MATWORK FOR BREAST CANCER REHAB

Transcription

1 page 1 STOTT PILATES MATWORK FOR BREAST CANCER REHAB INTRODUCTION STATISTICS & GENERAL DATA More than two million women in the US have been treated for Breast Cancer. With the advancement in research and treatments many of them will survive and live a full and healthy life. Under the direction of healthcare professionals these women will be encouraged to seek out fitness programs to assist in their recovery and give them the strength and endurance they will need to resume an active lifestyle. Throughout the process of fighting the disease, women will undergo various forms of treatment as a result will experience a variety of intense side effects. Treatments may include chemotherapy, radiation, lumpectomies, mastectomies, lymph node biopsies or dissection and reconstructive surgeries. Each of these treatments can create their own set of challenges. As one Cancer survivor quotes In barely a year, I ve aged a decade. Medication Side Effects: A group of current anti-cancer drugs called Aromatase inhibitors, such as Exemestane (Aromasin), Letrozole (Femara), and Anastrozole (Arimidex), are known to speed up bone loss and raise the risk of bone fractures. One other anti-cancer medication Tamoxifen, helps preserve bone, particularly at the hip. Weight Gain: Women usually put on five to 15 pounds during chemotherapy treatment. A 40-year old woman undergoing chemotherapy typically experiences a 2.5 percent boost in body fat in a single year that s equivalent to what a 40-year old might expect to gain in a decade. It s hypothesized that weight gain is contributed by factors such as undergoing longer chemotherapy regimens and taking the steroid Prednisone (prescribed as a supportive medication used during chemotherapy to help with adverse side effects). There is no firm evidence that pins the weight gain on medications but the weight gain is a reality and it may be significant. TREATMENT & SIDE EFFECTS Chemotherapy, a common treatment for Breast Cancer patients, has been shown to induce premature menopause as well as accelerate some other diseases such as Osteoporosis and Sarcopenia. Some anti-cancer drugs and treatments may prompt an increase in bone mass loss. Decreasing Circulating Estrogen: the estrogen Research suggests that in premenopausal women chemotherapy may speed up bone loss. At Harvard Medical School one study details that within one year after beginning chemotherapy, a woman can lose seven percent of the bone mass from her spine and four hormone can fuel some forms of Breast Cancer. More fat cells means more estrogen enzymes are released increasing risks. (Aromatase is the estrogen enzyme released by fat cells) percent from her pelvis, especially if it has induced premature menopause. This would take five years to occur if a woman were going through natural menopause. Further studies have been done at the Dana-Farber Cancer Institute and Brigham and Women s Hospital measuring changes in bone density in Breast Cancer patients. These studies do show that the increase is far greater when the woman are thrust into early menopause and that accelerated bone loss significantly less among those who didn t experience menopause but still more significant than the natural amount lost. Minimizing the Risk of Lymphedema: excess weight raises the risk of lymphedema. A BMI of 30 or higher is a significant risk. It s important that women attain a healthy weight after Breast Cancer treatment for many reasons: Improved Survival Rate: there is a quite a bit of research being conducted supporting the fact that the more weight gained the higher the risk of reoccurrence.

2 page 2 STOTT PILATES BREAST CANCER INTRODUCTION OSTEOPOROSIS & SARCOPENIA Osteoporosis is a gradual loss of bone density the primary sites for loss of bone density being the spine, hip and wrist. Level I Nodes: found in the lower underarm Level II Nodes: found high up in the underarm directly beneath the pec minor Level III Nodes: found between the top border of the pec minor and the collarbone It has been stated that the most vulnerable sites for bone fractures in women who have been treated for Breast Cancer are in the wrist, spine, and hip. Lymph Node Surgery: If invasive Breast Cancer is suspected, the surgeons will generally removes one or two nodes. They examine the nodes for Cancer cells. This Sarcopenia is an age-related loss of muscle mass, strength and function. The most significant muscle atrophy is seen in the fast twitch muscle fibers, which are recruited during high intensity, anaerobic movements. helps determine the stage of the Cancer. Axillary Dissection: Axillary dissection is the removal of one or more levels of the underarm lymph nodes. In the past they would remove all levels but research has shown Fortunately both Osteoporosis and Sarcopenia can be that if Cancerous cells do spread, positive nodes will first partly reversible or retarded with a healthy diet and an be found in the Level I region. It s unusual for cancerous appropriate exercise program. cells to skip Level I and go to Level II, yet be found in Level III. Surgeons have minimized what they will take LYMPHEDEMA for biopsy purposes hoping to not disrupt the entire Lymph is a milky fluid containing water, fat, bacteria and most importantly infection fighting cells. Just as our lymphatic channels. blood circulates through a network of various sized vessels the lymph travels through a similar network called lymph channels. The channels are thin walled and are located throughout the body. Sentinel Node Biopsy: A less invasive surgery a radioactive tracer or blue dye is used to track the flow of lymph from the affected breast to the first (sentinel) node it reaches. The sentinel node is removed, possibly with one or two others that may be attached to it. The Unlike the blood, which is actively pumped by the heart, the lymph is pushed through the lymph channels by various dynamic actions such as muscular contractions, pressure created by breathing, and motions in the organs around the channels. Valves throughout the channels keep the fluid flowing in one direction, Clusters of lymph nodes positioned in certain areas, such as the groin, underarm, neck, and knees, filter the lymph. The filtering system rids the body of foreign or flawed material such as bacteria and viruses, assisting the immune system in fighting disease. nodes are examined and if found negative (no Cancerous cells) it is presumed the other nodes down stream are negative. If the sentinel node is positive (Cancerous cells) an axillay dissection is performed to check other nodes. When lymph channels are altered whether by surgery, radiation, or infection, fluid back up can occur. As lymph collects there are fewer available channels for it to pass through, creating a bottleneck. Sometimes this happens within a few days post breast surgery because the channels were cut or blocked due to swollen tissue. In this case it typically goes away with simple lymphatic The largest lymph channels feed back in to the bloodstream through two ducts at the base of the neck. Lymph channels, bean sized lymph nodes, and other lymphoid tissues and organs, such as the thymus gland and the spleen comprise the lymphatic system. drainage exercises performed by a medical professional. It s more common that lymphedema occurs later on. According to the National Cancer Institute (NCI) it may occur within a few months or many years afterward. Lymph channels in the breast flow outward through clusters of lymph nodes in the armpit (axilla), upward through clusters of nodes in the collarbone, and inward through clusters of nodes behind the breastbone. The axillary nodes are the major drainage sites for the lymphatic system in the breast. They are divided in to three levels based on their relationship to the pec minor muscle. Lymphedema: Caused by a buildup of fluid in tissues in the upper arm, lymphedema is a painful side effect of Breast Cancer surgery. People with lymphedema suffer swelling, inflammation and impaired limb mobility. There are temporary (transient) and long lasting (chronic) cases. If signs are noticed early, encouraging lymphatic drainage can often help

3 page 3 STOTT PILATES BREAST CANCER INTRODUCTION Patients are advised to reduce the risk of lymphedema by doing the following: Care for the skin by keeping it clean, dry and supple. Take steps to avoid injury to the area, any cuts or punctures can lead to scarring and may affect lymphatic drainage. Wear gloves when washing dishes or gardening Avoid pet scratches, razors. Use an electric razor Be aware of extremes. Cold can cause chapping and cracks, extreme heat may boost lymph production, so limit time in sun, avoid hot tubs and saunas. Use compression garments when advised by medical staff and when traveling by air Eat well to support your immune system SURGERIES Lumpectomy: also called wide local excision, partial mastectomy, quadrantectomy, or tylectomy. The surgeon will remove Cancerous tissue plus a rim of surrounding healthy tissue called a clean or negative margin. The tissue is then tested to see if there are Cancerous cells found in the clean margins. When less tissue is removed the breast has little change in size or shape. The changes that occur are relevant to the amount of tissue removed. The nipple and the areola are left intact. The underlying pec muscles are untouched. Radiation is coupled with a surgical lumpectomy. Surgery and radiation may affect posture, flexibility, strength and energy. Radiation may cause the muscles to stiffen and shorten. The surgery may create tightness in the area of the incision effecting the posture of the upper quadrant referred to as protective posturing. An estimated one in four women treated for Breast Cancer will develop arm lymphedema. Frozen Shoulder may occur in extreme cases of stiffness and immobility. The Journal of the National Cancer Institute notes that lymphedema occurred in 17 percent of women who had underarm lymph nodes removed. Among women who also had radiation to the underarm and breast the number is raised to 41 percent. The greater the risk the greater number of lymph nodes removed. With sentinel dissection there is less of an occurrence of lymphedema. There is controversy over whether exercise is recommended for patients who suffer this condition. Therefore, it s important to be have a doctor s approval for exercise and then proceed with caution paying careful attention to changes in skin color, temperature, skin tightness, tingling or itchiness and of course signs of inflammation. Please note: exercise has its pluses and minuses when lymphedema is concerned. Muscle action and deep breathing does help to move the lymph through its channels, but vigorous exercise speeds blood flow and perhaps increases lymph production. Be cautious especially with forceful or repetitive arm movements. Also note: doctors will often recommend a compression sleeve be worn during all workouts. For ongoing care, patients may seek lymphedema therapists in the US there is a National Lymphedema Network that lists licensed therapists. Fatigue is common with any surgical procedure. It s further enhanced by the radiation treatment and may last four to six weeks after radiation according to the National Cancer Institute (NCI). Exercise guidelines: Walking is encouraged with lumpectomies as soon as the day of surgery. Within a week general balance and stretching exercise are recommended. ROM most important within a painfree range. Focus on low-load and short-ever exercises. Avoid lifting arms over shoulder height during healing stages. Be careful to support limbs especially in the case of node dissections and use props. In the case of an axillary dissection, the surgical drains should be removed before stretching and strengthening exercises are introduced. Mastectomy: The entire breast, nipple, and areola (dark circle of skin around the nipple) are removed. There are several variations and each affect different degrees of lymph node and muscle tissue. A simple (total) mastectomy remove the breast, nipple, areola, but not the lymph nodes or muscles underneath. A modified radical mastectomy removes the breast, nipple, areola, and pocket of fat containing underarm lymph nodes (axillary nodes).

4 page 4 STOTT PILATES BREAST CANCER INTRODUCTION A radical mastectomy which is rarely performed today, removes the breast, pectoral muscles beneath it, and all of the lymph nodes up to the collarbone. Like a lumpectomy, the challenges post surgery are related to posture, flexibility, energy and in the rare case of radical surgeries where the muscles are removed, strength and mobility can be seriously compromised. Regular functional daily living activities such as lifting groceries, doing laundry, turning the steering wheel, pulling open heavy doors, pushing revolving doors etc. are all compromised at least temporarily. Fatigue is further enhanced by radiation treatment and may last four to six weeks after radiation according to the National Cancer Institute (NCI). Exercise guidelines: Walking is encouraged as soon as the day after surgery. Within one or two weeks a program geared toward enhanced ROM, and balance. After two weeks, providing the surgical drains have been removed, gentle stretching may begin. Approximately four weeks post-op, a gentle low-load, strengthening program may begin. They must be able to stand upright and move throughout a comfortable ROM. All low-load, short-ever exercises are recommended. Avoid lifting arms over shoulder height during healing stages. Be careful to support limbs and in the case of node dissections, use props. In the case of an axillary dissection, the surgical drains should be removed before stretching and strengthening exercises are introduced. With a mastectomy the woman will then have to decide whether or not to have reconstructive surgery. Some women opt to wear specially made bras and not have reconstructive surgery. There are three types of reconstructive surgeries for Breast Cancer patients 1. Reconstruction with implants 2. TRAM flap reconstruction 3. LAT flap reconstruction 1. Reconstruction with Implants: Following the mastectomy the patient undergoes another surgery to reconstruct the breast or breasts with saline implants. The implant can be a one part or two part surgical procedure. If the woman has small breast the surgeon may be able to place a small implant beneath the pec major during a single procedure otherwise it s a two-step process. During the first procedure a tissue expander is inserted. After the mastectomy, the pec major is gently lifted away from the rib cage. This forms a pocket in which the expander is placed. A small quantity of saline solution is injected through a needle into a valve or port of the expander. This is left in tact for several weeks to allow for healing of the tissue. Then the expansion process begins solution will be injected every few weeks over the course of several months to gradually increase the chest wall musculature and overlying skin. The surgeon then removes the expander and inserts the implant. This whole process can be very painful. Sometimes the median pectoral nerve is cut which innervates the pectoral muscles. This adds laxity to the chest muscles, which may enhance the appearance of the reconstructed breast. However the muscles will be weaker on that side. Due to this lengthy process, it may take a longer time for the patient to resume a regular consistent exercise program. A recovery phase is important for each of the surgical procedures. Follow all the guidelines as listed under the Mastectomy heading. The surgery will result in the following side effects: Tightness in chest, under arm and on the side of the trunk Chest will be sore post-surgery Shoulder will internally rotate, protective type posture Arm & shoulder hurts, effecting ROM in the entire shoulder girdle Weak chest muscles making daily activities challenging Exercise Guidelines: The program should include ROM exercises for the entire shoulder girdle and restoring proper biomechanics and posture in the upper quadrant. All over strengthening of upper back musculature and core musculature to help support transfer of load from top to bottom and vice versa. We want them functional again.

5 page 5 STOTT PILATES BREAST CANCER INTRODUCTION 2. TRAM flap Reconstruction (Transverse Rectus Abdominal Muscle): There are two types of procedures used with the TRAM flap. 3. LAT (Latissimus Dorsi) Flap: This procedure removes the lat muscle from its origin and uses it along with skin, blood vessels and fat from the back. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which is used to reconstruct the breast. One of them, the Pedicel Flap, consists of taking tissue The blood supply remains the same. Many women have and half of the rectus abdominus muscle and re-routing it weakness in their arm, shoulder or back following surgery. via a tunnel up to the chest wall to reconstruct the breast. They often times will need to use an implant underneath The surgery will result in the following side effects: the flap to increase its mass if there isn t enough tissue. This flap is attached to its original blood supply. Tightness in back Difficulty rotating at waist Tightness under arm The other procedure is called the free flap. In this Limited shoulder motion surgery they cut the flap of skin, fat, blood vessels and Tightness in chest protective posturing muscle free from its original location and attach it to the Difficulty with movements that pull down blood vessels in the chest area. This is not as common as Poor posture, including forward head and the pedicel flap but some doctors think it can result in rounded shoulder a more natural shape. Program Highlights: Start walking the day after surgery. After the breast is reconstructed they have to close up ROM and balance work may begin two to four weeks the abdominal incision and in doing so they will use a post-op. Once they can stand upright and have regained mesh sheath to bring the fascia back together again, full pain-free ROM generally about 12 weeks post-op, similar to the procedure used with a hernia operation. begin a gentle strengthening routine. The surgery will result in the following side effects: Important like all other surgeries involving breast Tightness in abdominal area reconstruction to restore the shoulder ROM and Difficulty in standing strengthen the entire upper quadrant to improve Tightness in hip flexors biomechanics and posture. As the lat adducts and Weakness in core musculature internally rotates the arm we will focus on the Weakness resulting in poor posture surrounding back musculature to restore functional Lower back tightness strength, the rhomboids, deltoids, triceps, rotator cuff, Difficulty lying prone from surgical procedure, will and trapezius. dissipate in time Program Highlights: Start walking the day after surgery. ROM and balance work may begin 2-4 weeks post-op. Once they can stand upright and have regained full painfree ROM generally about 12 weeks post-op, begin a gentle strengthening routine. Because both the upper body and trunk have undergone extensive surgery. Aim to restore all biomechanics in the upper and lower quadrants. ROM exercise for both the shoulder and hip joints and gradual core strengthening. The TA and the obliques will be very important as they only have half of the RA. Start out with neutral alignment and work toward imprinting the spine to relieve stress on spine and the hip flexors. GENERAL EXERCISE GUIDELINES FOR BREAST CANCER PATIENTS ROM and low-load strength and endurance exercises are best. Create mobility, restore posture, and develop core strength and peripheral strength to balance out the muscular imbalances created from the surgeries. Breathing is Very Important: helps assist lymphatic cycle. Preliminary Client Intake Data: Be sure when working with private clients or when conducting group classes for Breast Cancer survivors that all participants have a Doctors approval to begin an exercise program.

6 page 6 STOTT PILATES BREAST CANCER INTRODUCTION It s important to note that there are many different types of treatments; some allow a participant to be active throughout and others have very specific guidelines on activity levels and which activities are appropriate and when. Be aware of what the client has gone through for treatment and educate yourself on their particular treatment. Be sure to find out if they are taking any medications. Some medication for Breast Cancer patients will effect the joints and muscles resulting in soreness and tenderness. With the many various medications on the market and the influx of new ones, it s almost impossible to know about the specific drugs and their effect on the patient. Don t feel you need to be an expert on medications, (you are the Pilates expert, not a doctor or nurse). However, you should ask the client what they are taking and if they know the potential side effects. If they do not know, you may want to encourage them to ask their affiliated Cancer center it s good for them to be completely educated along with you. Programming Notes: Positive feedback nothing negative do not correct, supportive cues are best tell them what they are doing right not what they shouldn t do keep it upbeat. Resources: There are many resources available for both the consumer and professional regarding the types of treatments, the side effects, the various surgeries and when and if exercise is appropriate at the different stages. First we encourage checking the local area to see if there are already people offering exercise programs either in club settings, community centers or in Cancer treatment centers. Cancer centers are great places to offer programs. Patients already have a relationship with the center and trust the information they receive there. Plus these centers are looking for specific mind-body programs to offer to their Cancer patients there has been some wonderful research stating that exercise does help a Cancer patient in a variety of ways. Plus, more often than not, the centers do not have qualified staff to implement such programs. A wonderfully descriptive book on treatments, side effects and exercise guidelines is: The Breast Cancer Survivors Fitness Plan by Dr. Carolyn Kaelin, Josie Gardiner and Joy Prouty. The exercises offered are fitness-oriented not Pilates-based but interesting to review. Have many props on hand to support all limbs No overhead movements or above shoulder-height until they have regained full pain-free ROM More is not better quality of movements, slow and controlled Sequence is extremely important do not overload one body part, keep switching between upper and lower body every one or two exercises Know the stage participants are at, be familiar with their particular treatments Warm up and cool downs are extremely important If they are doing their walking program with you, do it first then do the exercises REFERENCES breastcancer.org Breast Cancer If fatigued, be sure they rest komen.org Susan G. Komen Breast Cancer Foundation cancer.gov/cancertopics/types/breast National Cancer Institute

7 page 7 STOTT PILATES MATWORK FOR BREAST CANCER REHAB EXERCISES BREATHING 1. BREATHING SEATED seated, pelvis and spine neutral, knees flexed, hands by sides resting on Toning Balls in: prepare, ex: articulate spine forward from head, rolling Balls out, in: stay for three breaths, ex: roll up to vertical 2. BREATHING SUPINE between knees, hands by sides resting on Toning Balls in: prepare, ex: engage transversus abdominis and pelvic floor IMPRINT & RELEASE between knees, hands by sides resting on Toning Balls 1. TWO BREATHS ex: engage obliques and imprint spine, in: release 2. FOUR BREATHS in: prepare, ex: engage obliques and imprint spine, in: maintain imprint, ex: release LIFT ELBOWS / OPEN ELBOWS COMBO between knees, hands holding Toning Balls against shoulders (rest elbow on Foam Cushion if necessary) in: keep Balls against shoulders and lift elbows, ex: open elbows, in: close elbows, ex: lower elbows to Mat PROTRACTION & RETRACTION between knees, hands holding Toning Balls arms reaching toward ceiling 1. PROTRACTION TO NEUTRAL 2. RETRACTION TO NEUTRAL 3. FULL RANGE LEG SLIDES supine, pelvis and spine neutral, legs abducted hip-distance apart, knees flexed, balls of feet on Toning Balls, heels resting on Mat or between ribs and hips to help feel neutral alignment ex: extend one knee, rolling Ball away, in: roll Ball in 1. UNILATERAL PLANTAR FLEXED ELEVATION & DEPRESSION between knees, hands by sides resting on Toning Balls in: elevate shoulders toward ears, ex: return to neutral LIFT ELBOWS between knees, hands holding Toning Balls against shoulders (rest elbows of affected side or both sides on Foam Cushion) in: keep Balls against shoulders and lift elbows, ex: return OPEN ELBOWS between knees, hands holding Toning Balls against shoulders, elbows lifted ex: keep Balls against shoulders and open elbows, ex: return (may need to place Foam Cushion under affected sides) legend: in: = inhale; ex: =exhale 2. UNILATERAL DORSIFLEXED, dorsiflex ankle as leg extends 3. RECIPROCAL 4. BILATERAL, imprint spine and place cushion between knees if necessary SHOULDER BRIDGE supine, pelvis and spine neutral, legs abducted hip-distance apart, knees flexed, balls of feet on Toning Balls, heels resting on Mat 1. PREP in: prepare, ex: extend hips and lift pelvis, in: stay, ex: flex hips and lower pelvis to Mat 2. PREP WITH ROLL DOWN in: prepare, ex: extend hips and lift pelvis, in: stay, ex: start from thoracic and articulate spine down to Mat through flexion 3. ADD HEEL LIFT in: prepare, ex: extend hips and lift pelvis, in: stay, ex: lift one heel, in: lower heel, ex: lift opposite heel, in: lower heel, ex: articulate spine down to Mat through flexion

8 page 8 STOTT PILATES MATWORK FOR BREAST CANCER REHAB SIDE-LYING ARM CIRCLES side-lying, pelvis and spine neutral, knees and hips flexed, head resting on bottom arm or Foam Cushion, top arm reaching up to ceiling holding Toning Ball in: prepare, ex: circle arm from shoulder joint, making small circles. Reverse circles. Perform next eight exercises on one side then repeat from Clamshell on the other side LEG CIRCLES side-lying, pelvis and spine neutral, bottom knee and hip flexed, top leg long, in line with torso, head resting on bottom arm or Foam Cushion, top arm resting on Mat holding Toning Ball in: prepare ex: make small circles with top leg. Reverse circles EXTERNAL & INTERNAL SHOULDER ROTATION supine, pelvis and spine neutral, knees flexed, elbows flexed by sides (support elbow of affected side on Foam Cushion if necessary), holding Toning Balls, hands up toward ceiling in: open hands out to sides ex: lift hands CLAMSHELL side-lying, pelvis and spine neutral, knees and hips flexed, head resting on bottom arm or Foam Cushion, top arm resting on top thigh holding Toning Ball ex: keep toes together and lift top knee, in: return EXTERNAL SHOULDER ROTATION side-lying, pelvis and spine neutral, knees and hips flexed, head resting on bottom arm or Foam Cushion, top arm flexed with elbow resting on waist, (may need to place elbows on small cushion at waist), holding Toning Ball ex: keep elbow by side and externally rotate humerus, in: return HEAD NODS between knees, hands by sides resting on Toning Balls on one hand behind head for support in: nod head forward slightly, lengthening back of neck, ex: return to neutral AB PREPS between knees, hands by sides resting on Toning Balls in: nod head forward slightly, lengthening back of neck, ex: flex upper torso, rolling Balls along Mat, in: stay, ex: return to Mat SIDE LEG LIFTS side-lying, pelvis and spine neutral, bottom knee and hip flexed, top leg long, in line with torso, head resting on bottom arm or Foam Cushion, top arm resting on Mat holding Toning Ball in: lift top leg, plantar flexing ankle ex: lower top leg, dorsiflexing ankle TORSO ROTATION side-lying, pelvis and spine neutral, knees and hips flexed, head resting on bottom arm or Foam Cushion, top arm long resting on Mat holding Toning Ball in: roll Ball forward, rotating torso from shoulder to tail, ex: return LEG LIFTS supine, pelvis and spine neutral, knees flexed, hands by sides resting on Toning Balls in: prepare, ex: lift one leg to tabletop, in: stay, ex: return 1. UNILATERAL 2. ALTERNATING OBLIQUES between knees, one hand reaching across to opposite thigh, other hand resting on Ball or behind head ex: flex and rotate upper torso, sliding hand up toward knee as other hand rolls Ball along Mat, in: return to Mat. Repeat on other side

9 page 9 STOTT PILATES MATWORK FOR BREAST CANCER REHAB SINGLE LEG STRETCH 1. ONE LEG TABLETOP supine, pelvis and spine neutral, knees flexed, one foot on Mat, one leg tabletop, hands by sides resting on Toning Balls ex: extend gesture leg away from torso, in: return 2. BOTH LEGS TABLETOP supine, imprinted position, legs tabletop, hands by sides resting on Toning Balls ex: extend one leg away from torso, in: return, ex: extend opposite leg away from torso, in: return CAT STRETCH on all fours, pelvis and spine neutral, knees hip-distance apart in: prepare, ex: start from tailbone and sequentially articulate spine into flexion, in: stay, ex: start from tailbone and sequentially articulate spine back to neutral ARM REACHES on all fours, pelvis and spine neutral, knees hip-distance apart, one hand resting on Toning Ball ex: keep torso stable and roll Ball forward, in: return. Repeat on other side BACK ROW on all fours, pelvis and spine neutral, knees hip-distance apart, one hand holding Toning Ball, arm reaching forward of shoulder on Mat ex: pull elbow back toward waist, in: return. Repeat on other side TRICEP EXTENSION on all fours, pelvis and spine neutral, knees hip-distance apart, one hand holding Toning Ball, arm reaching forward on Mat in: pull elbow back toward waist, ex: extend elbow, in: flex elbow, ex: reach arm forward to Mat. Repeat with 3 extensions OFFERING seated, pelvis and spine neutral, legs crossed, elbows flexed by sides, hands forward, palms up in: reach hands straight forward ex: open arms out to sides, in: reach arms straight forward, ex: flex elbows 1. PALMS UP 2. PRONATION TO SUPINATION, start with palms down and rotate up as arms extend, return to palms down as elbows flex THORACIC EXTENSION LEG SLIDES on all fours, pelvis and spine neutral, knees hip-distance apart ex: keep torso stable and slide one foot straight back, in: return. Repeat on other side seated, pelvis and spine neutral, legs crossed, hands resting on knees in: open shoulders and lift sternum to ceiling ex: return TORSO ROTATION ARM REACHES / LEG SLIDES COMBO on all fours, pelvis and spine neutral, knees hip-distance apart, one hand resting on Toning Ball ex: keep torso stable and roll Ball forward, simultaneously, slide opposite foot straight back, in: return. Repeat on other side SHELL STRETCH sitting back on heels, spine flexed, hands resting on Toning Balls in: expand back and sides of rib cage, ex: allow ribs to compress seated, pelvis and spine neutral, legs crossed, hands resting on knees in: rotate upper torso reaching hand to opposite knee ex: return. Alternate sides THORACIC EXTENSION / TORSO ROTATION COMBO seated, pelvis and spine neutral, legs crossed, hands resting on knees in: open shoulders and lift sternum to ceiling ex: return, in: rotate upper torso reaching hand to opposite knee ex: return. Alternate sides

10 page 10 STOTT PILATES MATWORK FOR BREAST CANCER REHAB HALF ROLL BACK seated, pelvis and spine neutral, knees flexed hip-distance apart, hands resting on Toning Balls 1. PLAIN ex: increase flexion and roll lumbar spine toward Mat, in: return 2. BICEPS stay in flexion and lift hands, palms up ex: flex elbows bringing Balls to shoulders, 5-8x in: return 3. feet on Balls, heels down ex: increase flexion and roll lumbar spine toward Mat, in: return MERMAID seated, pelvis and spine neutral, legs crossed, one hand resting on Toning Ball in: lift arm to ceiling ex: laterally flex torso, rolling Ball out, in: return to vertical reaching arm to ceiling ex: lower arm SPINE STRETCH FORWARD seated, pelvis and spine neutral, legs crossed, hands resting on Toning Balls in front of body on Mat in: prepare ex: sequentially articulate spine into flexion from head, in: stay ex: return to vertical from tail 3. ONE LEG EXTENSION ex: increase flexion and roll lumbar spine toward Mat, extending one knee and rolling Ball out, in: return. Alternate legs