Training opportunities post surgery

A great opportunity presents itself after mastectomy: literally learning the lifts from the ground up.
First I can pay attention on improving the squatting positions and hip flexibility without distraction by more complex movements. Next the pulls (1st and 2nd) are added, and doing these movements incorrectly can immediately be felt in the upper body (stitches...). Lastly the overhead movements are added, and then everything can be put together.
Since the ego won't get in the way of adding weights to the bar too soon, perfection of technique is the primary focus at this time. It is a thrill to make the movements smooth and then fast and faster. Effortless effort.

It is a blessing to have experienced weightlifters cast a critical eye on the execution of the exercises and generously give feedback and tips for improvement.

with Fred Lowe

Complementary health approaches

The National Center for Complementary and Integrative Health (NCCIH) is a great resource to explore approaches and check on latest research. As of 2015 Congress has renamed NCCAM (including "alternative medicine") to NCCIH due to "alternative medicine" being uncommon. There is confusion about these terms, and NCCIH has defined them here:

• If a non-mainstream practice is used together with conventional medicine, it’s considered “complementary.”
• If a non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.”

What are complementary approaches and how popular are they?

There are two subgroups: Natural products and Mind and body practices.

Among US adults in 2012, the 10 most common approaches were:

17.7%   Natural products  (herbs, vitamins, minerals, probiotics)

10.9%   Deep breathing

10.1%   Yoga, Tai Chi, or Qigong

8.4%     Chiropractic manipulation

8.0%     Meditation

6.9%     Massage

3.0%     Special Diets

2.2%     Homeopathy

2.1%     Progressive relaxation

1.7%     Guided imagery

Reference: National Health Interview Survey

It is surprising that with these categories exercise is not one of them, and makes me wonder how exercise for health reasons would rank compared to these.

As of May 30, 2016 I have experience with (length of time practicing/using it):

Yoga* (32 years)

Meditation and Reiki (12 years)

Pilates (12 years)

Chiropractic care (1 year, regularly, previous 8 years as needed)

Vitamins (D3 and B12) (5 months)

Acupuncture (2 months)

Tai chi (3 weeks) 

Other things I did at some point:

Autogenes Training,  duration 1 year, 30 years ago

Alexander Technique, duration 6 months, 6 years ago

Massage, about 2x per year

* This includes deep breathing

Although some of my practices, yoga, Reiki, meditation,  are labeled "complementary approaches", they are regular routines and in my view are part of healthy living, same as exercise, so "complementary" does not seem the correct term.

What is acupuncture like?

A couple of weeks ago I would not have imagined having an acupuncture session, because of the idea of having needles stuck into me. Among complementary therapies, effects of acupuncture has been studied for a variety of symptoms, and many studies have demonstrated benefits. See for example, the summaries on the website of the National Cancer Institute (NCI): Research on acupuncture
It is very important to find a qualified therapist. There are licensing rules in most states (www.nccaom.org). The FDA approved sterile single use acupuncture needles by licensed practitioners.

I came to acupuncture, because there is an excellent therapist in my favorite yoga center.
Liz is compassionate, has experience with treating surgery patients, is well read, and we can talk about many topics: http://www.threemountainswellness.com  In each session she reminds me to eat healthy,  drink a lot of water, has suggestions for sleeping well, and all sort of other cool tips.

The experience of an acupuncture session is individual. Two weeks before surgery I had my first acupuncture session, and was very relaxed afterwards, just what I needed during an incredibly hectic week to get organized with work hand-overs, and to sort out health insurance and doctors appointments. The session was wonderful!
After surgery the experience of every session has been different, sometimes going very deeply into a meditative space, sometimes feeling super strong, sometimes very relaxed, but always balanced.  I regained my shoulder mobility quickly, and believe the acupuncture sessions played a crucial role in this.

The skin is swapped with alcohol to sterilize, and then a hair thin needle is inserted. After all needles are placed, some may be connected with electric wires. Does it hurt? I may have 1 or 2 points that do  hurt at the time of needle insertion. These points can be different from session to session, but nothing is so bad that the needle would have to be removed. Liz is vigilant to make sure everything is going well. And I LOVE it when she leaves the needles in for longer than an hour!
I'll be back!!!　 　

6th week exercise summary and looking beyond

It is not easy to figure out what is the right amount of exercise. Even when you know your body well, and you pay attention, what feels right may still be too much.

After some intensive exercises that included GHD sit-ups, I developed superficial thrombophlebitis across my abdomen. This is benign and will go away eventually (see post on cording). I also have swelling under my right arm, the location of sentinel lymph node biopsy, from chest to armpit to shoulder blade. This is bothersome. It helps to lift the right arm and sleep with the arm up, but fluid accumulates again when the arm is lowered. Due to this (and menstruating for the first time since surgery - unexpected!) this was a light week with a couple of days off or only some exercise. However the following are new accomplishments this week:

• Push-ups with exercise ball
• outdoor bicycling 
• a more "regular" weightlifting training session, including snatches with PVC pipe, strict press, overhead squats, drop snatches with 15kg bar. Then a clean & jerk series with 35 kg. Pulls (snatch grip) with 35 kg, and back squats at 60kg for a 90 minute workout   J   J   J  

I look forward to add more upper body strength next week.
Tip: As much as I was looking forward to NOT wearing a bra anymore, when the barbell touches the mastectomy scar, it is unpleasant! A yoga top with a built-in bra, provides a double layer that may help.

This completes the 3 to 6 week post surgery period. It was unclear from the official recommendations how much exercise one could possibly do during this time and my motivation for this blog. A summary is here: my exercises 3 to 6 weeks post surgery

Official recommendations:

• The American Cancer Society posts only stretches: week after surgery
• The Canadian Physiotherapy Associations says to start strengthening exercises at 4-6 weeks post surgery starting with 1-2 lbs: Exercises after breast surgery  

Unofficial  recommendations: There are blogs and forum posts by women sharing their own stories of recovery and exercise. These are usually slices in time. One blog and Facebook page with a more complete history is by Jen Hanks, who competes nationally in mountain bike races: http://athletefightscancer.blogspot.com

Weightlifting training session with clean & jerk at 35kg @ 6 weeks postop

Cording one week later

Happily, there is a marked improvement! I don't feel the tight bands anymore.

Mondor's syndrom of superficial thrombophlebitis can be a side effect of breast surgery or can also be caused by vigorous exercise, see https//www..breastcancercare.org.uk/.
Some cases in men have occurred due to push-ups or  yoga postures.

In my case it is likely the combination of mastectomy and circuit training that included 3 rounds of 10 fast reps GHD sit-ups.

The occurrence is likely underreported, not well-studied, and treatments are unclear. Physical therapy is described here: physical therapy for axillary cord formation

I am using stretches (lunges with arms back), and manual self-massage whereby taking areas of the chest and pulling them apart (at first it makes popping noises, then less so), and a herbal supplement that is anti-inflammatory. A few light days of exercises, but still including Pilates and weightlifting, and bicycling. No sit-ups!

Update from the future: It took about 3-4 weeks to resolve.

Here is a comparison:

2 days after GHD sit ups

one week later

Restorative yoga

Restorative yoga consists of supported yoga poses that allow on to completely real and gently stretch.
Some of these can be done very soon after surgery (supported back bend), others will help stretch the arms (child pose). Once it is possibly to gently lie on the front of the body, possibly with an extra cushion under the abdomen or chest, then supported twists are possible, too.

supported child pose

supoprted backbend

supported twist

An excellent, but intense, stretch for thighs, chest, shoulders, and arms is shown below.

intense stretch

Return to olympic weightlifting

End of 5th week postop:  It's been a long wait until the snatch, clean &jerk, and overhead squats are possible again even if only with an empty bar (15kg).

 

Cording

Cording refers to the development of palpable cords (tight bands) usually in the axillary region when it is called axillary web syndrome (AWS). Reported rates vary widely. There is little known when it occurs, or why it occurs, or how long it lasts.
Tight cords under the axilla limits range of motion, and sometimes aggressive stretches are used to improve shoulder mobility.
Not only is there little known about the origin (dilated thrombosed lymphatics, or thrombosed superficial veins, or both), risk factors are guesses, and it is unclear how to treat it.  Physical therapy (stretches), non steroidal anti-inflammatories, heat packs, lymphatic massage has been mentioned.
Some forums say there is little one can do to speed up the process.

In a literature review of 8 studies symptoms lasted between 1 week to 2 years, most resolved within 3 months. The prevalence can be high depending on the studies, there is no consensus on definition, treatment, or standardized screening.

References:

Piper M, Guajardo I, Denkler K, Sbitany H. Axillary web syndrome. Current understanding and new directions for treatment. Ann. Plastic Surg 2016; 76:S227-S231.

Moskovitz AH, Anderson BO, Yeung RS, et al. Axillary web syndrome after axillary dissection. Am J Surg. 2001;181:434–439.

O'Toole J, Miller CL, Specht M, Skolyny M, Jammallo L, Horick N, Elliott K, MNiemierko A, Taghian A. Cording following treatment for breast cancer. Breast Cancer Res Treat 2013; 140:105-111.

Even less is known about truncal cording "What is Cording?" National Lymphedema Network

This may be a case of underreporting, especially if the truncal cording does not limit daily activities or causes pain.

However I was not happy to have discovered this across my abdomen during the 5th week postop (see photo of left side during a lunge stretch).  Best guess: possibly due to overdoing the GHD sit-ups (3 sets of 10). To be continued ....

5th week postop exercise summary

This week after some speed intervals on a stationary bike and working on the machines for isolated leg muscles I noticed a group doing Tai Chi. It is good to try something new, so I went to a beginner's class. Slow meditative movements. I'll be continuing it as time permits.

• Back squats and front squats up to 85% max
• Speed intervals on a stationary bike 
• Rowing on a Concept2 rower with resistance level 3, 28-32 m/s, using mostly legs and abs
• Isolated leg muscles on gym machines
• Isolated arm muscles in a supine position with 8-10 lbs dumbbells
• Pilates for lower body and now also side lying leg exercises
• GHD sit-ups and hip extensions
• Push-ups against wall
• Deadlifts and pulls 35kg
• Box jumps
• Snatch with PVC pipe
• Cleans, push jerk, (gentle) split jerk with 15 kg bar

During this week I seemed to have developed some "cording" across my abdomen. This does not interfere with daily activities, but does affect stretches such as lunges.

Delightful woman in no distress

The essay "Nice 67 Y.O. male has brush with mortality" by Garrison Keillor (September 2009) made me wonder whether attributes for patients are commonly used in clinical notes. So I looked up mine. And sure enough "very pleasant 52-year-old female", "absolutely delightful 52-year-old woman", "delightful woman in no distress" are recurring themes. I am delighted to read this, of course.  In the essay, the nice 67 y.o. man said he had an edgy 27 y.o. man inside him. And I do know exactly what he means despite my calmness that was noted in the reports.

"She is well versed in the literature" and "she has done significant research in this regard" makes me wonder whether biostatisticians make difficult patients, because we question numbers, or easy patients, because we are thinking carefully? During the appointments I very much enjoyed the discussions about risk factors and probabilities, and learning more about treatments and expectations. Stephen Jay Gould commented in his essay "The Median isn't the message" how impossible it is to keep an intellectual away from literature. However, as researchers may well know, it is also easy to selectively choose literature to support one's hopes or fears. I am very grateful for my scientific friends and the doctors who were able to point out other studies to arrive at a more well rounded view of things.

It is also helpful to understand variability. The literature reports averages, which is not necessarily what outlooks are for individuals. This is more than clear when looking at forum posts where a range of experiences are reported, each are slices in time. It is to be expected that recovery paths and post exercise regimes can be quite different from one individual to the next.  Whatever path it will be, a "no distress" attitude makes life much easier.

4th week postop exercise summary

It is a great relief that the fluid retention under the arms is getting less. The pain at the ribs and latissimus under the arms is gone, or much less during stretches and after exercise. There are daily improvements in energy levels and in what is possible to do.

• Back squats up to 80% max
• Speed intervals on a stationary bike 
• Rowing on a Concept2 rower with resistance level 3, 28-32 m/s, using mostly legs and abs
• Isolated leg muscles and gym machines
• Isolated arm muscles in a supine position with 8-10 lbs dumbbells
• GHD sit-ups and hip extensions
• Pulls (1st and 2nd only) with empty barbell
• Gentle yoga stretches at a rope wall (less than 1 minute holds)

"To be cheerful is something you can choose."  
Garrison Keillor on Humanity in Healthcare 2012.

New experiences

In the gym I saw a Tai Chi and Qigong group class and decided it is time to try something new. So I went to the beginners class. To my surprise there were other math people in the class who kindly welcomed me J  Although I have no idea how to do the arm movements, the leg movements work well. I have balance. It comes in handy in weightlifting!

I also reflected on how quickly the usual work activities have caught up, needing to plan for work trips, and more. And so the feeling that I am always behind is back. That has to change! It is important to enjoy more time with family and friends!

Looks

Before surgery I looked at photos of brave women who posted their chest photos on the internet to make sure I (and my husband) would be prepared for how I may look afterwards. Not a pretty sight! However a nice husband like mine will tell you that it is much better to have you well without breasts than for you not to be there.

Reality check: after surgery I looked down my chest and thought: "I am going to like this."  I could move my shoulders, had good balance when getting up, and had a "leaner" look from the side. Love it! Many athletes don't have large breasts anyway, so I will fit right in.  Actually, most people don't notice anyway.

The first time after mastectomy meeting my friends they did look at my chest at least once. Curiosity. I would be, too. I was waiting for it.  I did think about confusing them by wearing a  breast form that comes with the postop camisole. But I will save that for my male colleagues when I get back to the office.

It is such a delightful thought that I don't have to wear bras anymore. For special occasions there are breast forms ("props"). Time will tell.

There are suggestions on the internet about clothing for the new you:

• colorful, swirly designs, busy patterns
• darker colors
• scarves
• vests or blazers
• jewelry and ornaments

Women choosing no reconstruction http://breastfree.org  or http://www.flatandfabulous.org

Surgical tape

26 days post surgery

The surgical tape peeled off easily this morning, and everything looks good!

It also gives a visual clue (redness=inflammation) on whether I can add more or different exercises. Better wait...

Back to teaching at the Yoga Center

After 3rd week post surgery

First time teaching Pilates classes with foam rollers again. It is so wonderful to be again with the faithful participants ready and eager to try the modifications and inventions that are more challenging without using arms. Due to daily Pilates exercises my core muscles are stronger than ever! 

It is time to very carefully try out stretches on the rope wall again.