environmental stressors, allergens, chronic stress (both physical and mental), poor foods (sugary, processed, or fast food), and hormonal imbalance, among others.

But there’s good news for those of us who have a regular yoga practice. Several studies now report that a regular yoga practice:

1. suppresses inflammation
2. lowers the level of several pro-inflammatory molecules in the body
3. reduces a subset of pro-inflammatory molecules called cytokines, thereby relieving severe pain associated with the inflamed tissue

More specifically, studies report that yoga reduces inflammation in patients with cardiovascular problems and also improves levels of glucose and insulin in diabetic patients. There are also reports demonstrating yoga’s role in curbing inflammation that may serve as a panacea for people recovering from cancer. It turns out that following several rounds of radiation and/or chemotherapy cancer survivors suffer from persistent and debilitating fatigue for months or even years. Scientists believe that the cancer treatment procedures trigger an inflammatory process that fails to turn off. In addition to the weakness and pain from the cancer therapy procedures, these patients now suffer from inflammation that draws on the body’s resources, resulting in chronic fatigue. It is estimated that about a third of breast cancer survivors suffer from inflammation and chronic fatigue for several years after they complete treatment.

In a recent paper published in the Journal of Clinical Oncology Yoga’s Impact on Inflammation, Mood, and Fatigue in Breast Cancer Survivors: A Randomized Controlled Trial, researchers looked at 200 breast cancer survivors who had completed all the breast cancer treatments. The randomized, controlled trial involved only yoga novices. The yoga group practiced yoga twice a week for 12 weeks with take-home DVDs to practice at home. The control group was wait-listed to receive the same yoga sessions after the completion of the trial. The group that had practiced yoga for three months reported less fatigue and higher levels of vitality three months after the treatment had ended. The yoga group also reported significantly improved sleep. Additionally, three cytokine proteins in the blood that are markers for inflammation were all lowered by 10 to 15 percent. The novelty of the study was that it offered biological evidence of the benefits of yoga in addition to people's own reports of how they felt.

Cancer treatment leaves patients with high levels of stress, fatigue, and insomnia, which may trigger inflammation that in turn triggers tissue damage, leaving the patients completely debilitated and in a downward spiral. As we are now well aware, yoga reduces stress and fatigue (see Stress, Your Health, and Yoga ) and helps people to sleep better (see Sleep: A Pillar of Life), all of which may ultimately block the inflammatory process thus providing immense benefits to the cancer survivors. I guess you would agree with me that you cannot find a better, cheaper, and effective therapy for combating inflammation!

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