Case History 2. Introduction. Anatomical Considerations

Transcription

1 Case History 2 Introduction Breast cancer is the most common malignancy in women in the western world. Each year about 50,000 women are diagnosed in the UK. The disease is more common in women who are 50 and over, but it can also affect younger women. Medical treatments for breast cancer may include surgery, radiotherapy, chemotherapy and hormone therapy. The type of surgery varies greatly, from radical mastectomy with removal of all the breast material as well as some supporting fascial structures, to minimal invasive breast saving operations and lymph node biopsy from the axilla. Surgery may include various breast reconstruction procedures. Treatment is often associated with side effects which may affect a patient s function and quality of life, for example, upper limb swelling, reduced shoulder mobility, neural tissue injuries causing sensory and motor dysfunction, fatigue, pain, anxiety and depression. With more women now living with their disease, issues of survivorship, both physical and psychosocial, are of increasing importance. Anatomical Considerations During surgery connective tissue is dissected and many muscles, nerves, and veins of the upper torso and armpit are affected. Some of the major muscles that may be affected are the pectoralis major and minor, latissimus dorsi, serratus anterior, and subscapularis. Breast and axillary scarring together with compromised tissue gliding and shearing ability between supporting fascial and connective tissue structures are commonly recognized as contributing to limited shoulder movements and some of the other impairments 1

2 The photographs below are examples of the restrictions that can develop following surgery. Note the tight cords at the elbow and in the armpit (my pupil did NOT show this level of restriction). Photograph 1 Photograph 2 Photograph 3 2

3 How yoga can help? Numerous studies have shown that combining mind and body practices that are part of yoga have tremendous potential to help patients manage the psychosocial and physical difficulties associated with treatment and life after cancer, beyond the benefits of simple stretching (the Journal of Clinical Oncology). Several studies show women with breast cancer who practiced yoga had lower levels of stress hormones and reported less fatigue and better quality of life (Integrative Cancer Therapy 2011). A study, published in Complementary Therapy Medicine, 2009, revealed that yoga (which included meditation, relaxation and breathing techniques) for breast cancer can help alleviate one of the most common accomplices of cancer: anxiety. Initial Assessment This pupil came to me six months after completing treatment for breast cancer. She had a lumpectomy on the right breast with removal of some of the lymph nodes, followed by chemotherapy. She is 53 years old and had done some yoga in the past in preparation for the birth of her first child 16 years ago but none since. She is planning to return to work 18 hours a week as a business manager at a local primary school in September. She walks her dog for an hour every day and has found this very helpful in building up her stamina and motivating herself in the early days post treatment when the fatigue was crushing. She has no other medical or musculoskeletal conditions. The problems she reported were; 1. Stiffness in the shoulder girdle area, particularly putting her hand behind her back. 2. Tightness and tenderness in the armpit, particularly over the scar and an area of tenderness and tightness on the breast over the scar tissue. 3. She reported periods of extreme fatigue which was slowly getting better but has nowhere near the levels of energy that she had prior to her diagnosis. 5. She said she had times of anxiety even though she had been given the all clear at her most recent check up. She said her cancer had been caught in the early stages and her prognosis was good. The observations I made were; 1. Slight elevation and protraction of the right shoulder girdle, internal rotation of the arm consistent with tension in the upper trapezius and across the pectorals. 2. Slight thoracic kyphosis and forward head position. 3. Slight anterior tilt of the pelvis with lax abdominals 3

4 4. Slight internal rotation of the hips with some pronation of the left foot in standing. She discussed the possibility of doing yoga with her surgeon and was told that it would be fine but that she should avoid anything too vigorous or strenuous. She was very open to trying yoga and had read up a lot about it. I saw her on a 1:1 basis and we agreed on a six week course. Class 1 Savasana 1 knees bent over a bolster, hands on the abdomen in order to feel the abdomen rise and fall with the breath, a small folded towel under her head to keep it in neutral. Supta Panangusthasana 1a (Supine leg stretch) I used this as I didn t want the emphasis immediately on the chest and shoulder area. I emphasised folding in the groin and rolling the ball in the socket, holding the leg loosely so as not to build tension in the shoulders and neck, the other leg extending away from the body. Supta Vajrasana Little boat Gravity Pose I with weight of the arms dropping into the shoulders, in order to release any tension that had built up from holding the legs in the previous poses. Jatara parivartanasana I (supine twist I) with the knees close to the chest to protect the lumbar spine. Rotation was tight moving away from the right and I gave her a bolster to rest the weight of her legs and a pillow under the right forearm to minimise tension across the chest wall, armpit and along the arm. The emphasis was on opening the rib cage with the breath. She did both sides twice, without holding for too long. I asked her to extend the upper leg, as she was able, in order to counter pose the bent knee position that she had been in for the previous poses. Then rolled over into; Pindasana ( child pose ) resting on her forearms, palms of the hands level with the head. I put a pillow under her bottom to encourage her to rest back on her heels. From here she moved into Adho Mukha Svanasana c ( all fours ) Here the emphasis was on getting some weight bearing through the arms, activating the shoulder girdle stabilisers and freeing the neck Bindalasana a and b (cat pose) emphasising the extension of the upper spine and the lengthening of the lower spine. I got her to repeat this several times, slowly and with a flowing movement, paying attention to the flow of the breath. From the all four position I then got her to rock back onto her heels, feeling long in the spine and opening in the armpit. I thought this was a good place to get arm elevation with the body moving away from the arm, whilst the arm felt stable and supported by the ground. From here I asked her to come up slowly into; 4

5 Tadasana (standing) rolling shoulder girdles baclwards one at a time several times and then swinging the arms gently releasing tension, front to back and then progressing into arms wide up to the side, with elbows soft. My intention here was to feel width across the chest. Namaste a (praying hands in front) followed by Gomukasana a (cow arms low preparation) Toe exercises lifting and spreading toes, feeling heels and outside borders of feet. Trikonasana a and b (Triangle preparation) Simple balance pose lifting one foot off the ground, unstable at first, improved by standing next to the wall and with some repetition Pranayama in Sukasana (sitting cross legged) on two blocks with knees supported by cushions, back supported with a big cushion against the sofa. I wanted her to sit with support as I felt it would be too much effort for her to hold an unsupported sitting posture for breathing. I also thought this would be a good position to teach a simple breath. I chose an exhalation technique, with the emphasis on blowing out gently to lengthen the out breath and deepen the inhalation. We did three cycles of five breaths and then sat quietly for another three minutes. Savasana supported with a rolled towel under the head, bolster under the knees and two small cushions to support the forearms and wrists. This allowed the right glenohumeral joint to rest back on the floor as it was slightly protracted when she lay with the arms fully extended. I then covered her with a large blanket and she rested for 12 minutes. She asked what she should practice before the next class so I suggested that she use savasana with her legs on a chair, sofa or over cushions for support and that she lie for 10 minutes or as long as she felt comfortable, and that she focus on the rise and fall of the belly as she breathed. I suggested that she might use this pose to deal with fatigue, as an alternative to going to bed to rest. Class 2 She said she had practiced the relaxation and found it extremely helpful as a way of resting mid afternoon. As she is new to yoga I decided I would do a similar class to give her a chance to familiarise her with the postures, while introducing a few new ones. Savasana I Gravity Pose II adding the legs this time as well as the arms I asked her if she would like to try a little buzzing breath (Bramari) in this position and I lay down and did it with her. I felt it was a good opportunity and posture in which to introduce it. We did five exhalations. She thought it was hilarious. We progressed into; 5

6 Mula Banda (pelvic tilt) emphasising the lengthening of the lumbar spine on the exhalation. Setu banda sarvangasana b (half back arch) with an emphasis on creating space between the ears and shoulders. I was also thinking of thoracic spine extension in this position and activating abdominals. Jatara Parivartanasana 1 (Supine twist) again rotating away for the operated side was much more restricted and required the right arm to be much closer to the body in order to stay grounded. I placed a small rolled towel under the forearm to take tension out of the arm and a bolster under the legs for support. She did this twice on both sides, with a focus on opening the rib cage with the breath and stretching the top leg into knee extension; rolled back into the centre. Savasana V - modified by bending the elbows and supporting the arms over a bolster. Rested for a few minutes. Pindasana (child pose) arms by side, small cushion under bottom, moving into Adho mukha svanasana c (all fours) Bidalasana (cat) moving through a sequence of rounding the upper back, rocking back onto the heels which allowed the armpit to open and extend and then coming back into cat with upper spine moving in. Adho mukha svanasana d (dog preparation) with knees bent, repeated twice but not held as I thought that would be too strenuous then back into all fours. Tadasana - shoulder circling backwards, arm swinging around the body and then out to the side. Simple neck stretches into side flexion using the weight of the head and dropping the shoulder to create space. Gomukhasana b (half cow arms low) the right arm more restricted than the left so I asked her to repeat the movements three times and then shake the arms loose Gomukhasana a (cow arm preparation above) and then shaking the arms loose again Tadasana - one arm up with the elbow soft and then adding in a side bend/ stretch Utanasana letting the head hang, back of the neck loose, arms folded loosely, knees bent, coming up on the exhalation Trikonasana a b c and d Pranayama - as before supporting the lower back with a cushion up against the sofa, with two small blocks under the sitting bones and two cushions under the knees to help the hips to open. In this position, I asked her again to focus on the exhalation, with her hands resting on her abdomen. Savasana exactly as she had done in the first lesson 10 mins 6

7 At the end of the class I made a note to add in another balance pose next time. She asked if could suggest one or two poses to do at home as well as Savasana. I suggested the supine twist and that she could explore different positions for the arms, possibly moving the right arm a little further away from the body (abduction and lateral rotation) so as to open the chest wall. Class 3 Savasana - legs up the wall as I thought I would add in some variation,(i suggested this for use as a restorative pose at home), rolled towel under the head, legs apart (abduction), hip flexion alternate legs then; Salamba sarvangasana b (shoulder balance preparation with feet on the wall) I chose this because it seemed a natural progression from the previous pose and can feel safe and contained to prepare for shoulder balance. It specifically allows the trunk to move away from the arms. I felt it was important to just get the feel for it but not to hold the position. From here going back to centre and rolling sideways into; Pindasana knees apart for variation and arms extending beyond the head ( into flexion, abduction and lateral rotation), coming up onto all fours (cat). I asked if she could try lying prone but this was not comfortable so I made a note to come back to it another time. Instead chose; Sukasana using two blocks as the pupil has stiff hips, from this position I added a side bend with the arm up, elbow soft, both sides. Marichyasana III preparation twist and then into a symmetrical pose Tadasana swinging the arms loosely around the body to release any tension that might have built up, moving into arms wide up to side with elbows soft and arms up with elbows elbows soft, neck flexion and side flexion stretch. Garudasana arms a (eagle preparation) with knees bent to encourage the back of the waist to stay long as she was inclined to extend in the lumbar spine. I also encouraged a deep exhalation, pulling in the abdomen and activating the pelvic floor as well as grounding through the feet during this pose. Gomukhasana a (cow arms preparation) - low and then upper arm followed by; Namaste a (praying hands in front) Vrikasana (tree) preparation with one foot raised resting on the other. This was not easy at first but was instantly better when done next to the wall. I then added in one arm up over the head movement elbows soft. 7

8 Trikonasana a b d preparation wide arms with an emphasis on widening across the chest, back into Tadasana and into; Utanasana with knees considerably bent so that the arms could reach the floor and then arms crossed and then to a support Pranayama sitting supported as before with a similar breathing technique, 5 mins Savasana as before x 10 minutes Objectives for Future Yoga Practice I would now be comfortable with progressing her into more challenging poses. Some examples are; Adho mukha svanasana - Dog preparation using support into full down dog, plank and up dog, from all fours into Fox with leg raised, to build strength in the upper body In Tasasana - full eagle arms and cow arms using a belt, Namaste arms behind starting very low, in order to improve flexibility of the shoulder girdle. Trikonasana and Parsvakonasana,Warrior I moving towards warrior III, wide leg forward bend. Sitting poses Dandasana with a belt and Paschimottanasana and Marischyasana preparation III and a simple salute to the sun sequence. In Pranayama I would do more of the Bramari breath and add in Viloma and Ujayii. I would avoid Nadhi Sodhama for the moment in case of causing any tension around the shoulders and arms. Working away from the site of scarring and tightness can still have an effect because of the connections between layers of fascia and connective tissue which run through the body. Self Reflection I have found it difficult to keep to the word count limit for this case study as there is so much information on the subject. So I have only used the minimum number of classes. My objectives for this pupil were to introduce her to a gentle practice that she could begin to do at home. I also wanted to take the focus off the breast and armpit and emphasise the surrounding areas, working on loosening the neck, shoulder girdles and thoracic spine. I felt it was important to keep things very simple and to repeat movements to gain familiarity. I am satisfied that none of the poses have caused any discomfort, that she is understanding the importance of the breath and has felt very well after the yoga classes. I have erred on the side of caution. Prone lying did not work but we could come back to that with a support (maybe a bolster) under the hips to avoid any compression of the breast. She could then begin to work into Salabhasana 1 (baby back bend) activating and strengthening lower 8

9 trapezius, facilitating extension of her thoracic spine and optimising the position of the right shoulder girdle. I am mindful to make no long term promises but just to suggest the benefits as they might be felt in the moment. I will build up the time spent in pranayama. Maeve Larkin September Bibliography (journal of clinical oncology) Yoga as Medicine: The Yogic Prescription for Health and Healing Paperback July 31, 2007 by Timothy McCall Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies, Journal of Alternative and Complementary Medicine. 2010;16(1):3 12. Janice K. Kiecolt-Glaser, Yoga's Impact on Inflammation, Mood, and Fatigue in Breast Cancer Survivors: A Randomized Controlled Trial. JCO Apr 1, 2014: ; published online on January 27, 2014 NB; please note the word count includes the bibliography, all headings and titles, brackets and illustrations 9