Jane is a 40-year-old woman. She had a mastectomy 2 years ago and still has restrictive movement due to tightness and numbness on the left side. She has beginner to intermediate fitness and walks 1 hour 3 days a week. She has osteoarthritis in wrist and hands.
GENERAL CONSIDERATIONS AND COMMENTS
The assumption here is that Jane has had a radical mastectomy with little or modest lymph node involvement, but she may have had reconstructive surgery. The reality for Jane is she will always have some tightness and numbness on her left side and she will have to work hard her entire life to avoid scar tissue hardening and restricting movement. She is still at risk for Lymphedema and if she sees her left arm and wrist swelling up she should consult her oncologist and most likely be fitted with a compression sleeve. She will be able to achieve a full range of motion and ignore the numbness. We all have one side that is stronger than the other, and for Jane, the left side will always be slightly weaker but not in a way that is noticeable or hampers her activities.
Jane’s osteoarthritis in her hands is commonplace for people to feel the symptoms of wear and tear on the joints, although Jane is rather young for this to be occurring. Chances are she has osteoarthritis in other parts of her body which would be showing up on the bi-annual Xrays that Jane has to monitor bone density as the presumption is that Jane is taking post-cancer medication for at least the next 3 years. If the joints, such as the thumbs, are unrelentingly painful, Jane May have to consider a surgical option. Meantime, if heat and hand exercises can keep Jane out of surgery, the better off she will be, as this kind of surgery only tends to be effective for a decade.
GOALS OF TREATMENT
The goals of treatment are to give Jane a full range of motion on her left side, following the mastectomy. A second goal is to give Jane a range of exercises she can do at home, so the osteoarthritis in her hands is barely noticeable or symptom-free. Some at-home exercises for Jane’s post-mastectomy regimen are also included. Jane’s primary care may well prescribe anti-inflammatory medicine and an ibuprofen cream that Jane can use on her hands.
EXERCISES TARGETING HANDS AND WRISTS
Heat will help Jane. She needs to warm her hands first thing in the morning through hot showers/ heating pad/ paraffin wax bath. Then she can proceed to any number of hand and wrist exercises promoting mobility. Using an Ibuprofin cream before putting one’s hands in a heating pad would be ideal. Note that while we are designing a daily home regimen, Jane’s hands need to be loosened up before she does Reformer exercises which involve her gripping a bar or strap. Recommended exercises can include ( there are others, but this is a very good start). Important here is to note that these exercises are not to be done to exhaustion but to the point where Jane’s hands and wrists are feeling looser.
- If Jane likes music have, her listen to a piano piece and imagine she is playing along with the pianist. No specific number of reps. X 3-5 reps
- Finger Spiders up and down a wall keeping wrist flat. X3-5 rep
- Lay wrist flat, fingers spread and then slightly raise and clench a fist. 3-5 rep
- Supinate the arm, spread fingers, and open and close fist. 3-5 reps
- Very small rubber ball, squeeze it with the whole hand as if you were making a fist. 3-5 reps
- Very small rubber ball, pinch between thumb and forefinger. 3-5 reps
- Touch each finger to thumb in sequence. 3-5 reps
EXERCISES TARGETING LEFT SIDE TIGHTNESS AND NUMBNESS: It is my belief that although Jane has Intermediate fitness, some of the very simplest of exercises will achieve Jane’s mobility objectives. If I had a Wunda chair, or even a barrel, I would use it for this client for side lying and arm-over stretches. Our exercises are designed to stretch scar tissue, increase range of arm movement as well as restore arm strength. Note that Jane’s arm on her left side is likely to tire quite easily, so we do as many exercises as possible in a session and encourage Jane to continue working exercises #1-5 below at home.
- Stand, engage the core and bend over and do a few arm circles with both arms in both directions. This is a very easy exercise and it puts no stress on Jane’s arm while loosening her up. X 5-10 reps
- Stand and raise both arms to horizontal, vertical, backwards, forwards. Note when and where movement is restricted. Use a Pilates Ring for variation when In vertical ballet arm second position. This is a good movement to repeat at the end of the session to see whether the range of motion and the numbness have improved after each session. The abdominal core will be engaged as well as muscles under the arms.X 5-8 reps
- Stand and gently clasp ( being mindful of Jane’s osteoarthritis in her hands) a small tennis size soft rubber ball between hands, engage the abdominal core and underarm muscles while moving straight arms in as many different directions as possible. This will be stretching out scar tissue.X 5 reps in any direction
- Stand and take the wooden bar from the Reformer and clasp it behind the back. Engaging the core and underarm muscles, do spinal rotations from the obliques. This will start to stretch out scar tissue on Jane’s back. Also flexing forward and back will also help with backside scar tissue stretching. X 5 reps
- Side lying cross arms and open out one side to stretch with one arm still bent. This will open up and strengthen pectoral muscles which have a tendency to seize up after a mastectomy. X 5 reps
- Sitting modified or full Mermaid. Both sides of the body. When Jane pushes the bar through on her left arm, she is stretching the scar tissue, and when she is doing the exercise on the reverse side, we are not only stretching scar tissue under her arms but scar tissue that might ( probably) extends to her back. X 5 reps
- Sideways sitting (carriage joint between legs), hands on each end of the metal fixed bar, push down and through, and over and up. (Laurette’s exercise). While this encourages the use of core and spinal lift, the importance to Jane is increasing her range of motion as well as stretching scar tissue.X 5 reps
- Sit with feet, legs straight braced on the headrest. Right hand on the left side of the bar. Lean back with a straight back but torso rotation and look at outstretched straight arm. This will stretch out both underarm scar tissue and back scar tissue especially if we add diagonally crossing over with one hand and pushing through on the return.X 5 reps
- On supine back, core and arm muscles engaged, take swinging metal bar and take it through and up vertically. Arms will stretch upwards and scar tissue eased.X 5 reps
- At some point when Jane is ready, I would graduate her to long box Breast Stroke and Cleopatra. Both of these exercises would extend her arms out in slightly different positions than our first 9/exercises. Since she is an Intermediate student, she should be able to do these quite early on in her exercise program. X 5 reps
EXERCISES TO COMPLETE A WHOLE BODY AND BALANCED WORKOUT
All exercises are done with abdominal core engaged and underarm and upper thoracic and muscles engaged ( Teres minor and major, and serratus anterior ) without jamming shoulder blades together. The point of listing these here is that Joe Pilates believed that the whole body should receive a workout. I would always include some of these in Jane’s regimen.
PRE-MAT: These are always good to prepare a client for exercises on the Reformer so that they can perform the Reformer exercises more fluidly and powerfully.
- Pelvic Clock – Supine. Legs bent to loosen the base of the spine while keeping glutes and legs inactive. X 5 reps
- Knee sways – for upper thigh stretch and modest gluteal stretch. X 5 reps
- Knee Folds. Supine, knees bent, feet flat. Clasp one leg at a time, moving closer to the chest. Alternate legs. Engage the core but do not move the Pelvis. X 5 reps
- Leg Slides (Supine Hip Extension) Supine, Legs Bent feet on the floor, to lengthen leg out from thigh, and feel hamstring stretch. Stretch out one leg at a time. Add variation of ankle rotation and toes wiggling. X3 reps each side
- Stretch Supine, knees bent and feet flat. One leg crossed over the other. Take a knee in the opposite hand, pull stretch over for 3 inhalations/ exhale, outer thighs and gluteal and piriformis stretch. Twice on each side.
- Supine One leg/ knee bent. Other Leg straight up vertical in the air for small circles, 5 in each direction (clockwise and counter-clockwise). Loosens the hips and works adductors.
- Frog. Feet in straps. This works on hips and adductors. X 5 reps
- Leg circles. Feet in straps and legs out straight, doing circles 5 clockwise and then 5 counter-clockwise.
- Works on hip flexors and adductors and glutes. X 5 reps
- Hamstring Stretch feet in straps. As Jane is an intermediate client we can add an extra challenge of a small softish rubber tennis sized ball between her knees so that Jane becomes even more aware of her Adductors. X 5 reps
- Legs V out to side and back up to straight. Feet in straps. Works on Hip flexors and adductors. The important thing is slow control of the legs using a strong core.X 5 reps
- Footwork Variations, targeting hamstrings, IT band, or ankle and feet mobility. These include V position, feet together toes wrap, feet together on heels, feet in the second position on heels, or wide and turnout. For this Intermediate client, I would include feet together and then exercises back and forth using one leg at a time. This requires more strength. X 5 reps
- Running in place for calf stretching and strengthening. X 5 reps
- Heel Lowers for calf stretching and strengthening. X 5 reps
- Eve’s lunge, I would omit this exercise until all signs of osteoarthritis subsided. There is a tendency to grip the bar here. If Jane can do the lunge hands-free, then this would be an excellent modification for her.
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