Adjustments to weightlifting training

Background
The pectoralis major ("pec") muscle is said to decrease in function and size after surgery. This may lead to reduced shoulder mobility. The fascia of this muscle is removed during a mastectomy. The reason for the removal is to reduce chest wall recurrence. To close the wound after breast tissue removal the skin is "quilted" to the muscle to reduce the risk of seroma formation.  Do these surgical procedures/techniques impact exercise?

Training observations
At 14 weeks post surgery I am attempting maximum lifts. I feel strong after having practiced more squats, more flexibility exercises, and more core exercises, since surgery. Volume training at reduced weights has been going well. Thus lifting the heavy barbell off the floor works, so do cleans. But the overhead portion of the movements do not "feel right," or do not feel the way it was before. And with heavier weights it becomes more noticeable. Here are a few observations:

1. The removal of the breast tissue creates a different balance, equivalent to 1-2kg weight. Thus muscles need to adjust, the brain needs to learn different signals. The proprioceptive sense can be off.
2. In overhead lifts such as jerk or snatch, the latissimus dorsi ("lats"), the muscle below the shoulder blade, spasms. It may be the case that I lean slightly back (observation 1).
3. In snatch or jerk  the elbow turnover is slower than before and elbows are often bent. Bent elbows instead of the "lockout" can be caused by not engaging the lats properly (observation 2).
4. During a split jerk at max weight, the right shoulder may collapse (possibly also of proprioceptive origin).

Lymph nodes were removed from the right side. There is still swelling under the right arm that can increase a day after exercises that are weight bearing on arms, such as push ups.

Plan

• built up deltoid and pec muscles hoping that this will improve the balance, e.g. with push-ups, planks on foam roller, behind the neck presses.
• strengthen back muscles and increase shoulder blade stability, e.g. GHD hip extensions with  or without weights, Sots presses, Good mornings.
• push presses and power snatches at a weight that challenges the feeling of it not being "right"

Ideas and thoughts from the experts (physical therapists, nurses, exercise science students, and others)

• Daily scar massage helps to keep the scar tissue supple and flexible. 
• Fascia is a protective layer around the muscle. Due to the removal the muscle can become more easily irritated. Nerves may have been damaged during the removal process, and thus the brain does not receive expected signals and needs to "retrain."
• Kineseo taping the pectoralis and serratus muscles can help reduce swelling as it gives a signal to the lymph flow.
• A well fitting compression shirt may support lymph flow and reduce swelling.
• A common problem after mastectomy is rotator cuff tendonitis due to overhead movements when the back is not straight. Namely, if tight pec muscles lead to internal shoulder rotation.

References
Most literature focuses on shoulder mobility after breast cancer surgery. The following two references do indicate the relationship of overhead stretch with back and chest muscles.

Stegink-Jansen et al.  Computer Simulation of Pectoralis Major Muscle Strain to Guide Exercise Protocols for Patients After Breast Cancer Surgery. Journal of Orthopaedic & Sports Physical Therapy 2011: 41(6); 417-426. Link to article

Findings: The overhead stretch produced one of the highest strain for clavicular, sternal, and abdominal portions of the muscle. (=meaning that this stretch uses the muscle more)

Muraki et al. Lengthening of the Pectoralis Minor Muscle During Passive Shoulder Motions and Stretching Techniques: A Cadaveric Biomechanical Study. Physical Therapy 2009: 89(4); 333-341. Link to article

Findings: The greatest length of the muscle is achieved with 30 degrees scapular retraction.

Tips for better sleep

At my recent appointment ("survivorship clinic") suggestions were made for better sleep. This can mean going to sleep, or staying asleep, or getting back to sleep, or sleeping enough hours. I was surprised that the only recommendations offered were listening to soothing music or drinking warm milk. In general, those don't work for persistent sleeplessness.

Up until a few years ago I enjoyed blissfully long hours of sleep, about 8 hours. It was very easy to fall asleep and stay asleep. And when there was a lot going on, all my yoga tricks helped.  But then sleeping hours became more elusive and none of these methods worked. It became especially difficult to go back to sleep after waking up at night. I thought I had to accept that we sleep less as we get older, we should stop stressing, maybe read a little in the middle of the night for an hour or two, or however long it takes. But I changed my mind on this subject. The longer we follow this pattern, the harder it is to get back to the blissful state of sleeping longer hours.  Here are some things I find useful, and I am now back to sleeping 7-7.5 hours at least 2 or 3 days each week instead of just 6 hours every day.

• Acupuncture may help with underlying issues to bring us back to a more balanced state.
• The system of Reiki has a number of practices: meditation (Joshin Kokyo Ho, the precepts) or hands-on healing (do it yourself).
• Tai Chi is a moving meditation, and finishes with a closing movement that is "grounding."
• Getting off screen time about an hour before the regular bedtime (and keeping a regular bedtime). No more food intake at least 3 hours before bedtime,  and nothing "heavy." This time can be used for meditation or some of the other practices mentioned here.
• Restorative yoga puts the body in a fully supported yoga pose such as supported child pose, supported twist, and legs up the wall.
• Washing the feet with COLD water, and rubbing them dry afterwards with a rough cloth, massaging with almond oil.

Caveat: if sleeplessness is due to worry or too many thoughts, then these tips may not be sufficient.

Tips I tried and tested and they didn't work for me: light exercise, intense exercise, weightlifting, soothing music, different kinds of pillows (water pillow, ergonomic pillow, between legs pillow), different types of breathing techniques, tea, warm baths, short meditations (for example, less than 20 minutes), essential oils (lavender, peppermint). All of these are good things, but they are not sufficient to help me staying asleep. I can go to sleep just fine, but wake up at night.
Ear plugs do help somewhat, but some ear plugs are contaminated in the unopened packet, and I am prone to ear infections.

Good luck!

Reiki meditation

One of the most important things on the breast cancer path is to stay grounded. This means we can cope with daily life, good or bad news, and do what is needed in a healthy, balanced state of mind.

The Japanese system of Reiki brings a wealth of meditation techniques that help with achieving this. One of these meditations has been enormously helpful to me: to process the breast cancer diagnosis, to prepare for or go through procedures, to recover after surgery. It is called Joshin Kokyo Ho and is practiced as follows.

Bring your awareness to the point below your navel (called the hara). Set your intent that you want to heal yourself and that you receive whatever you need. Breathe comfortably in and out through your nose.

1. Place the palms of your hands together to centre the mind and set the intent. Close your eyes.
2. Place your hands in your lap, palms facing upwards.
3. With each in breath feel the energy coming in through the nose, moving down to the hara and filling the body with energy.
4. On the out breath, expand the energy out of the body, through your skin, and continue to expand the energy out into your surroundings.
5. Repeat steps 3 and 4 until finished (5-30 minutes, whatever works for you). 
6. Place the palms of your hands together to give thanks.

The description is for sitting to help focus (steps 1 and 2), but lying down works, too! You may fall asleep then.  J

My teacher, Frans Stiene, shares his wealth of knowledge of this system, e.g. grounding

Weightlifting: PAL study

There is not much information for weightlifting athletes who want to return to their pre-diagnosis activities. The research study described below is about small weights, starting with 1-2 pounds (= 0.1 to 1 kg) dumbbells and lowest possible settings on the resistance machines, and increases were in small increments. But there was that no set upper limit for the weight.  Before this women were told not to ever lift more than 5-15 pounds (= 2 to 7 kg).

My theory: strength exercises are controlled movements, where one pays attention to correct form and gains strength. This transfers to normal daily activities, which can be much more complex. It is to be expected that the trained group can do such activities better than the no exercise group, thus leading to favorable outcomes.

The Physical Activity and Lymphedema (PAL) trial assessed the safety of strength training in breast cancer patients without an upper limit on the weight.

Participating women were 1-15 years post breast cancer diagnosis with stable or no lymphedema. There were 148 women in the exercise group (71 with lymphedema) and 147 in the control group that did not exercise (70 with lymphedema). Recruitment was from 2005-2007. The study protocol called for biweekly training, with supervision during the first 13 weeks and unsupervised training the following 9 months. 

OUTCOME: The amount of weight lifted did not make lymphedema worse, the weightlifting group had fewer and less severe flare-ups. Among the women without lymphedema at the start of the study 11% of the WL group vs 17% of non-exercise group developed lymphedema within the 12 months of the study (defined by increase in arm swelling).

PROTOCOL:  The weightlifting sessions lasted 60-90 minutes with 10 min cardiovascular warm-up, followed by stretching, then 5-15 min core exercises (for injury prevention),  strength exercises, and then finished with stretching (for injury prevention). For the strength portion both resistance machines and free weights were used (for muscles of the chest, back, shoulders, quadriceps, hamstrings, and gluteals, as well as biceps and triceps).
If there were no changes in lymphedema, the weight was increased after one week (0.5-1 pound increase). If there was a worsening, exercises were skipped or weight was reduced until symptoms cleared up. If 2 or more sessions were missed, the weights and exercises were reduced due to the possibility of de-conditioning.


References:
Schmitz.  Weightlifting and lymphedema: Clearing up misconceptions (about interpretations of the PAL trial with  7 guidelines)

Schmitz et al. Physical Activity and Lymphedema (The PAL Trial): Assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials. 2009 May ; 30(3): 233–245.

Schmitz et al Weightlifitng for women at risk for breast cancer related lymphedema. JAMA. 2010;304(24):2699-2705

The National Lymphedema Network: Position paper on exercise