Y4c Poses – the Good, Bad and the Ugly!

yoga4cancer

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MANUAL ird Edition TABLE OF CONTENTS

Welcome About y4c and Disclaimers Module #1 – The Foundation #1.1 – Introduction and the ABCs Module #2 – Physical and Emotional State of a Survivor #2.1 – Cancer Basics #2.2 – The Human Body and Immunity #2.3 – Cancer staging and Diagnostic Tools #2.4 – Western Cancer Treatments #2.5 – Common Side Effects Module #3 – The Science of Yoga #3.1 – Scientific Foundation of the y4c Methodology #3.2 – Yoga Benefits #3.3 – Warm-up Vinyasa Module #4 – The y4c Methodology #4.1 – Introduction / The y4c Method #4.2 – y4c Sequences and Poses #4.3 – y4c Tools #4.4 – y4c Class Plan Module #5 – Preparing to Teach #5.1 – Advice and Cautions Appendix

I am thrilled to welcome you to the yoga4cancer community and want to thank the thousands of yoga teachers and other healthcare practitioners that have participated in my trainings since 2005. Together we help cancer survivors and patients live longer, healthier and happier lives through the practice of yoga.

My philosophy is that ‘true compassion comes through knowledge and understanding’. Only when we understand the unique challenges – both physical and emotional – of our students can we best provide guidance and leadership to achieve a healing yoga practice.

The training you are about to undergo will provide you with information, tools, insights about cancer and its treatment after a cancer diagnosis. This manual has been provided to reinforce and support your training, homework assignments and ultimately to effectively support your cancer community. It’s a compilation of expert resources, my essays, other articles, practical guides and unique yoga poses that I have used and improved since my own cancer diagnosis and treatments in 2002. Some of the enclosed content is purely mine, whilst others I have relied on expert third parties to help provide the scientific data and insight. All sources are well noted for your further use.

My advice is that this training should mark the beginning of your thirst for knowledge and understanding of the cancer community. Research on both cancer and yoga are still in their infancy and will continue to evolve. Embrace the curiosity that led you to this training, as it will be your ultimate asset. Learn the facts, dispel myths and gain knowledge to be truly compassionate yoga teachers.

We have important work to do together. Let’s get started!

Best, Tari Prinster Founder, yoga4cancer LLC and the Retreat Project (501c3)

© yoga4cancer 2018 2 ABOUT YOGA4CANCER yoga yoga4cancer (y4c) is a specialized yoga methodology that is TM tailored to address the specific physical and emotional needs left by cancer and its treatments. This unique approach is not y4c just gentle or restorative yoga, but focuses on how to stimulate cancer the immune system through movement, improve flexibility and strength along with how to reduce anxiety and boost overall well-being. y4c was developed by Tari Prinster – a cancer survivor and master yoga teacher. Tari has been offering teacher training, classes, and retreats across the US and beyond since 2003. She was featured in the film YogaWoman, recipient of the first Annual Seva Leadership Award by Yoga Journal, and regularly presents at Yoga Journal and other industry conferences. y4c is currently helping thousands of cancer patients and survivors in the US and other International markets through:

§ Classes & Privates § Teacher Trainings & Workshops § Publications and Resources § Retreats

Today, we help hundreds of survivors. With your help, we will help millions.

Yoga 4 Cancer is a registered LLC in New York State.

y4c Vision: yoga4cancer is prescribed and available for all those touched by cancer.

© yoga4cancer 2018 3 Medical Disclaimer The y4c Teacher Training Manual contains text, graphics, images, and other content (collectively “Content”), which are for informational purposes only. Content contained in this document is not intended to be a substitute for professional medical advice, diagnosis, or treatment. A qualified healthcare professional should be consulted for medical advice and answers to personal health questions. This y4c Teacher Training Manual does not constitute an attempt to practice medicine.

Ownership and Proprietary Rights The brands, names, logos, trade names, trademarks, service marks and other distinctive identifications (collectively “Marks”) in the y4c Teacher Training Manual, including, without limitation, “Yoga 4 Cancer” and “y4c” are the trademarks and intellectual property of and proprietary to Yoga 4 Cancer, LLC. You have no right to use any of these Marks or any marks confusingly similar thereto for any purpose without the express prior written consent of Yoga 4 Cancer, LLC, such consent shall be in the sole and absolute discretion of Yoga 4 Cancer, LLC. No part of this y4c Teacher Training Manual may be reproduced in any form except by prior written permission from Yoga 4 Cancer, LLC.

Fair Use Notice This Manual contains copyrighted material, the use of which has not always been specifically authorized by the copyrighted owner. This material is made available for educational purposes. It is believed that this constitutes a ‘fair use’ of any such copyrighted material as provided for in Title 17 U.S.C. section 107 of the US Copyright Law. This material is distributed without charge or profit.

Introduction and the ABCs

The y4c Methodology was developed over the past two decades through personal experience, medical and scientific fact-finding, applied professional experience and ultimately results. When Tari was diagnosed with breast cancer, she found yoga extremely helpful during her treatment and recovery process. Her personal experience with the benefits of yoga for cancer ignited a passion to learn more and uncover the science behind both yoga and cancer. Ultimately, Tari became a Vinyasa yoga instructor and developed a teaching approach tailored specifically to cancer survivors—one that can be adapted to suit different types of cancer, stages of treatment and recovery. The goal of this training is to share the methodology with you.

The following ideas are key to the y4c (yoga4cancer) Methodology and approach:

Awareness True compassion grows out of understanding and knowledge. Understanding begins with awareness of our own preconceptions about cancer and yoga, and a willingness to continually investigate and challenge those notions, seeking out facts.

For example, people may have the following misconceptions about cancer and yoga:

§ Cancer is one disease. FALSE. There are hundreds of categories of cancer, and within each category there may be several types, all requiring different treatments and involving different side effects.

§ Cancer is a death sentence. FALSE. Many people do not die from cancer, and the numbers who survive are continually growing. This means more people will need yoga and other solutions to help them recover and maintain a strong Immune System into the future.

§ Cancer is the hard part. FALSE. The treatments such as surgeries, chemotherapy, and

§ Yoga for cancer is all about relaxation. FALSE. Active exercises have benefits for survivors, including supporting the Immune System, strengthening bones, and providing a sense of empowerment. The y4c method includes both active and restorative poses.

§ Yoga won’t hurt you. FALSE. There are many styles of yoga and movements that can be harmful to cancer survivors. A responsible teacher must know how to modify these to provide a safe class.

Awareness also applies to the teacher’s own fears about cancer and death. Whether you are a survivor or not, this training will encourage you to face your fears, since facing them is an important step toward deepening your understanding of what cancer survivors may experience.

“When I heard three little words—invasive ductal carcinoma—that means you have cancer; it took my breath away. An uninvited guest, cancer came into my life and refocused me. The diagnosis was only the beginning of my breathless moments. The parade of treatment options, decisions, side effects, medication, expenses, insurance forms, phone calls, and empty hours of waiting for test results—all left me floating on a sea of uncertainty and fear. No matter what kind or stage, cancer or other life-threatening traumas steal the breath, cloud the mind, and weaken the body.” — Tari Prinster

We must also be aware, and acknowledge, that the science of yoga and cancer is still in its infancy. More research is coming out, but further studies are needed and much remains unknown. So awareness also means remaining aware of the limits of our understanding—both in terms of the science, and in terms of the inner experience of a particular survivor—and the possibility of misunderstanding.

“Do not imagine that you already understand and impose your imperfect understanding on those that come to you for help.” — B.K.S. Iyengar

“Do not imagine that you already understand Benefits

Awareness leads to a better understanding of the benefits of yoga for cancer survivors. In the y4c approach, we strive to be informed about the physical benefits of certain types of poses and movements, as well as the emotional benefits yoga can offer in helping to reduce the stress, fear and anxiety that may accompany a cancer diagnosis and treatments.

During this training, we will explore and discuss specific benefits, so you will be prepared to teach classes that can help students regain strength and mobility after surgery, support a healthy Immune System, protect and strengthen bones that may be weakened from treatments, and reduce stress.

Additionally, the y4c approach places an emphasis on educating students about the benefits so they will have a sense of how they can participate in their own healing process. This is an important means of empowering survivors and giving them hope.

Conveying the benefits to students in a way that is clear and accessible is a skill. It must be done with sensitivity. Keep in mind that cancer patients are often overwhelmed with technical information from doctors and specialists—procedures, statistics, facts, medical jargon, and anatomical explanations are all part of the cancer journey.

The C Word

We use the word ‘cancer’ in y4c classes. Rather than tiptoeing around the issue, the aim is to

© yoga4cancer 2018 7 provide a safe space where cancer can be openly acknowledged. Thus, one goal of the training is to increase your comfort level with using the word cancer, so you can use it confidently. Of course, there’s no need to use it repeatedly or focus on cancer throughout class, but don’t avoid it—your students can’t.

Other C words are also important to the y4c approach:

Curiosity and Care. Be curious about your students, get information about their specific situation and needs (surgeries, treatments, injuries, etc.), and modify accordingly so the class will be safe for them. Know what to avoid and why.

Community. A big draw of the classes is the sense of togetherness or family they can offer, beyond the walls of a hospital or support group. How can you help foster a feeling of community in your classes?

Compassion. It is likely compassion brought you to this training. But remember, it should be backed by an effort to understand. What a cancer survivor wants may be different from what you think. Most cancer survivors don’t want to be coddled or treated as weak, but are eager to feel, look and act normal again.

Control. Loss of control is common among many cancer survivors. The yoga practice can help students regain a feeling of control.

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” — Maya Angelou

#2.1 - Cancer Basics As previously discussed, true compassion comes from knowledge. Therefore, without specific understanding of the physical and emotional challenges of a cancer patient or survivor, a yoga teacher is challenged to develop the most effective, comforting yoga practice to aid a cancer patient or survivor. Caring for another being is so important, but understanding must be rooted in scientific and medical facts. Without this grounding, well-intentioned compassion can inadvertently become harmful or ineffective. So our starting point is familiarizing ourselves with expert information on the basics of cancer, its treatments and side effects, so that true compassion is achievable.

We do not pretend to be doctors or medical experts. We have relied on experts and reputable national institutions such as the National Cancer Institute and American Cancer Society for the information we are sharing here. We have compiled the relevant information from these sources. However, please know that new research and better ideas emerge every day. It is hard to keep up! So, the concepts on these pages are not all the information that you should or could know to develop the required skills to work with survivors. This is your starting point. Please research and feed your curiosity through facts and information. Also, our understanding of cancer—just as it is the case with yoga—is still in its infancy. Facts, research and guidance continue to evolve – so must our understanding and knowledge.

Often breast cancer becomes the focus in y4c trainings and in yoga classes, in general, because of its high incidence (about 29% of all new cases are breast cancer). Plus, it’s one of the best researched as well as one of the most physically debilitating types of cancer. But it’s not the only cancer that can be addressed by yoga. Most of the science, principles, poses and practices reviewed in the training are relevant and necessary for all types of cancer survivors. This methodology and my teachings are valid to all cancers – regardless of type, stage, gender, location, etc.

At the same time, hundreds of other cancers exist and each person’s cancer experience varies

© yoga4cancer 2018 9 enormously from the treatments, physical and emotional challenges. And often the cancer distracts from other health issues that need to be understood or mitigated. Cancer doesn’t stop diabetes or heart issues! So, part of this process is to provide you the basics and arm you with the confidence to engage your students about their specific cancer and treatment side effects. They can provide you with the blueprint you need to build the best practice for them. To help you, we have developed an ‘Intake’ process later in the training to help you gain the necessary information from any new student.

Being diagnosed with cancer sets a survivor on the fast track for a doctorate from ‘Cancer University’, and so too yoga for ‘yoga for cancer’ teachers. So many questions arise; what is a cancer, what causes cancer, which poses should a cancer patient/survivor do or not do, and many more. The answers to these questions give us information about the critical question of prevention and avoiding recurrence or new cancers.

So, where do we start? Let’s start with thinking about cancer like a scientist would. We start by thinking about it as a puzzle and asking questions. We ask ourselves how a particular cancer behaves. Okay, it is life threatening, but how does it act? How does it evolve in the body and how does it respond to our treatments to eliminate it or manage its growth?

We can only answer these questions by examining the behavior of a cancer cell versus a non- cancer cell. Understanding normal, healthy cell behavior is the key. What is normal cell behavior?

Call it mystery or miracle— life starts when one egg cell (ovum) and one sperm cell bind together and start doing their job. They begin to divide and grow, each cell born of another, the growth controlled by genetic code. Two cells grow to four, then 16, 32, 64 and so on until the body has an estimated 75-100 trillion cells! Dancing all together, each cell is programmed by its genes on what to do, how to divide, and how to become an eye or a toe—eventually, this mass of dividing, differentiating cells becomes a complete human body composed of interlocking biological systems.

Every human cell behaves like this: § It is born from a similar cell.

It is these last stages where a healthy cell versus a cancer cell acts differently. A cancer cell refuses to die and the body cannot identify and/or kill this unruly cell. So like the ‘healthy cell’, it begins to multiply unchecked and exponentially, and can either grow large (e.g. a tumor) or spread throughout the body (e.g. metastatic cancer). Regardless, this unchecked growth of cells will impact the normal cell behavior, causing what we understand as cancer.

Since Richard Nixon declared the War on Cancer in 1971, billions of dollars have been poured into research looking for a cure, which remains elusive 40+ years later. Only until recent research has so dramatically pointed to the inherent root of cancer being DNA have we taken into account that everyone has pre-cancer cells. I agree with Thomas Bosch, an evolutionary biologist at Kiel University who published, The Primordial Roots of Cancer | Acumen | OZY, who says, “Knowing your enemy from its origins is the best way to fight it and win many battles.” That is our goal in this Module, to know enough about cancer so we can make proper judgments about how to use a yoga practice to win that ‘War on Cancer’. http://www.ozy.com/acumen/what-if-cancer-simply-can-t-be-cured/33199

Miriam-Webster Dictionary definition: cancer [kan-ser] –noun, genitive Cancri [kang-kree] 1. any evil condition or thing that spreads destructively; blight. 2. astronomy: the Crab, a zodiacal constellation between Gemini and Leo. 3. astrology: the fourth sign of the zodiac: the cardinal water sign. 4. a malignant tumor of potentially unlimited growth that expands locally by invasion and systemically by metastasis.

What is cancer?

Cancer is the general name for a group of more than 100 diseases. Although there are many kinds of cancer, all cancers start because abnormal cells grow out of control. Untreated cancers can cause serious illness and death.

Normal cells in the body

The body is made up of trillions of living cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person’s life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.

How cancer starts

Cancer starts when cells in a part of the body start to grow out of control. Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. Cancer cells can also invade (grow into) other tissues, something that normal cells cannot do. Growing out of control and invading other tissues are what makes a cell a cancer cell.

Cells become cancer cells because of DNA damage. DNA, or Deoxyribonucleic Acid, is in every cell and it directs all the cell’s actions. In a normal cell, when DNA gets damaged, the cell either repairs the damage or the cell dies. In cancer cells, the damaged DNA is not repaired, and the cell doesn’t die like it should. Instead, the cell goes on making new cells that the body doesn’t need. These new cells all have the same abnormal DNA as the first cell does.

People can inherit abnormal DNA, but most DNA damage is caused by mistakes that happen while the normal cell is reproducing or by something in the environment. Sometimes the cause of the DNA damage may be something obvious like cigarette smoking or sun exposure. But it’s

In most cases, the cancer cells form a tumor. Some cancers, like leukemia, rarely form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow.

How cancer spreads

Cancer cells often travel to other parts of the body where they begin to grow and form new tumors. This happens when the cancer cells get into the body’s bloodstream or lymph vessels. Over time, the tumors replace normal tissue. The process of cancer spreading is called metastasis.

How cancers differ

No matter where a cancer may spread, it’s always named for the place where it started. For example, breast cancer that has spread to the liver is called metastatic breast cancer, not liver cancer. Likewise, prostate cancer that has spread to the bone is called metastatic prostate cancer, not bone cancer.

© yoga4cancer 2018 13 Different types of cancer can behave very differently. For instance, lung cancer and skin cancer are very different diseases. They grow at different rates and respond to different treatments. This is why people with cancer need treatment that is aimed at their kind of cancer.

Tumors that are not cancer

Not all tumors are cancer. Tumors that aren’t cancer are called benign. Benign tumors can cause problems – they can grow very large and press on healthy organs and tissues. But they cannot grow into or invade other tissues. Because they can’t invade, they also can’t spread to other parts of the body. These tumors are almost never life threatening.

How common is cancer?

According to the American Cancer Society, half of all men and one-third of all women in the US will develop cancer during their lifetimes.

Today, millions of people are living with cancer or have had cancer. The risk of developing many types of cancer can be reduced by changes in a person’s lifestyle, for example, by staying away from tobacco, limiting time in the sun, being physically active, and healthy eating.

There are also screening tests that can be done for some types of cancers so they can be found as early as possible – while they are small and before they have spread. In general, the earlier a cancer is found and treated, the better the chances are for living for many years.

I hope you find this basic information from the American Cancer Society useful. Now, let’s go to another source for the causes of cancer, which vary from genetics to environmental to behavioral. Often causation is multi-variant, and no one thing can be found to cause cancer. In recent years, causation has become better understood, but there is still a long way to go.

Cancer is not one disease and seldom is there one cause. Hundreds of different types exist, and both symptoms and severity vary with each individual. As a yoga teacher, you will see many types through your practice and teaching.

What causes cancer?

Source: What Causes Cancer? From News Medical Net written by Dr. Ananya Mandal, MD (http://www.news-medical.net/health/What-Causes-Cancer.aspx)

Cancers are a broad group of diseases and accordingly have a wide range of causes. Each cancer is different according to its biology and pathophysiology. All animals and even plants are susceptible to cancers.

The body is made up of trillions of living cells. These cells grow, divide, and die in an orderly fashion. This process is tightly regulated and is controlled by the DNA machinery within the cell. In a baby or a child, normal cells divide rapidly to allow for growth. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.

© yoga4cancer 2018 15 When cells of the body at a particular site start to grow out of control, they may become cancerous. Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. In addition, these cells can also invade other tissues. This is a property that normal cells do not possess.

Cancer cells originate from normal cells when their DNA or blueprints within the cell nucleus are damaged. DNA is in every cell and it directs the entire cell’s actions, growth, death, protein synthesis, etc. When DNA is damaged in a normal cell the cell either repairs the damage or the cell dies.

Normally, the body safeguards against cancer via numerous methods, such as: apoptosis which is the normal controlled process by which cells die on their own accord, helper molecules (some DNA polymerases which protect against DNA damage), possibly cellular senescence or aging, etc.

In cancer cells, the damaged DNA is not repaired, and the cell does not die. Instead it gives rise to more such abnormal cells with abnormal DNA. These new cells all have the same defective DNA of the original cancer cell.

DNA damage may be inherited from parents or may be a spontaneous mutation that occurs during the lifetime of a person. DNA damage may also be triggered by exposure to certain environmental toxins such as those present in cigarette smoke. There are, however, multiple factors that may cause cancer and it is difficult to pinpoint an exact cause.

Mutations may be: § Those in the error-correcting machinery of a cell. This may cause accumulation of errors rapidly in the cell and its progeny. § Those in signaling (endocrine) machinery of the cell. This leads to the transmission of the error signals to nearby healthy cells as well. § Those that allow the cells to migrate and disrupt more healthy cells away from the primary site of origin. § Those that make the cell immortal so that the abnormal cell refuses to die.

According to World Health Organization (WHO), common risk factors for cancer include: • Tobacco use • Alcohol use • Obesity • Dietary factors, including insufficient fruit and vegetable intake • Physical inactivity • Chronic infections from helicobacter pylori, hepatitis B virus (HBV), hepatitis C virus (HCV) and some types of human papilloma virus (HPV) • Environmental and occupational risks including ionizing and non-ionizing radiation

Cancer-causing agents

Agents that may cause cancer include:

Chemical carcinogens Several chemicals and environmental toxins are responsible for changes in normal cellular DNA. Substances that cause DNA mutations are known as mutagens, and mutagens that cause cancers are known as carcinogens.

Particular substances have been linked to specific types of cancer. Tobacco smoking is associated with many forms of cancer, and causes 90% of lung cancer. Similarly, prolonged exposure to asbestos fibers is associated with mesothelioma; cancer of the mesothelium which is the protective lining of internal organs such as lungs, heart abdomen.

Tobacco is also related to other cancers such as lung, larynx, head, neck, stomach, bladder, kidney, esophagus and pancreas as it contains other known carcinogens, including nitrosamines and polycyclic aromatic hydrocarbons.

Ionizing radiation Radiation due to radon gas and prolonged exposure to ultraviolet radiation from the sun can lead to melanoma and other skin malignancies. Radiation therapy given for one type of cancer

Viral and bacterial infections Some cancers can be caused by infections with pathogens. Notable among these include liver cancers due to Hepatitis B and C infections; cervical cancer due to infections with Human Papilloma virus (HPV); Epstein Barr virus causing Burkitt’s lymphoma and gastric or stomach cancer due to Helicobacter pylori infection.

Genetic or inherited cancers Common examples are inherited breast cancer and ovarian cancer genes including BRCA1 and 2. Li-Fraumeni syndrome includes defects in the p53 gene that leads to bone cancers, breast cancers, soft tissue sarcomas, brain cancers, etc. Those with Down’s syndrome are known to develop malignancies such as leukemia and testicular cancer.

Hormonal changes Notable among these are changes in the female hormone levels estrogen. Excess estrogen promotes uterine cancer.

Immune system dysfunction Impaired immunity including HIV infection leads to several cancers including Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and HPV-associated malignancies such as anal cancer and cervical cancer.

As just explained, the cause of cancer is a mix of both controlled and uncontrolled factors. And pinning down the particular cause is very challenging. But some of the above facts give us a hint at a powerful tool to prevent and manage cancer; the human body itself. We will explore that in the following section.

Potential cancer-causing agents surround us or are within us throughout our lives. Yet not everyone with equal or more exposure to these agents gets cancer. How can we explain how someone who never smoked a cigarette gets lung cancer versus a pack-a-day smoker doesn’t? It cannot be entirely explained by secondary smoke exposure.

So we must explore the question of ‘Who gets cancer?’ The answer is close at hand. Perhaps you know the answer already. We start the important study of the Immune System with this question because it is when a person’s Immune System fails that an active cancer diagnosis happens.

The Immune System has a huge job. It works to protect our body from harm, whether that harm is an oncoming truck, a virus or cancer. Knowing how it works ultimately gives us the tools we need to understand how yoga supports the Immune System in doing its job.

The Immune System’s job is to protect the body’s integrated communities of cells while they do their work—keeping us alive. Whenever you get sick, the Immune System responds by sending an army of natural killer cells and antibodies, like a police escort out of town. In this case, out of the body.

A virus or bacterium that has caused your flu or cold is easy for the Immune System to identify; but cancer is more difficult to detect. Cancer cells do not always look like strangers (which is why I think of them as “sneaky”). Because cancer cells mutate from normal cells, they can escape detection by the body’s defenders. When this happens, we get cancer.

We have compiled the following resources to explain the Immune System in great detail. But first, below is my simple interpretation of the role or job of the immune system:

What is the job of the Immune System? Answer: To protect the body from dangers by: 1. Barring Entry

Now let’s turn to the National Institute of Allergy and Infectious Diseases for the latest information. As you read, try to imagine how the whole system works rather than one organ or type of cell. The key sentence in the passage below is: ‘The secret to its success is an elaborate and dynamic communications network.’ As you will learn, so much about cancer as well as new treatments focus on cellular communication, also called signaling.

What is the Immune System?

Source: National Institute of Allergy and Infectious Diseases

“The Immune System is a network of cells, tissues, and organs that work together to defend the body against attacks by ‘foreign’ invaders. These are primarily microbes—tiny organisms such as bacteria, parasites, and fungi that can cause infections. Viruses also cause infections, but are too primitive to be classified as living organisms. The human body provides an ideal environment for many microbes. It is the Immune System’s job to keep them out or, failing that, to seek out and destroy them.

When the Immune System hits the wrong target, however, it can unleash a torrent of disorders, including allergic diseases, arthritis, and a form of diabetes. If the Immune System is crippled, other kinds of diseases result.

The Immune System is amazingly complex. It can recognize and remember millions of different enemies, and it can produce secretions (release of fluids) and cells to match up with and wipe out nearly all of them.

The secret to its success is an elaborate and dynamic communications network. Millions and millions of cells, organized into sets and subsets, gather like clouds of bees swarming around a hive and pass information back and forth in response to an infection. Once immune cells receive the alarm, they become activated and begin to produce powerful chemicals. These

Although scientists have learned much about the Immune System, they continue to study how the body launches attacks that destroy invading microbes, infected cells, and tumors while ignoring healthy tissues. New technologies for identifying individual immune cells are now allowing scientists to determine quickly which targets are triggering an immune response. Improvements in microscopy are permitting the first-ever observations of living B cells, T cells, and other cells as they interact within lymph nodes and other body tissues.

In addition, scientists are rapidly unraveling the genetic blueprints that direct the human immune response, as well as those that dictate the biology of bacteria, viruses, and parasites. The combination of new technology and expanded genetic information will no doubt reveal even more about how the body protects itself from disease.”

What is the structure of the Immune System?

“The organs of the Immune System are positioned throughout the body. They are called lymphoid organs because they are home to lymphocytes, small white blood cells that are the key players in the Immune System.

Bone marrow, the soft tissue in the hollow center of bones, is the ultimate source of all blood cells, including lymphocytes. The thymus is a lymphoid organ that lies behind the breastbone. Lymphocytes known as T lymphocytes or T cells (‘T’ stands for ‘thymuses’) mature in the thymus and then migrate to other tissues. B lymphocytes, also known as B cells, become activated and mature into plasma cells, which make and release antibodies.

Lymph nodes, which are located in many parts of the body, are lymphoid tissues that contain numerous specialized structures.

• T cells from the thymus concentrate in the paracortex. • B cells develop in and around the germinal centers. • Plasma cells occur in the medulla.

© yoga4cancer 2018 21 Lymphocytes can travel throughout the body using the blood vessels. The cells can also travel through a system of lymphatic vessels that closely parallels the body’s veins and arteries.

Cells and fluids are exchanged between blood and lymphatic vessels, enabling the lymphatic system to monitor the body for invading microbes. The lymphatic vessels carry lymph, a clear fluid that bathes the body’s tissues.

Small, bean-shaped lymph nodes are laced along the lymphatic vessels, with clusters in the neck, armpits, abdomen, and groin. Each lymph node contains specialized compartments where immune cells congregate, and where they can encounter antigens.

Immune cells, microbes, and foreign antigens enter the lymph nodes via incoming lymphatic vessels or the lymph nodes’ tiny blood vessels. All lymphocytes exit lymph nodes through outgoing lymphatic vessels. Once in the bloodstream, lymphocytes are transported to tissues throughout the body. They patrol everywhere for foreign antigens, then gradually drift back into the lymphatic system to begin the cycle all over again.

Immune cells and foreign particles enter the lymph nodes via incoming lymphatic vessels or the lymph nodes’ tiny blood vessels.

The spleen is a flattened organ at the upper left of the abdomen. Like the lymph nodes, the spleen contains specialized compartments where immune cells gather and work. The spleen serves as a meeting ground where immune defenses confront antigens.

Other clumps of lymphoid tissue are found in many parts of the body, especially in the linings of the digestive tract, airways, and lungs—territories that serve as gateways to the body. These tissues include the tonsils, adenoids, and appendix.”

The preceding information from NIH is a basic functional definition of the Immune System. We now have a good idea of what its job is. But exactly where is it in the body? Our ultimate aim is to understand how yoga can help the Immune System do its job. When I ask my students for the location of the Immune system, I get a broad range of answers, but often people say it is the Lymphatic System.

And that is partially correct. The Lymphatic System is part of the Immune System. Almost all parts and systems of the body perform certain roles, so the Immune System is really distributed throughout the body with each system playing a part. The roles they play both individually and collectively make up the Immune System.

Each of these systems has distinct roles to play. Understanding these systems in correlation with how yoga can help improve their functions brings us closer to our ultimate aim with this training.

Cultivating Immunity: Every body and every part of ‘the body’ has a job.

At the moment of birth, when the doctor slaps your bottom, you take your first breath. Lungs fill with air, and cells continue to grow. All your interconnected body systems function without conscious effort.

Blood flows, bringing oxygen to every cell, because your heart pumps it everywhere. The brain sends signals up and down the spine to every extremity. Your stomach churns, hormones dash about. While all this occurs, the powerful Immune System begins to protect us.

The cells of each system have a programmed role in the Immune System process along with other roles (e.g. hormonal or digestion, etc.). Our discussion has to be a general one, although we recognize the many complicated technical questions about how the Immune System works on the cellular level.

© yoga4cancer 2018 23 Simply and briefly explained below: • Skin – (integumentary system) This is our fortress wall, our first line of defense! As our largest organ, it covers and protects us, but it also has receptors that send signals through the nervous system when something is potentially dangerous. • Nervous system sends signals to the brain after quickly interpreting signals that something is wrong. Nerves serve as intelligence agents, delivering messages to keep information flowing to all parts, and skin and nerves become part of the Immune System in the way they work together to identify and analyze danger. • Respiratory system includes the nose and the hair follicles that line it. When you take air from outside your body in through your nose, and you feel a tickle, that makes you sneeze. This is a normal, protective immune response. Your muscles are expelling something identified as foreign. This is an example of the nervous and muscular system working together to protect you from potential harm. • Musculoskeletal system consists of our bones, connective tissue and muscles. Our bones are a line of defense, so critical to life, because they serve in part as factories for new blood cells to replenish and maintain all cells. The musculoskeletal system also produces white blood cells that become lymphocytes which provide specific defense against cancers. Obviously, our bones are moved by the second part of this system—our muscles. In addition, certain muscles move the soft tissue of organs such as the heart, lungs, stomach and intestines. Internal organs have special jobs of keeping our body clean of toxins and safe from potential harm. Muscles help them do their job. • Digestive system can recognize something threatening, such as rotten food, and its first impulse is to expel it before it gets further into the body. So working with the stomach muscles is one way the digestive system gets rid of threats—throwing up! • Endocrine System The endocrine system has a vital role in the front line of defense against viruses, bacteria and cancer. It stores and produces antibodies plus anti-cancer agents such as lymphocytes and T-cells. These endocrine agents float through the body’s blood and lymph fluids on search and destroy missions. • Cardiovascular system The heart muscle pumps to move fluid through our arteries and veins, known as the circulatory system. This system helps keep blood fresh, clean and rich with life-giving oxygen, healing nutrients and transports the protective agents of the endocrine system.

© yoga4cancer 2018 24 • Lymphatic System This system is commonly misidentified as encompassing the entire Immune System. The lymphatic system provides an infrastructure, starting with a lymph highway—a network of tiny channels that form a one-way passage for lymph fluid to travel throughout the body and a whole network of “trash bins” called lymph nodes.

Here is an illustration on how I see the Immune System along with the other systems and ultimately their vital interconnectivity.

That is a brief and broad view of how the different systems of the body, working both individually and together, make up the Immune System and provide necessary protection. All these are examples of how the body can either identify rogue precancerous cells or support itself to function normally (as in defense of a common cold). It is this basic understanding of human biology that is fundamental to understanding the effectiveness and impact yoga can have on the body and any cancer cells.

© yoga4cancer 2018 25 Continuing the study of the human body systems, let’s take a closer look at all the systems with special attention to the Cardiovascular and Lymphatic systems. How they relate and work together will give us the biological understanding of how yoga becomes a part of creating better immunity.

Skin (Integumentary System) The skin is a large component of the Immune System as well as the body’s largest organ. The skin is our fortress wall, the body’s first line of defense. It covers and protects us, but it also has receptors to send signals through the nervous system when something is potentially dangerous or it senses the presence of something foreign. Think of a sentry flashing a signal to an officer in a tower, asking for a decision.

Nervous System The nervous system is another line of defense. Receptors in the skin, for example, send nerve signals to the brain with the message, “That stove top is hot!” The nervous system quickly interprets the signal and assesses what could be wrong, sending messages to other systems for help with the threat. In the case of something too hot that would cause a burn, the nervous system tells skeletal muscles to “move away.” Such responses have evolved over many millions of years to be extremely rapid and not need conscious thought, which would only slow the response.

Nerves serve as intelligence agents, delivering messages to keep information flowing to all parts of the body. The skin and nerves become part of the Immune System in the way they work together to identify and analyze danger. Nerves can help to bring about balance, and other times they can also be a source of false alarm. There are times when we need stimulation to get systems moving and communicating, keeping in balance with the rest we need. There are times when too much nervous arousal can be very harmful, particularly when it has no outlet for release.

Respiratory System Every cell in the body needs a continuous supply of oxygen. That is why we breathe. The respiratory system is designed to move air in and out of our lungs. You might wonder how the respiratory system draws air into the lungs: it starts with the engagement of a special muscle

© yoga4cancer 2018 26 called the diaphragm—a dome-shaped muscle that lies across the bottom of the chest cavity. The diaphragm controls our breathing. When you inhale, it extends downward, making more space for the lungs. When you exhale, it contracts upward to release air out.

When you inhale, air is drawn into the mouth and/or nose, passes through the larynx, trachea, and bronchial tubes, and much like an inflating balloon, the lungs expand. The oxygen-rich air fills the nearly 600 million tiny spongy sacs called alveoli. A network of pulmonary capillaries surrounds them. Here is where the magic happens. Oxygen is collected and absorbed into the arterial bloodstream from the alveoli. At the same time another exchange happens, oxygen- depleted blood flows past the thin walls of the alveoli and releases carbon dioxide into them. This gas exchange—pulling oxygen in and pumping carbon dioxide out—is the primary function of the respiratory system.

However, there is more going on here than the exchange of air and gas. This process removes other unfriendly things besides carbon dioxide from your body. For example, when you inhale through your nose, several things can tickle it, making you sneeze. That is a normal, protective immune response. Your muscles are expelling something identified as foreign; perhaps spring pollen or a cold virus. It’s a wonderful response, barring entry into the body before any unwanted element can take hold.

Now let’s take this to another level, one of the most magnificent aspects of the human body. How does the respiratory system cultivate immunity and aid our resistance to cancer? Simply, by being the catalyst or electricity to our garbage disposal system—the lymphatic system. The diaphragm’s movement assists the lymphatic system by assisting the thoracic duct—the largest lymph node in the body—and its vital role in detoxification. So just like a sneeze, every breath, especially those big ones, helps your body remove harmful foreign bodies, and this includes rogue cancer cells. A thorough explanation of that process is described in Chapter 3 of Yoga for Cancer, Benefit #1: Yoga Detoxifies the Body (page 67).

The wonders of the respiratory system also have a significant impact on both the nervous and cardiovascular systems. Research studies have shown that controlled breathing is an effective relaxation tool that reduces stress hormones, improves sleep, and reduces anxiety. Modifying the pace and depth of our breathing can quiet the mind.2 Similarly, creating calmness by using

© yoga4cancer 2018 27 simple yoga breathing techniques such as pranayama (discussed on pp. 93, 107) lowers blood pressure and has become a useful tool for those managing cardiovascular disease.3 You can explore this concept in more detail in Yoga for Cancer, Chapter 3, Benefit #8: Yoga Helps Manage Fear and Anxiety, p 75.

Musculoskeletal System This system is made up of the bones, muscles, cartilage, tendons, ligaments, joints, and other connective tissues that enable our movements and also form and protect our internal organs. Its role may seem obvious, but there are hidden gems in it that contributes to our immunity.

Our skeleton not only provides the structure and strength of our body, but it is an essential line of defense. Our bones are so critical to life because they serve as factories for new blood cells. The bone marrow at the center of large bones, such as the legs and hips, is a soft, spongy tissue that produces fresh blood cells that replenish and maintain all body cells, keeping them nourished, oxygenated and functioning so they can protect us from infections and disease.

Muscles are what move the bones. And as they help the body move away from harmful things, this is the obvious role the musculoskeletal system plays in the Immune System. Nerves, muscles, and bones all work in close concert for even the smallest of actions, such as lifting a finger from a hot stove. However, there is yet another lesser known role. Muscles, small and large, are distributed throughout the body, and aside from moving bones, they also move the soft tissue of organs such as the heart, lungs, stomach, and intestines. Internal organs have special muscles to help them function. Inhale, for example, and you’re working the diaphragm muscle.

The actions of the muscles in our bowels also demonstrate how healthy muscles are the motors of a healthy Immune System. Their job is getting the danger out the door. While all the waste is moving through, something else is happening—a constant analysis and identification of danger by the secret agents that protect us, thanks to the endocrine, lymphatic, and cardiovascular systems. Enzymes, antibodies, and lymphocytes all hang out in our intestines, ready to identify and attack threats.

As we move closer to bringing yoga science into this picture, reflect for a moment on how

They work together, whether they are the muscles of your hand moving away from a threatening mosquito about to bite you or respiratory muscles, such as the diaphragm, bringing oxygen to nurture leg muscles when you are taking a walk or running a marathon. Muscle movement is critical to our immunity and well-being.

Digestive System The digestive system plays an important role in both helping feed the trillions of cells in the body and identifying harmful and foreign toxins. And it’s a model of how the body systems are entirely interlinked. For example, that big breakfast you just ate was delicious. Now that you have filled your fuel tank, ready for the hard day ahead, your digestive system silently begins to examine everything you ate using tiny muscles to move everything along as it examines and digests the food. When the digestive system recognizes something harmful, it activates the muscles to expel what is harmful. It’s doing its job when we get sick to our stomach and regurgitate, or have diarrhea. Both are a physiological response to a “threat” and it happens with the aid of muscles. Together they play an important part in the Immune System.

Endocrine System You may be familiar with the fact that the endocrine system produces hormones that tell the body what to do, and control how you feel—for example, when you are hungry, sleepy, or fertile. But the endocrine system also makes a hormone in the thymus that links with a white blood cell to form natural, cancer-fighting lymphocytes called T-cells to identify, capture, and kill potential threats.

A virus or bacterium that has caused your flu or cold is easy for the Immune System to identify, but cancer is more difficult to detect. Cancer cells do not always look like strangers (which is why I think of them as “sneaky”). Because cancer cells mutate from normal cells, they can escape detection by the body’s defenders.

So, the endocrine system has a vital role in the front line of cancer defense. Anti-cancer cells

© yoga4cancer 2018 29 are formed, in effect, with the collaboration of the skeletal system (or bone marrow where new white blood cells are formed) and the cardiovascular system (blood that carries our natural, cancer-fighting cells throughout the body to protect us), and they are stored in the lymph nodes, waiting to eliminate mutating cells. All day and night, anti-cancer agents such as lymphocytes and T-cells float through the body’s blood and lymph fluids on search and destroy missions. Most of the time we are well protected.

See Thymus Gland (page 43) for an illustration of the complete Endocrine system.

Cardiovascular System The meaning of cardio is heart. Vascular refers to blood vessels, arteries, veins, and capillaries that circulate the blood. Our heart is an organ that pumps oxygenated blood through a vast network of arteries to every part of the body; the deoxygenated blood is circulated back to the heart through our veins. The blood always circulates through the body in the same direction. The muscles of the heart create this continuous movement of blood. As the blood circulates throughout the body, it carries critical nutrients, antibodies, hormones, enzymes, lymphocytes (our natural anti-cancer agent) and oxygen to all the cells of the body. It also carries away waste products so that they can be removed from the body. Without a continuous blood supply, cells and body tissues would die.

We all know that keeping blood flowing properly is critical to staying alive. Most everyone is aware that this movement happens best with strong heart muscles and unclogged veins and arteries through which blood can travel. And we are keenly aware of what happens when heart muscles stop or a blood vessel is clogged. The heart is the delivery system of all things good and some things not so good throughout our body. It is an essential team player in the serious business of maintaining immunity.

More on the Cardiovascular System The following explanation of the Cardiovascular System is taken from the patient information from Cancer Research UK.

The blood circulates throughout the body. It carries nutrients (food) and oxygen to all the cells of the body. And it carries away waste products so that they can be removed from the body. Without a blood supply, cells and body tissues die.

The circulation The blood moves around the body inside the circulatory system. This is made up of blood vessels (tubes) called arteries, veins and capillaries. The blood keeps moving through these blood vessels because it is pumped by the heart.

Arteries carry blood that is full of oxygen from the heart to all parts of the body. As the arteries get further and further away from the heart, they get smaller and smaller. Eventually they turn into capillaries. These are the smallest blood vessels. They go right into the tissues. Here the blood in the capillaries gives oxygen to the cells and picks up the waste gas, carbon dioxide, from the cells.

The capillaries are connected to the smallest veins in the body. The veins get bigger and bigger as they carry the blood back towards the heart. The blood passes through the right side of the heart and goes to the lungs where it gets rid of carbon dioxide and picks up more oxygen. It then passes through the left side of the heart and is pumped back around the body.

The blood always circulates through the body in the same direction. As well as oxygen and carbon dioxide, many other substances are carried in the blood. The blood circulating through the digestive system picks up digested food products and carries them to the liver to be used or stored.

The circulation can help explain why some cancers nearly always spread to the same place. Cancers of the colon (large bowel) often spread to the liver. This is because blood circulates from the bowel through the liver on its way back to the heart. If there is a cancer in the large bowel, and some cancer cells escape into the circulation, they may stick in the liver as the blood passes through. They can then begin to grow into secondary cancers.

The blood is about 55% plasma and 45% cells. Plasma is mostly water with some proteins and other chemicals dissolved in it. There are three main types of cells in the blood § White blood cells § Red blood cells § Platelets

White blood cells There are several different types of white cells in the blood in differing amounts. They all play a part in the immune response. This is the response of the body to infection, or anything else the body recognizes as ‘foreign’. These blood cells can be made very quickly and generally have a short life. Some only live for a few hours, others for a few days.

There isn’t an exact ‘normal’ figure for the number of cells in your blood (called your blood count). ‘Normal’ for a large man wouldn’t be the same as for a small woman. But generally, the normal white cell count is between about 4,000 and 11,000 cells per cubic millimetre of blood. If you have surgery or an infection, your white blood cell counts will go up within a day or two.

The most common type of white blood cells are the neutrophils (sometimes called leucocytes). There are between 2,000 and 7,500 of these per cubic millimetre of blood. They are important for fighting infection. If you have chemotherapy, and especially if you have high doses, your neutrophil count usually drops quite quickly.

The next most common are the lymphocytes. A normal lymphocyte count is between 1,500 and 4,500 cells per cubic millimetre of blood. Lymphocytes are involved in making antibodies as part of the immune response. There are both B lymphocytes and T lymphocytes.

Other white blood cells are present in smaller numbers in the circulating blood. There are between § 40 and 400 eosinophils

Red blood cells Red blood cells give the blood its red color. They contain a pigment called hemoglobin. There are more than 4 or 5 million red blood cells in every cubic millimetre of blood. A red blood cell can live for up to 120 days (about 4 months). Doctors can measure the amount of hemoglobin (Hb) in our blood. They measure the Hb level in grams per decilitre of blood (g/dL) or grams per litre of blood (g/L). Healthy men usually have a level between 13 to 18 g/dL (130 to 180 g/L). Healthy women usually have a level between 11.5 to 16.5 g/dL (115 to 165g/L).

Red blood cells attach to oxygen and carry it within the blood to the tissues. When they get to an area where the oxygen is needed, they release the oxygen and pick up carbon dioxide, which they carry back to the lungs. A shortage of red blood cells is called anemia. The role of the red blood cell in carrying oxygen explains why very anemic people usually feel breathless.

Platelets Platelets are really bits of much bigger cells called megakaryocytes. A normal platelet count is between 150,000 and 440,000 per cubic millimetre of blood. Platelets are very important in blood clotting. They clump together to form a plug to help stop bleeding. They then release other chemicals to clot the blood and repair the blood vessel.

How and where blood cells are made All the different types of blood cells develop from one type of cell called a ‘blood stem cell’. In adults, blood stem cells are normally found in the red bone marrow inside the bones. Blood cells are made in the bone marrow in the skull, ribs, sternum (breast bone), spine and pelvis. The stem cells divide and multiply to make the blood cells. These cells develop and mature (differentiate) as they grow into white cells, red cells or platelets.

If you are having chemotherapy, the number of white blood cells, red blood cells and platelets in your blood is likely to go down for a time. Developing blood cells multiply all the time as they mature. Chemotherapy kills cells that are actively multiplying. So blood cells are killed by the chemotherapy drugs. The white cell counts go down first, because many white cells naturally die off within a few days. Normally these are replaced by newly developed white cells. But chemotherapy will have killed some of the developing white cells. It usually takes a week or two before more cells can be made.

Mature red blood cells live for about three months, so there are fewer multiplying at any one time. So you often don’t get low in red cells (anemic) until further into your chemotherapy course. If your red blood cell level gets very low, you may need a blood transfusion.

Chemotherapy can also make your platelet level drop. If it does, you may get nose bleeds, or notice a red rash on your skin like tiny bruises. Your doctor may then want you to have a platelet transfusion. After high dose chemotherapy, it can take longer for the platelet count to get back to normal than any other blood cell count.

Some biological therapies can also lower your levels of white blood cells or red blood cells.

We come now to the lymphatic system, which when stimulated through yoga, can be your most powerful tool to keep the Immune System strong. The lymphatic system is an infrastructure, starting with a lymph highway—a network of tiny channels that form a one-way passage for lymph fluid to travel throughout the body. This is similar to the cardiovascular system, which you know consists of veins and arteries allowing blood to circulate. Unlike the cardiovascular/circulatory system, however, the lymph highway has stopping points for examination, the detention centers or reprocessing plants called lymph nodes. All day and night, lymph fluid, containing toxins, unwanted bacteria or rogue cancer cells, collects throughout the body. In fact, during a normal day in a normal body, one to two liters of lymph fluid are moved through the body. (Source: http://www.womens-health-advice.com/lymphatic- system.html) Therefore, the lymphatic system is vital to maintain health.

A tiny space surrounds most cells, filled with a clear fluid called interstitial fluid. Every cell is suspended, continually nurtured by the blood supply with proteins, vitamins, hormones and antibodies. Oxygen and nutrients from blood plasma flow through openings in the capillary walls into the interstitial fluid to feed and maintain cells. During the process of feeding, cells throw off by-products that are considered waste. This could be anything—dead cells, bacteria, viruses, or other foreign agents.

Suspended in interstitial fluid, the debris is then delivered to the lymph system through tiny lymphatic capillaries of the lymph highway, like debris floating down a sewer system on its way to a treatment plant. When the interstitial fluid begins its journey into the lymph system’s tiny canals, it is called lymph fluid. All day and night, lymph fluid collects throughout the body. In fact, during a normal day in a normal body, four liters of lymph fluid are moved through the body and eliminated. (For images and information about the thoracic duct, the largest lymphatic vessel, go to http://www.healthline.com/human-body-maps/female-abdomen)

Lymph flows through the tiny tunnels connecting nodes, ducts and glands along the way that serve as containers for examination—the detention centers or reprocessing plants, otherwise known as lymph nodes. Here, the secret agent team of examiners, including lymphocytes and antibodies, wait to sort through the waste for errant cells and toxic elements.

© yoga4cancer 2018 35 These secret agents will attack rogue cells like cancer once they both arrive in a “detention center.” It is here that the T-cells and other disease-fighting agents meet up with the invaders, or mutating cells, from within the body. If, for instance, the right antibody from a flu vaccine is present to neutralize this year’s strain, it happens here. The potential threat is irrigated out of the body without causing infection.

If it is not, the lymph node or gland enlarges as a sign that there is a “stranger.” The virus is isolated while the rest of the Immune System rallies assistance. That is why doctors inspect the nodes where they are close to the skin surface such as under the arms, in the groin, and on the upper chest.

Nodes vary in size and density throughout the body. More of them are located in places like the mouth, nasal passages, and neck where food and toxins first enter the body. The stomach and intestines are surrounded by lymph glands that are constantly examining waste. In the body’s center is the main and most important lymph node—so big it is called a duct. It is here that the lymph fluid collects and is conveyed into the venous circulation system to be filtered and flushed out of the body through the spleen, kidneys, liver, and finally, the bladder. The thoracic duct is the main detention center of the lymphatic system. It runs parallel to and is nestled close to the spinal column from the top of the lumbar spine (lumbar 2) to the base of the neck (thoracic 1 and cervical 7).

Why do we care? Because the location and function of this duct forms the scientific foundation of yoga’s healing power. The thoracic duct along its narrow, long vertical path is in constant contact with the movement of the horizontal diaphragm muscle, which is massaged by the action of breathing. This knowledge reveals a little secret and creates magic to aid recovery and maintain lifelong health for everyone, not only for the cancer patient and survivor. It is key to the y4c Methodology.

Keeping our lymph fluids moving is critical to our health as well, and essential to our immunity. However, unlike the heart of the cardiovascular system, the lymphatic system has no specific muscle. So to cleanse, revitalize and detoxify our body, the lymphatic system depends on other muscles and gravity to move lymphatic fluids. Here is where I begin to make the case that yoga can be the organ muscle of the lymphatic system. Details on how this works are

The human body has two fluid highways: blood and lymph. They are similar in structure, but have differences. Lymph has checkpoints along its passageway: nodes, glands, and ducts. We want the content of the lymph fluid to stop for examination, but not stay or linger long. Yet, we want the blood to flow continuously without interruption.

Merriam-Webster Dictionary: The part of the circulatory system that is concerned especially with scavenging fluids and proteins that have escaped from cells and tissues and returning them to the blood, with the phagocytic removal of cellular debris and foreign material, and with immune responses, that overlaps and parallels the system of blood vessels in function and shares some constituents with it, and that consists especially of the thymus, spleen, tonsils, lymph, lymph nodes, lymphatic vessels, lymphocytes, and bone marrow where stem cells differentiate into precursors of B cells and T cells—called also lymphoid system, lymph system.

Job of the Lymphatic System:

1. Garborator (Sewage LYMPH NODES System) – To collect toxins and harmful foreign objects

from the body. RIGHT LYMPHATIC DUCT

2. Terminator (The Cancer THORACIC DUCT Bouncer) – To eliminate much like a Sewage System waste or potentially harmful debris. SPLEEN

LYMPH VESSELS

To aid our discussion, please use LYMPH NODES the included illustration of the Lymphatic System’s relevant elements and their interconnection.

Source: Patient information website of Cancer Research UK

‘The lymphatic system is a system of thin tubes that runs throughout the body. These tubes are called lymph vessels or lymphatic vessels.

The lymphatic system is like the blood circulation - the tubes (vessels) branch through all parts of the body like the arteries and veins that carry blood. But the lymphatic system tubes are much finer and carry a colorless liquid called lymph.

Lymph is a clear fluid that circulates around the body tissues. It contains a high number of lymphocytes (white blood cells). Plasma leaks out of the capillaries to surround and bathe the body tissues. This then drains into the lymph vessels. The fluid, now called lymph, then flows through the lymphatic system to the biggest lymph vessel - the thoracic duct. The thoracic duct then empties back into the blood circulation.

Lymph glands

Along the lymph vessels are small bean-shaped lymph glands or ‘nodes’. You can probably feel some of your lymph nodes. There are lymph nodes in many parts of your body including: § Under your arms, in your armpits § In each groin (at the top of your legs) § In your neck

There are also lymph nodes that you cannot feel in § Your abdomen § Your pelvis § Your chest

Other lymphatic system organs The lymphatic system includes other body organs. These are the: § Spleen

The spleen is under your ribs on the left side of your body. The spleen has two main different types of tissue, red pulp and white pulp. The red pulp filters worn out and damaged red blood cells from the blood and recycles them. The white pulp contains many B lymphocytes and T lymphocytes. These are special white blood cells that are very important for fighting infection. As blood passes through the spleen, these blood cells pick up on any sign of infection and begin to fight it.

The thymus is a small gland under your breast bone. The thymus helps to produce special white blood cells. It is usually most active in teenagers and shrinks in adulthood.

The tonsils are two glands in the back of your throat. The adenoids are at the back of your nose, where it meets the back of your throat. The tonsils and adenoids (also called the ‘nasopharyngeal’ tonsils) help to protect the entrance to the digestive system and the lungs from bacteria and viruses.

What the lymphatic system does The lymphatic system does several jobs in the body. It

• Drains fluid back into the bloodstream from the tissues • Filters lymph • Filters the blood • Fights infections

Draining fluid into the bloodstream As the blood circulates, fluid leaks out from the blood vessels into the body tissues. This fluid is important because it carries food to the cells and waste products back to the bloodstream. The leaked fluid drains into the lymph vessels. It is carried through the lymph vessels to the base of the neck where it is emptied back into the bloodstream. This circulation of fluid through the body goes on all the time.

© yoga4cancer 2018 40 Filtering lymph The lymph nodes filter the lymph fluid as it passes through. White blood cells attack any bacteria or viruses they find in the lymph as it flows through the lymph nodes. If cancer cells break away from a tumor, they often become stuck in the nearest lymph nodes. This is why doctors check the lymph nodes first when they are working out how far a cancer has grown or spread.

Filtering the blood This is the job of the spleen. It filters the blood to take out all the old worn out red blood cells and then destroys them. They are replaced by new red blood cells that are made in the bone marrow. The spleen also filters out bacteria, viruses and other foreign particles found in the blood. White blood cells in the spleen attack bacteria and viruses as they pass through.

Fighting infection When people say, “I’m not well, my glands are up” they are really saying they have swollen lymph nodes because they have an infection. Many ways the lymphatic system helps fight infection include: • Helping to make special white blood cells (lymphocytes) that produce antibodies • Having other blood cells called macrophages inside the lymph nodes which swallow up and kill any foreign particles, for example germs

This function of the lymphatic system is really part of the Immune System.’

There are two body parts that we have referenced previously that require specific focus for this training because of the vital role they play in immunity. And, most important to our job as yoga teachers, we can use yoga to support and strengthen their function in providing immune protection. We highlighted them here using these definitions and references.

Thoracic Duct

Source: Healthline.com http://www.healthline.com/human- body-maps/thoracic-duct#6/1

“The thoracic duct is the biggest lymphatic vessel in the human body, and plays a key role in the lymphatic system. It is also called the left lymphatic duct or the alimentary duct. A large part of the body’s lymph is collected by this duct, and drained into the bloodstream near the brachiocephalic vein between the internal jugular veins and the left subclavian. The typical length of this duct in an adult averages between 38 and 45cm and the diameter is about 5mm. It originates from the second lumbar vertebra level and goes to the neck’s root. The duct arises from the combination of the left and right lumbar trunks and the intestinal trunk in the abdomen. The thoracic duct gets extended in the chest area and from there it curves towards the internal jugular vein and the left carotid artery at the C7 vertebra. It travels through the aortic aperture diaphragm and rises along the posterior mediastinum. It carries up to four liters of lymph each day. This action is primarily caused by the breathing action and assisted by the smooth muscle of the duct.”

In adults, the thoracic duct transports up to 4 L of lymph per day. The lymph transport in the thoracic duct is mainly caused by the action of breathing, aided by the duct’s smooth muscle

© yoga4cancer 2018 42 and by internal valves that prevent the lymph from flowing back down again. For more images and information about the thoracic duct, the largest lymphatic vessel, go to www.healthline.com/human-body-maps/thoracic-duct.

What is the Thymus Gland? Source: Inner Body.com http://www.innerbody.com/image_endoov/lymp04-new.html

“The thymus gland is a gland that forms part of the Immune System. It is situated in the upper 1. part of the chest, behind the breastbone, and is made up of two lobes that join in front of the 2. trachea. Each lobe is made of lymphoid tissue, consisting of tightly packed white blood cells and fat. The thymus enlarges from about the 8. 3. 12th week of gestation until puberty, when it begins to shrink. Its function is to transform 4. lymphocytes (white blood cells developed in 1. Pineal Gland 5. the bone marrow) into T-cells (cells developed 2. Pituatry Gland 6. in the thymus). These cells are then 3. Parathyroid Glands transported to various lymph glands, where 4. Thymus Gland they play an important part in fighting 5. Adrenal Glands 7. infections and disease. Swelling of lymph 6. Pancreas glands and fever are a signal that immune 7. Ovaries cells are multiplying to fight off invaders of the 8. Thyroid Gland body: bacteria, fungi, viruses or parasites. © 2013 Hormone Health Network

T cells are your fighter cells. They help the Immune System kill invaders to the body, such as bacteria. T cells, frontline defenders of the Immune System, recognize cells that don’t belong in the body—such as bacteria—and set off a cascade of events to kill them.

Exercise is proven to increase the ‘responsiveness’ of T cells in cancer survivors so they are able to better defends against secondary cancers and others types of infections.”

How do you know you have cancer? Have we not all had a lump or unusual pain and immediately asked yourself, “Cancer?” A diagnosis is best made by a doctor, not our imagination or fears. Fortunately, we have many excellent diagnostic tools. Along with advances in cancer treatments, there are constant advances in how a cancer is initially detected and analyzed. However, there seems to be an increasing awareness and critique of over diagnosis, which is a topic for another discussion.

When you feel something, have chronic unusual pain or other symptom(s) present, you go to a doctor who initially orders tests and procedures. These are used to recognize, locate and analyze a potential cancer. Then along with the age and medical history of the patient, the results determine the stage of the cancer.

Tests and procedures may include: § Biopsy procedures: such as, fine needle aspiration, surgical biopsies, including tissue, lymph node, and bone marrow. § Imaging tests: such as, X-ray, MRI, PET and CAT scans, Ultrasound. § Endoscopic tests: medical procedure performed with an endoscope, for example, a bronchoscope, colonoscope, or laparoscope. § Laboratory tests: such as blood, urine, and/or other body fluids, PSA for prostate cancer, PAP smear for cervical cancer, CEA for colorectal cancer, and other tests to determine tumor markers, for example, breast cells that indicate hormone receptors.

Such testing and procedures are the bane of survivorship. After diagnosis and treatment plans are completed, a survivor is faced with a lifetime of periodically scheduling these tests.

Cancer Staging One important topic for every survivor is how cancers are categorized or staged, usually with regard to the threat they pose and their course of treatment. Cancers vary in terms of how aggressively they are tested. The testing can include various biopsies and tissue samples, testing to determine the size of the first tumor and, most importantly, to see if there is any

© yoga4cancer 2018 44 evidence that the cancer cells are present and if the lymph system that could carry them to other parts of the body. It is from these facts that an oncologist will assign a ‘stage’ to a particular cancer and, along with the age of the patient, suggest a treatment plan. Similarly, a yoga teacher knowing these facts and the medically assigned ‘stage’, is very helpful for many reasons. Some of these reasons include a general but quick way of gathering information about a student’s treatment plan and prognosis; how much knowledge the survivor has about his/her cancer; some of his/her deeper psychological concerns; and an opportunity for you to demonstrate your awareness which can be very reassuring to a student.

National Cancer Institute explains staging in the following way: Source: http://www.cancer.gov/cancertopics/factsheet/detection/staging

1. What is staging? “Staging describes the severity of a person’s cancer based on the size and/or extent (reach) of the original (primary) tumor and whether or not cancer has spread in the body. Staging is important for several reasons: § Staging helps the doctor plan the appropriate treatment. § Cancer stage can be used in estimating a person’s prognosis. § Knowing the stage of cancer is important in identifying clinical trials that may be a suitable treatment option for a patient. § Staging helps healthcare providers and researchers exchange information about patients; it also gives them a common terminology for evaluating the results of clinical trials and comparing the results of different trials.

Staging is based on knowledge of the way cancer progresses. Cancer cells grow and divide without control or order, and they do not die when they should. As a result, they often form a mass of tissue called a tumor. As a tumor grows, it can invade nearby tissues and organs. Cancer cells can also break away from a tumor and enter the bloodstream or the lymphatic system. By moving through the bloodstream or lymphatic system, cancer cells can spread from the primary site to lymph nodes or to other organs, where they may form new tumors. The spread of cancer is called metastasis.”

2. What are the common elements of staging systems?

© yoga4cancer 2018 45 Staging systems for cancer have evolved over time. They continue to change as scientists learn more about cancer. Some staging systems cover many types of cancer; others focus on a particular type. The common elements considered in most staging systems are as follows: § Site of the primary tumor and the cell type (e.g., adenocarcinoma, squamous cell carcinoma) § Tumor size and/or extent (reach) § Regional lymph node involvement (the spread of cancer to nearby lymph nodes) § Number of tumors (the primary tumor and the presence of metastatic tumors, or metastases) § Tumor grade (how closely the cancer cells and tissue resemble normal cells and tissue)

3. What is the TNM system? The TNM system is one of the most widely used cancer staging systems. This system has been accepted by the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC). Most medical facilities use the TNM system as their main method for cancer reporting. The TNM system is based on the size and/or extent (reach) of the primary tumor (T), the amount of spread to nearby lymph nodes (N), and the presence of metastasis (M) or secondary tumors formed by the spread of cancer cells to other parts of the body. A number is added to each letter to indicate the size and/or extent of the primary tumor and the degree of cancer spread.

Primary Tumor (T) TX: Primary tumor cannot be evaluated T0: No evidence of primary tumor Tis: Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called pre-invasive cancer) T1, T2, T3, T4: Size and/or extent of the primary tumor

© yoga4cancer 2018 46 Regional Lymph Nodes (N) NX: Regional lymph nodes cannot be evaluated N0: No regional lymph node involvement N1, N2, N3: Degree of regional lymph node involvement (number and location of lymph nodes)

Distant Metastasis (M) MX: Distant metastasis cannot be evaluated M0: No distant metastasis M1: Distant metastasis is present

For example, breast cancer classified as T3 N2 M0 refers to a large tumor that has spread outside the breast to nearby lymph nodes but not to other parts of the body. Prostate cancer T2 N0 M0 means that the tumor is located only in the prostate and has not spread to the lymph nodes or any other part of the body.

For many cancers, TNM combinations correspond to one of five stages. Criteria for stages differ for different types of cancer. For example, bladder cancer T3 N0 M0 is stage III, whereas colon cancer T3 N0 M0 is stage II.

Stage Definition

Stage 0 Carcinoma in situ

Stage I, Stage II, and Stage Higher numbers indicate more extensive disease: Larger tumor size III and/or spread of the cancer beyond the organ in which it first developed to nearby lymph nodes and/or tissues or organs adjacent to the location of the primary tumor

Stage IV The cancer has spread to distant tissues or organs

© yoga4cancer 2018 47 Connecting the dots between a Diagnosis + Stage to equal a Treatment Plan is not so easy or straightforward for any cancer. In other words, we cannot assume a survivor’s stage has automatically determined the course of treatment chosen by that person. Staging helps doctors make recommendations. But as yoga teachers, we can use this information as a guide that will help us gather critical information about our yoga students. The only assumptions that can be made are that: § Every treatment plan is determined by the biology of the cancer. § Every treatment plan is suggested based on the health of the individual diagnosed. § Every individual makes choices based on their doctors’ recommendations and their personal feelings. § Everybody, every human body and every cancer is different.

Essentially, every individual may choose and have different treatment plans depending on his/her physiological or psychological comfort. In other words, two individuals with Stage 3 colon cancer may have entirely different treatment plans. Why? Our focus on these distinctions gives insights into the emotional side of someone ‘who has come to you for help’ through yoga practice. I have created this chart using breast cancer staging as an example of the usual initial treatment recommendations to demonstrate the complexity of options.

✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

✔ ✔ ✔ ✔ ✔

✔ ✔ ✔ ✔

✔ ✔ ✔ ✔ ✔

✔ ✔

✔

© yoga4cancer 2018 48 Using this chart: This chart is confusing because, except for the advanced stage 4, it appears not all treatment options are options for all patients. The differences between stages are not obvious. Yet it seems among all breast cancer survivors, not everyone goes the same treatment route. What this means is an individual has chosen treatment based on their psychological as well as the physical state of being. For a yoga teacher, understanding that there was choice involved, makes interviewing a new student extremely important.

Familiarity with the psychology behind difficult choices informs your understanding and cultivates compassion that others can feel. Consider these examples:

Two students have the same Stage 0 diagnosis. One may choose a double mastectomy and no Radiation Therapy. Whereas, the other chooses a Lumpectomy and Radiation Therapy. Why? They will have different long- and short-term side effects from their choices.

Remember size of a tumor is a factor in determining stage. A common choice for a Stage 2 survivor, whose tumor is small, invasive and has lymph node involvement, is Lumpectomy, Radiation Therapy and Chemotherapy. But it is not uncommon for this person to alternatively choose Mastectomy, no Radiation Therapy and no Chemotherapy. Confusing, right?

Perhaps even more so is the case of two individuals Stage 4, where one chooses initially mastectomy and chemotherapy, the other, Palliative chemotherapy. What psychological states do these choices indicate?

The challenge remains how to get critical information, both psychological and physical, quickly. We will review this chart again and discuss of how staging can help you as a yoga teacher when we begin the “Are You Ready” section of this training.

An important diagnostic tool is the Sentinel Node Biopsy (SLNB). It is performed on many or most type of cancers – actually it began with penile and testicular cancers - but I often use a breast cancer example as it is most common amongst students and tends to be more invasive due to the location of the lymph nodes in breast area. This diagnostic process is used to determine if a cancer has invaded the lymphatic system. Such a determination is pivotal to a cancer patient and survivor’s journey as it helps prescribe a treatment plan. The procedure is a surgery usually done under general anesthesia.

Even though it was developed with the goal of making cancer treatment surgery minimally invasive, there can be long term side effects such as: risk of lymphedema, limited range of motion, and painful scar tissue. Therefore, it is important for a yoga teacher to know is that it is a diagnostic procedure, not a cancer treatment, and that it carries challenges that can be addressed with a yoga practice.

National Cancer Institute explains Sentinel Node Biopsy in the following way.

What are lymph nodes? Source: National Cancer Institute- http://www.cancer.gov/cancertopics/factsheet/detection/sentinel-node-biopsy

“Lymph nodes are small round organs that are part of the body’s lymphatic system. They are found widely throughout the body and are connected to one another by lymph vessels. Groups of lymph nodes are located in the neck, underarms, chest, abdomen, and groin. A clear fluid called lymph flows through lymph vessels and lymph nodes.

Lymph originates from a fluid, known as interstitial fluid that has diffused, or ‘leaked’, out of small blood vessels called capillaries. This fluid contains many substances, including blood plasma, proteins, glucose, and oxygen. It bathes most of the body’s cells, providing them with the oxygen and nutrients they need for growth and survival. Interstitial fluid also picks up waste products from cells as well as other materials, such as bacteria and viruses, to help remove them from the body’s tissues. Interstitial fluid eventually collects in lymph vessels, where it

Lymph nodes are important parts of the body’s Immune System. They contain B lymphocytes, T lymphocytes, and other types of Immune System cells. These cells monitor lymph for the presence of ‘foreign’ substances, such as bacteria and viruses. If a foreign substance is detected, some of the cells will become activated and an immune response will be triggered.

Lymph nodes are also important in helping to determine whether cancer cells have developed the ability to spread to other parts of the body. Many types of cancer spread through the lymphatic system, and one of the earliest sites of spread for these cancers is nearby lymph nodes.

What is a sentinel lymph node? A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread from a primary tumor. Sometimes, there can be more than one sentinel lymph node.

What is a sentinel lymph node biopsy? A sentinel lymph node biopsy (SLNB) is a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present.

A negative SLNB result suggests that cancer has not developed the ability to spread to nearby lymph nodes or other organs. A positive SLNB result indicates that cancer is present in the sentinel lymph node and may be present in other nearby lymph nodes (called regional lymph nodes) and, possibly, other organs. This information can help a doctor determine the stage of the cancer (extent of the disease within the body) and develop an appropriate treatment plan.

What happens during an SLNB? A surgeon injects a radioactive substance, a blue dye, or both near the tumor to locate the position of the sentinel lymph node. The surgeon then uses a device that detects radioactivity to find the sentinel node or looks for lymph nodes that are stained with the blue dye. Once the sentinel lymph node is located, the surgeon makes a small incision in the overlying skin and removes the node.

© yoga4cancer 2018 51 The sentinel node is then checked for the presence of cancer cells by a pathologist. If cancer is found, the surgeon may remove additional lymph nodes, either during the same biopsy procedure or during a follow-up surgical procedure. SLNBs may be done on an outpatient basis or may require a short stay in the hospital.

SLNB is usually done at the same time the primary tumor is removed. However, the procedure can also be done either before or after removal of the tumor.”

“A radioactive substance and/or blue dye is injected near the tumor (first panel). The injected material is located visually and/or with a device that detects radioactivity (middle panel). The sentinel node(s) (the first lymph node(s) to take up the material) is (are) removed and checked for cancer cells (last panel).”

© yoga4cancer 2018 52 What are the benefits of SLNB? “In addition to helping doctors stage cancers and estimate the risk that tumor cells have developed the ability to spread to other parts of the body, SLNB may help some patients avoid more extensive lymph node surgery. Removing additional nearby lymph nodes to look for cancer cells may not be necessary if the sentinel node is negative for cancer. All lymph node surgery can have adverse effects, and some of these effects may be reduced or avoided if fewer lymph nodes are removed. The potential adverse effects of lymph node surgery include the following: • Lymphedema, or tissue swelling. During SLNB or more extensive lymph node surgery, lymph vessels leading to and from the sentinel node or group of nodes are cut, thereby disrupting the normal flow of lymph through the affected area. This disruption may lead to an abnormal buildup of lymph fluid. In addition to swelling, patients with lymphedema may experience pain or discomfort in the affected area, and the overlying skin may become thickened or hard. In the case of extensive lymph node surgery in an armpit or groin, the swelling may affect an entire arm or leg. In addition, there is an increased risk of infection in the affected area or limb. Very rarely, chronic lymphedema due to extensive lymph node removal may cause a cancer of the lymphatic vessels called lymphangiosarcoma. For more on lymphedema see page 72 of this manual. • Seroma, or the buildup of lymph fluid at the site of the surgery. • Numbness, tingling, or pain at the site of the surgery. • Difficulty moving the affected body part.”

After diagnosis comes the prescription. In the Western model, an oncologist, or cancer doctor, gets the basic information about a person’s cancer and then proceeds to recommend a treatment plan. This section includes descriptions of common cancer treatments. There are many here and new ones are constantly being developed. We hope that you will return to the on-line references provided here to keep yourself updated on new developments as you continue your practice.

This is the ideal place to mention that often, the cancer is not usually visible nor, in early stages, physically disabling. But the consequences of treatments are. Treatments can have lasting physical impact on cancer survivors and can be challenging both physically and emotionally. In my own experience, the cancer did not hurt, the treatments did. To understand how and what a survivor is experiencing and to best support them, as yoga teachers we need to know the typical Western treatments, how they are designed to attack cancer, and how they make a patient feel.

Below is an excerpt about treatment methods from the National Cancer Institute as provided to cancer patients:

Treatment Methods: Courtesy of the National Cancer Institute (http://www.cancer.gov)

The treatment plan depends mainly on the type of cancer and the stage of the disease.

Doctors also consider the patient’s age and general health. Often, the goal of treatment is to cure the cancer. In other cases, the goal is to control the disease or to reduce symptoms for as long as possible. The treatment plan may change over time.

Most treatment plans include surgery, radiation therapy, or chemotherapy. Some involve hormone therapy or biological therapy. In addition, stem cell transplantation may be used so that a patient can receive very high doses of chemotherapy or radiation therapy.

Some cancers respond best to a single type of treatment. Others may respond best to a combination of treatments.

Treatments may work in a specific area (local therapy) or throughout the body (systemic therapy): • Local therapy removes or destroys cancer in just one part of the body. Surgery to remove a tumor is local therapy. Radiation to shrink or destroy a tumor also is usually local therapy. • Systemic therapy sends drugs or substances through the bloodstream to destroy cancer cells all over the body. It kills or slows the growth of cancer cells that may have spread beyond the original tumor. Chemotherapy, hormone therapy, and biological therapy are usually systemic therapy.

Your doctor can describe your treatment choices and the expected results. You and your doctor can work together to decide on a treatment plan that is best for you.

Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each person, and they may change from one treatment session to the next.

Before treatment starts, the healthcare team will explain possible side effects and suggest ways to help you manage them. This team may include nurses, a dietitian, a physical therapist, and others.

At any stage of cancer, supportive care is available to relieve the side effects of therapy, to control pain and other symptoms, and to ease emotional and practical problems.

Surgery In most cases, the surgeon removes the tumor and some tissue around it. Removing nearby tissue may help prevent the tumor from growing back. The surgeon may also remove some nearby lymph nodes.

© yoga4cancer 2018 55 The side effects of surgery depend mainly on the size and location of the tumor, and the type of operation. It takes time to heal after surgery. The time needed to recover is different for each type of surgery. It is also different for each person. It is common to feel tired or weak for a while.

Most people are uncomfortable for the first few days after surgery. However, medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with the doctor or nurse. The doctor can adjust the plan if you need more pain relief.

Some people worry that having surgery (or even a biopsy) for cancer will spread the disease. This seldom happens. Surgeons use special methods and take many steps to prevent cancer cells from spreading. For example, if they must remove tissue from more than one area, they use different tools for each one. This approach helps reduce the chance that cancer cells will spread to healthy tissue.

Similarly, some people worry that exposing cancer to air during surgery will cause the disease to spread. This is not true. Air does not make cancer spread.

Radiation Therapy Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Doctors use several types of radiation therapy. Some people receive a combination of treatments: § External radiation: The radiation comes from a large machine outside the body. Most people go to a hospital or clinic for treatment 5 days a week for several weeks. § Internal radiation (implant radiation or brachytherapy): The radiation comes from radioactive material placed in seeds, needles, or thin plastic tubes that are put in or near the tissue. The patient usually stays in the hospital. The implants generally remain in place for several days. § Systemic radiation: The radiation comes from liquid or capsules containing radioactive material that travels throughout the body. The patient swallows the liquid or capsules or receives an injection. This type of radiation therapy can be used to treat cancer or control pain from cancer that has spread to the bone. Only a few types of cancer are currently treated in this way.

© yoga4cancer 2018 56 The side effects of radiation therapy depend mainly on the dose and type of radiation you receive and the part of your body that is treated. For example, radiation to your abdomen can cause nausea, vomiting, and diarrhea. Your skin in the treated area may become red, dry, and tender. You also may lose your hair in the treated area.

You may become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Fortunately, most side effects go away in time. In the meantime, there are ways to reduce discomfort. If you have a side effect that is especially severe, the doctor may suggest a break in your treatment.

Chemotherapy Chemotherapy is the use of drugs that kill cancer cells. Most patients receive chemotherapy by mouth or through a vein. Either way, the drugs enter the bloodstream and can affect cancer cells all over the body.

Chemotherapy is usually given in cycles. People receive treatment for one or more days. Then they have a recovery period of several days or weeks before the next treatment session. Most people have their treatment in an outpatient part of the hospital, at the doctor’s office, or at home. Some may need to stay in the hospital during chemotherapy.

Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly: § Blood cells: When drugs damage healthy blood cells, you are more likely to get infections, to bruise or bleed easily, and to feel very weak and tired. § Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture. § Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

Some drugs can affect fertility. Women may be unable to become pregnant, and men may not be able to father a child.

Hormone therapy uses drugs or surgery: § Drugs: The doctor gives medicine that stops the production of certain hormones or prevents the hormones from working. § Surgery: The surgeon removes organs (such as the ovaries or testicles) that make hormones.

The side effects of hormone therapy depend on the type of therapy. They include weight gain, hot flashes, nausea, and changes in fertility. In women, hormone therapy may make menstrual periods stop or become irregular and may cause vaginal dryness. In men, hormone therapy may cause impotence, loss of sexual desire, and breast growth or tenderness. It is important to know that hormonal therapy is not hormone replacement therapy. HRT is not used to treat breast cancer. HRT is taken by some women to treat troublesome menopausal side effects such as hot flashes and mood swings. HRT is used to raise estrogen levels that drop after menopause. In addition, it is important to know that hormonal therapy is not chemotherapy. Chemotherapy is the use of any drug to treat any disease. But to most people, the word chemotherapy means drugs used for cancer treatment. It is often shortened to “chemo.” Surgery and radiation therapy remove, kill, or damage cancer cells in a certain area, but chemo can work throughout the whole body.

Both hormonal therapy and chemotherapy are drugs/chemicals administered to the body in a variety of forms and procedures.

More information on hormonal therapy see: www.breastcancer.org/treatment/hormonal and www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/hormone/what- hormone- therapy-is.

Biological Therapy Biological therapy is another type of systemic therapy. It helps the Immune System (the body’s natural defense system) fight cancer. For example, certain patients with bladder cancer

© yoga4cancer 2018 58 receive Bacillus Calmette Guerin (BCG) solution after surgery. The doctor uses a catheter to put the solution in the bladder. The solution contains live, weakened bacteria that stimulate the Immune System to kill cancer cells. BCG can cause side effects. It can irritate the bladder. Some people may have nausea, a low-grade fever, or chills.

Most other types of biological therapy are given through a vein. The biological therapy travels through the bloodstream. Some people get a rash where the therapy is injected. Some have flu-like symptoms such as fever, chills, headache, muscle aches, fatigue, weakness, and nausea. Biological therapy also can cause more serious side effects, such as changes in blood pressure and breathing problems. Biological therapy is usually given at the doctor’s office, clinic, or hospital.

Stem Cell Transplantation Transplantation of blood-forming stem cells enables patients to receive high doses of chemotherapy, radiation, or both. The high doses destroy both cancer cells and normal blood cells in the bone marrow. After the treatment, the patient receives healthy, blood-forming stem cells through a flexible tube placed in a large vein. New blood cells develop from the transplanted stem cells. Stem cells may be taken from the patient before the high-dose treatment, or they may come from another person. Patients stay in the hospital for this treatment.

The side effects of high-dose therapy and stem cell transplantation include infection and bleeding. In addition, graft-versus-host disease (GVHD) may occur in people who receive stem cells from a donor. In GVHD, the donated stem cells attack the patient’s tissues. Most often, GVHD affects the liver, skin, or digestive tract. GVHD can be severe or even fatal. It can occur any time after the transplant, even years later. Drugs may help prevent, treat, or control GVHD.”

© yoga4cancer 2018 59 Breast Reconstruction Cancer treatment surgeries can be debilitating, even the surgeries that are used for diagnosis. At this point in our study of cancer, it is important to make the distinction between a procedure, a treatment, and reconstructive surgery.

§ Procedure: Such as the Sentinel Node Biopsy or a colonoscopy - are diagnostic. § Treatment: Such as prostatectomy, removal of the prostate, is a surgery to surgically remove cancer cells. § Reconstruction: Specifically, breast reconstruction is not a treatment for cancer. And it is elective. It is an optional post-treatment surgery to rebuild a breast.

In the case of breast cancer, Sentinel Node Biopsy will diagnose the cancer, a mastectomy to remove the cancer and a reconstruction to rebuild the breast. A breast can be rebuilt through several different types of reconstructive surgery.

What people don’t often realize is that breast reconstruction surgery is particularly invasive and is beyond the surgery typically associated with getting breast implants. It can leave lasting side effects that are often more debilitating then any of the other procedures or treatments. With a significant increase in women electing for this option, it is important for us to consider how these surgeries impact the body and understand the side effects as we proceed to apply the science of yoga to the recovery.

Taken from the National Cancer Institute website is information and details about breast reconstruction.

Courtesy of the National Cancer Institute (http://www.cancer.gov)

What is breast reconstruction? ‘Many women who have a mastectomy—surgery to remove an entire breast to treat or prevent breast cancer—have the option of having more surgery to rebuild the shape of the removed breast.

Breast reconstruction surgery can be either immediate or delayed. With immediate

© yoga4cancer 2018 60 reconstruction, a surgeon performs the first stage to rebuild the breast during the same operation as the mastectomy. A method called skin-sparing mastectomy may be used to save enough breast skin to cover the reconstruction.

With delayed reconstruction, the surgeon performs the first stage to rebuild the breast after the chest has healed from the mastectomy and after the woman has completed adjuvant therapy.

A third option is immediate-delayed reconstruction. With this method, a tissue expander is placed under the skin during the mastectomy to preserve space for an implant while the tissue that was removed is examined. If the surgical team decides that the woman does not need radiation therapy, an implant can be placed where the tissue expander was without further delay. However, if the woman will need to have radiation therapy after mastectomy, her breast reconstruction can be delayed until after radiation therapy is complete.

Breasts can be rebuilt using implants (saline or silicone) or autologous tissue (that is, tissue from elsewhere in the body). Most breast reconstructions performed today are immediate reconstructions with implants.

How do surgeons use implants to reconstruct a woman’s breast? Implants can be inserted underneath the skin and chest muscle that remain after a mastectomy, usually as part of a two-stage procedure.

In the first stage, the surgeon places a device called an expander under the chest muscle. The expander is slowly filled with saline during visits to the doctor after surgery. In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant 6 weeks to 6 months after mastectomy.

Expanders can be placed as part of either immediate or delayed reconstructions. An optional third stage of breast reconstruction involves recreating a nipple on the reconstructed breast.

How do surgeons use tissue from a woman’s own body to reconstruct the breast? In autologous tissue reconstruction, a piece of tissue containing skin, fat, blood vessels, and

© yoga4cancer 2018 61 sometimes muscle is taken from elsewhere in a woman’s body and used to rebuild the breast. This piece of tissue is called a flap. Different sites in the body can provide flaps for breast reconstruction. § TRAM flap: Tissue, including muscle, that comes from the lower abdomen. This is the most common type of tissue used in breast reconstruction. § DIEP flap: Tissue that comes from the abdomen as in a TRAM flap, but contains skin, fat and the Deep Inferior Epigastric Perforator. The latter is the main blood vessel that runs through the tissue that will be used to reconstruct the breast. § Latissimus dorsi flap: Tissue that comes from the middle and side of the back.

More rarely, flaps are taken from the thigh or buttocks. Wherever the flaps come from, they can either be pedicled or free. With a pedicled flap, the tissue and attached blood vessels are moved together through the body to the breast area. With a free flap, the tissue is cut free from its blood supply and attached to new blood vessels in the breast area.

Rarely, an implant and autologous tissue will be used together. They might be used together when there isn’t enough skin and muscle left after mastectomy to allow for expansion and use of an implant (3). In these cases, the autologous tissue is used to cover the implant.

How do surgeons reconstruct the nipple and areola? After the chest heals from reconstruction surgery and the woman has completed adjuvant therapy, a surgeon can reconstruct the nipple and areola. Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple. A few months after nipple reconstruction, the surgeon can recreate the areola. This is usually done using tattoo ink. However, in some cases, skin grafts may be taken from the groin or abdomen and attached to the breast to create an areola.

Skin-sparing mastectomy that preserves a woman’s own nipple and areola (called nipple- sparing mastectomy) is performed by some surgeons on select women who are at low risk of cancer recurrence.

What factors can affect the choice of breast reconstruction method? Most women can choose their type of breast reconstruction method based on what is

© yoga4cancer 2018 62 important to them. However, some treatment issues are important to think about. For example, radiation therapy can damage a reconstructed breast, especially if it contains an implant. Therefore, if a woman knows she needs radiation therapy after mastectomy, that information may affect her decision.

Sometimes, a woman may not know whether she needs radiation therapy until after her mastectomy. This can make planning ahead for an immediate reconstruction difficult. In this case, it may be helpful for the woman to talk with a reconstructive surgeon in addition to her breast surgeon or oncologist before choosing the type of reconstructive surgery.

Other factors that can influence the type of reconstructive surgery a woman chooses include the size and shape of the breast that is being replaced, the woman’s age and health, the availability of autologous tissue, and the location of the breast tumor.

Each type of reconstruction has factors that a woman should think about before making a decision. Some of the more common concerns are listed below.

Reconstruction with Implants Surgery and recovery § Enough skin and muscle must remain after mastectomy to cover the implant § Shorter surgical procedure than for reconstruction with autologous tissue; little blood loss § Recovery period may be shorter § Many follow-up visits may be needed to inflate the expander and insert the implant Possible complications § Infection § Pooling of blood (hematoma) within the reconstructed breast § Extrusion of the implant (the implant breaks through the skin) § Implant rupture (the implant breaks open and saline or silicone leaks into the surrounding tissue) § Formation of hard scar tissue around the implant (known as a contracture) Other considerations § Can be damaged by radiation therapy

© yoga4cancer 2018 63 § May not be adequate for women with very large breasts § Will not last a lifetime; the longer a woman has implants, the more likely she is to have complications and to need to have her implants removed or replaced § Silicone implants may provide a more natural-looking breast shape than saline § The Food and Drug Administration (FDA) recommends that women with silicone implants undergo periodic MRI screenings to detect possible “silent” rupture of the implants

Reconstruction with Autologous Tissue Surgery and recovery § Longer surgical procedure than for implants; more blood loss § Recovery period may be longer § Pedicled flap reconstruction is a shorter operation than free flap but requires more donor tissue § Free flap reconstruction uses less donor tissue than pedicled flap reconstruction but is a longer, highly technical operation requiring a surgeon with experience re-attaching blood vessels Possible complications § Necrosis (death) of the transferred tissue § Blood clots § Pain and weakness at the site from which the donor tissue was taken § Obesity, diabetes, and smoking may increase the rate of complications Other considerations § May provide a more natural breast shape than implants § Less likely to be damaged by radiation therapy than implants § Leaves a scar at the site from which the donor tissue was taken

Any type of breast reconstruction can fail if healing does not occur properly. In these cases, the implant or flap will have to be removed. If an implant reconstruction fails, a woman can sometimes have a second reconstruction using autologous tissue. If an autologous tissue reconstruction fails, a second flap cannot be moved to the breast area, and an implant cannot be used for another reconstruction attempt due to the lack of chest tissue available to cover the implant.

What type of follow-up care and rehabilitation is needed after breast reconstruction? Any type of reconstruction increases the number of side effects a woman may experience compared with those after a mastectomy alone. A woman’s medical team will watch her closely after surgery for complications, some of which can occur months or even years later.

Women who have autologous tissue reconstruction may need physical therapy to help them make up for weakness experienced at the site from which the donor tissue was taken, such as abdominal weakness. A physical therapist can help a woman use exercises to regain strength, adjust to new physical limitations, and figure out the safest ways to perform everyday activities.’

© yoga4cancer 2018 65 Reference Images The following images will illustrate breast reconstruction methods described. In addition, here are several anatomy details to use as reference. These will be helpful as you go forward to understand the short- and long-term side effects of cancer treatments and breast reconstruction.

Anatomy of the breast

Latissimus Dorsi Muscle

Rectus Abdominis Muscles

Side view of breast area with filled tissue expander in place

A Tissue expander-filled

B Port

C Catheter

D Syringe

E Ribs

F Pectoralis major muscle

G Other muscles of the chest wall (3 lines to one letter)

Breast Reconstruction: TRAM FLAP

TRAM, trans-rectus abdominis muscle reconstruction.

A Lines of reconstructed breast incisions

B Right trans rectus abdominis muscle

C Left TRAM muscle is swung over to recreate the new breast

D Incision circle of re-positioned “belly button" incision

E Line of abdominal surgery

Breast Reconstion usind the Deep Inferior Epigastric Perforator. The latter is the main blood vessel that runs through the tissue that will be used to reconstruct the breast.

A Lines of reconstructed breast incisions

B Circling "belly button" that is unchanged.

C Line of abdominal surgery incision

Breast Reconstruction: LAT FLAP

So far, this dense module has been focused on the science, details of cancer and its treatments so that as an educated professional, you can understand the individualized and complex nature of the diagnosis. There are hundreds of cancers and even more variations on treatment protocols or plans. And as you might expect, there is a huge array of how individuals can react to diagnosis, treatments or recovery.

Since cancer manifests itself in everyone differently, every patient has a history of conditions unrelated to their cancer, and each individual reacts to surgery, chemicals and radiation differently, so it is difficult to identify the side effects in an individual. We can conjecture based on observation or your own personal experience. If you are a survivor, you might have had certain side effects or heard reports from others, there are warnings by the medical community and published information. But, I strongly urge you to remember the individuality of cancer and that everyone reacts differently.

To help you, I have compiled a list of potential side effects from cancer treatments. Although it is long, it is not totally comprehensive. There can be others. This list includes both short- and long-term side effects. Some are common to all patients, such as anxiety. Some may seem common and are not, such as hair loss. Some may be surprising because they are not commonly discussed or disclosed, such as constipation and premature menopause. And remember, some individuals will not experience any side effects, but will have been warned about these by doctors, literature, and friends that can induce fear, depression and worry. My aim is that this list helps to cultivate your awareness of the most feared and common side effects so you can better understand their journey and apply this understanding to your yoga practice.

All side effects can be very debilitating and often have an impact on a cancer patient or survivor long after the cancer treatments have been completed. However, yoga can help reduce and sometimes prevent many. In the subsequent sections, you will learn more about what pose or breathing instructions would be useful to prevent, help and improve many of the side effects listed below. To follow, more in depth information on a few of the more common

Common Side Effects from Cancer Treatments: Abdominal Pain Fever Nausea Allergic Reactions Gas (Flatulence) Neuropathy Anemia Hair Changes Nosebleeds Anxiety Headaches Numbness Appetite Changes Heart Problems* Osteoporosis (Bone Loss) Armpit Discomfort Hematoma (Blood Build-Up) Phantom Pain Back Pain High Blood Pressure (Hypertension) Post-Traumatic Stress Disorder Bleeding and Bruising Problems Hot Flashes (PTSD) Blood Clots and Phlebitis Infection Premature Menopause Bone and Joint Pain Injection Site Reaction Rash Breathing Problems Insomnia (Trouble Sleeping) Scar Tissue Formation Cold and Flu Symptoms Itching Skin Discoloration Constipation Kidney Problems Skin Sensitivity Coughing Leg Cramps Swallowing Problems Dehydration Liver Problems Sweating Delayed Wound Healing Loss of Libido Taste and Smell Changes Depression Low Blood Pressure (Hypotension) Urinary Tract Infection (UTI) Diarrhea Low White Blood Cell Count Urine Discoloration Dizziness Lung Problems Vaginal Dryness Dry Mouth, Eyes, Skin Lymphedema Vision and Eye Problems Electrolyte Imbalance Memory Loss Vomiting Endometriosis Menopausal Symptoms Weakness Fatigue Mouth and Throat Sores Weight Changes Fertility Issues Nail Changes

1) Lymphedema Source: Courtesy of the National Cancer Institute (http://www.cancer.gov)

‘Lymphedema occurs when the lymph system is damaged or blocked. Fluid builds up in soft body tissues and causes swelling. It is a common problem that may be caused by cancer and cancer treatment. Lymphedema usually affects an arm or leg, but it can also affect other parts of the body. Lymphedema can cause long-term physical, psychological, and social problems for patients. Lymphedema often occurs in breast cancer patients who had all or part of their breast removed and axillary (underarm) lymph nodes removed. Lymphedema in the legs may occur after surgery for uterine cancer, prostate cancer, lymphoma, or melanoma. It may also

When the lymph system is working as it should, lymph flows through the body and is returned to the bloodstream. § Fluid and plasma leak out of the capillaries (smallest blood vessels) and flow around body tissues so the cells can take up nutrients and oxygen. § Some of this fluid goes back into the bloodstream. The rest of the fluid enters the lymph system through tiny lymph vessels. These lymph vessels pick up the lymph and move it toward the heart. The lymph is slowly moved through larger and larger lymph vessels and passes through lymph nodes where waste is filtered from the lymph. § The lymph keeps moving through the lymph system and collects near the neck, then flows into one of two large ducts: o The right lymph duct collects lymph from the right arm and the right side of the head and chest. o The left lymph duct collects lymph from both legs, the left arm, and the left side of the head and chest. § These large ducts empty into veins under the collarbones, which carry the lymph to the heart, where it is returned to the bloodstream.

When part of the lymph system is damaged or blocked, fluid cannot drain from nearby body tissues. Fluid builds up in the tissues and causes swelling.

Possible signs of lymphedema include swelling of the arms or legs.

§ Swelling of an arm or leg, which may include fingers and toes. § A full or heavy feeling in an arm or leg. § A tight feeling in the skin. § Trouble moving a joint in the arm or leg. § Thickening of the skin, with or without skin changes such as blisters or warts. § A feeling of tightness when wearing clothing, shoes, bracelets, watches, or rings. § Itching of the legs or toes.

Daily activities and the ability to work or enjoy hobbies may be affected by lymphedema.

These symptoms may occur very slowly over time or more quickly if there is an infection or injury to the arm or leg.

Cancer and its treatment are risk factors for lymphedema. Lymphedema can occur after any cancer or treatment that affects the flow of lymph through the lymph nodes, such as removal of lymph nodes. It may develop within days or many years after treatment.

§ Most lymphedema develops within three years of surgery. Risk factors for lymphedema include the following: § Removal and/or radiation of lymph nodes in the underarm, groin, pelvis, or neck. The risk of lymphedema increases with the number of lymph nodes affected. There is less risk with the removal of only the sentinel lymph node (the first lymph node to receive lymphatic drainage from a tumor). § Being overweight or obese. § Slow healing of the skin after surgery.

§ A tumor that affects or blocks the left lymph duct FACT: Up to 15.5% of all cancer or lymph nodes or vessels in the neck, chest, survivors and 30% of breast cancer underarm, pelvis, or abdomen. survivors develop Lymphedema. § Scar tissue in the lymph ducts under the

collarbones, caused by surgery or radiation Source: Journal of Oncology therapy.

Loss of bone mass is common as people age. Cells that help rebuild bone don’t get replaced at the same rate, resulting in bones that become thin and porous (full of tiny holes). This condition, called osteoporosis, is the most common type of bone disease. People with osteoporosis are more likely to suffer fractures and painful disabilities because of weakened, fragile bones.

More than 80% of osteoporosis cases occur in post-menopausal women, who have lower levels of estrogen, a vital hormone for bone density. Bone loss can also occur in men or women with poor nutrition, inadequate intake of calcium and vitamin D, or who are confined to bed for long periods due to illness.

Cancer treatments can also contribute to bone loss. Possible causes of cancer-related osteoporosis and bone fractures include: § Some chemotherapy drugs can decrease calcium levels in the body § Radiation therapy to the pelvic region, especially for women over the age of 65 § Spread (metastasis) of cancer to the bone from the original tumor site § Hormone therapy to suppress testosterone in prostate cancer patients § Steroid treatments

A nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body. It usually begins in the hands or feet and gets worse over time. Neuropathy may be caused by cancer or cancer treatment, such as chemotherapy. It may also be caused by physical injury, infection, toxic substances, or conditions such as diabetes, kidney failure, or malnutrition. Also called peripheral neuropathy.

4) Weight Gain

When people think of cancer patients, they imagine skinny, fragile bodies. And yes, this is often the case during active treatment, prolonged treatment or late stages of cancer. But for many people, weight gain is the side effect of cancer treatment. Weight gain has significant impact on both physical and psychological aspects of a survivor’s life. However, the greatest concern of weight gain is possible recurrence.

Obesity is a key indicator of both cancer incidence and recurrence. The American Cancer Society recommends that obese individuals increase the standard weekly exercise from 150 minutes to 300 minutes per week to reduce the chances of cancer or recurrence. Thus, managing one’s weight should be a focus of any cancer patient or survivor (and all people).

5) Menopausal symptoms Courtesy of MD Anderson Cancer Center

Menopausal symptoms, including hot flashes, night sweats, and vaginal dryness, affect many women who receive chemotherapy, radiation to the pelvis, or surgical removal of the ovaries. These symptoms also affect women who were already postmenopausal at the time of their diagnosis, since survivors of several types of cancer (e.g., breast cancer, endometrial and ovarian cancers) are often advised to stop taking hormone replacement therapies containing estrogen.

© yoga4cancer 2018 76 6) Constipation Constipation is a common problem for cancer patients. Cancer patients may become constipated by any of the usual factors that cause constipation in healthy people. These include age, changes in diet and fluid intake, and not getting enough exercise. In addition to these common causes of constipation, there are other causes in cancer patients. § Medicines § Diet § Bowel movement habits § Conditions that prevent activity and exercise (e.g. broken bones, fatigue, weakness, depression, etc.) § Intestinal disorders § Muscle and nerve disorders § Changes in body metabolism § Environment § Narrow colon (e.g. scars or surgery)

7) Chemobrain Source: MD Anderson Cancer Center

Chemobrain, formally known as cognitive dysfunction, is a symptom reported by many cancer patients. Chemobrain, or difficulty in efficiently processing information, is a legitimate, diagnosable condition that may be caused by chemotherapy treatment, the cancer itself, or secondary medical conditions such as anemia.

Always tell your doctor about any changes in your thinking. He or she may refer you to a neuropsychologist. Neuropsychological evaluations for chemobrain are considered medical procedures, not a mental health benefit, and as such are covered by health insurance.

Symptoms of Chemobrain § Difficulty concentrating on a single task § Problems with short-term memory; forgetting details of recent events § Feeling mentally “slower” than usual § Confusing dates and appointments

© yoga4cancer 2018 77 § Misplacing objects § Fumbling for the right word or phrase These symptoms generally will fade after chemotherapy ends, but each patient is different. Some may take a year or more after treatment to feel normal again; others may never regain full cognitive function.

Treatment Not many treatments for chemobrain currently exist, although some patients may find relief from some drugs. People can use the following coping strategies to minimize the effects of chemobrain: § Exercise: Even five minutes of mild to moderate activity may improve mental function. § Memory Aids: Using a notebook, planner or list to keep track of things as they come to mind. A small recorder can also come in handy. § Treat fatigue and sleep problems: these conditions can worsen chemobrain symptoms. § Manage depression and anxiety: easing stress and elevating mood can ease chemobrain symptoms. § Minimize distractions: Employers are required by the Americans with Disabilities Act to make reasonable accommodations for health-related impairments such as chemobrain. A more soundproof environment, such as an office or a cubicle in a different location can decrease distractions and improve concentration in the workplace.

In 2014, there was more positive research on yoga and ‘cognitive problems’ for breast cancer survivors. In a randomized controlled trial, it was found that participants of a 12-week Hatha yoga program vs. a control witnessed a 3% improvement in their cognitive ability. Furthermore, those that practiced most frequently (vs. less frequently) reported better improvement. (Source: Oncology Nurse Advisor 2014)

8) Fatigue Source: American Society of Clinical Oncology, 2014

Fatigue can be hard to describe. You feel like you don’t have any energy and are tired all the time. But there’s not a specific cause, such as doing errands all day, working out, or other exertion. When you’re tired from exertion, if you get enough sleep that night, you usually feel

© yoga4cancer 2018 78 better the next day. With fatigue, you feel tired all the time and lose interest in people and the things you normally like to do. Fatigue is the most common side effect of breast cancer treatment. Some doctors estimate that 9 out of 10 people experience some fatigue during treatment and it can last for months after treatment ends.

The American Society of Clinical Oncology (ASCO) guidelines on fatigue recommend: § All cancer patients be screened for fatigue at least once a year; § Anyone who reports moderate to severe fatigue should have a comprehensive assessment; § Any treatable contributing factors, such as pain, depression, sleep problems, lack of exercise, poor diet, anemia, and treatment side effects, should be addressed.

The guidelines also say that fatigue is best treated by remedies that don’t involve medicines, including: § Physical activity: Doctors should encourage all fatigue sufferers to do at least 150 minutes of moderate exercise (fast walking, cycling, swimming) per week, with two more strength- training sessions per week, unless the strength sessions shouldn’t be done because of lymphedema or other issues. Survivors who have a high risk of injury from exercise, such as people with neuropathy or heart problems, should be referred to a physical therapist or exercise specialist. § Psychosocial interventions: Cognitive behavioral therapy and other types of talk- educational therapy have been shown to ease fatigue in cancer survivors. Doctors should refer people to psychosocial therapists who specialize in cancer. § Mind-body interventions: Complementary and holistic mindfulness-based therapies such as yoga and acupuncture have been shown to reduce fatigue in cancer survivors. More research is needed before touch therapy, massage, music therapy, relaxation therapy, Reiki, and Qigong can be recommended. Doctors should refer people to licensed/certified practitioners who specialize in cancer.

The guidelines say that some stimulants and other medicines that boost wakefulness can help ease fatigue in people with severe cases or people who are still receiving cancer treatment. But there isn’t much scientific evidence that these medicines help treat fatigue in people who have finished cancer treatment and are considered disease-free. Some small studies have

9) Anxiety and Depression Source: National Cancer Institute

Anxiety is a state of feeling apprehension, uncertainty, and fear. High levels of concern and unremitting worry usually lead to some level of dysfunction.

Up to 21% of cancer patients may have persistent anxiety symptoms, although it appears that only a small percentage had any symptoms of anxiety prior to cancer diagnosis or treatment.

Cancer patients and their families commonly experience anxiety over fears, therapies, their ability to live life as they have known it, and uncertainty about their future. Their distress may also be related to other physical, psychological, social, spiritual, practical, end-of-life, and loss issues that derive from the cancer. Anxiety may also be a component of other syndromes (e.g., a primary anxiety disorder or an underlying panic disorder that is unmasked by advanced cancer).

Anxiety often co-occurs with adjustment disorders and/or depression. An adjustment disorder is a psychological response to an identifiable stressor which results in the development of clinically significant emotional or behavioral symptoms. (Ref. 1) Common symptoms seen in depression, such as loss of appetite, decreased libido, and insomnia, may also be part of anxiety states.

10) Insomnia Source: Courtesy of the National Cancer Institute (http://www.cancer.gov)

Insomnia is an experience of inadequate or poor-quality sleep characterized by one or more of the following: difficulty falling asleep, difficulty maintaining sleep, early morning awakening, non-refreshing sleep, or daytime consequences of inadequate sleep (e.g., tiredness or fatigue, anergia, poor concentration, or irritability).

© yoga4cancer 2018 80 Insomnia is a very common complaint. Some 30 to 40% of adults in the general primary care population report difficulty sleeping at some time over a 12-month period, and 10 to 15% report chronic problems with insomnia. The prevalence of insomnia increases with age and is associated with physical illness such as cancer. In most studies of insomnia among cancer patients, the majority of respondents reported insomnia. Studies show prevalence rates as high as 63%.

11) Heart Problems

To list heart problems as a side effect from cancer treatments is a very broad statement and a scary thought. We know that heart disease is the leading cause of death in the US; about 600,000 people die every year. (Source: Center of Disease Control and Prevention). Getting ‘cancer’ does not nullify the risk or challenges faced from other diseases—such as heart disease. And often due to the environmental factors (such as the very rapidly increasing rate of obesity) and other diseases usually parallel a cancer diagnosis. Cancer treatment can worsen the health and function of the cardiovascular system.

Harvard Medical School says that: Cancer treatments can be the proverbial double-edged sword. Radiation therapy and chemotherapy are increasing the number of people who survive cancer. These treatments can also cause these same people to develop cardiovascular disease.

Source: Harvard Health Publications, August 2012

#3.1 – Scientific Foundation of the y4c Methodology

Yoga is as scientific as it is spiritual. The laws of physics govern the body and movement. The law of gravity establishes the principles of movement, including resistance, restriction and compression. We experience these movement principles when we practice yoga. Through our practice of movement, meditation and breathing, we also discover the science of physiology hard at work, and in this methodology, we explore the Relaxation Response as an example. Powerful concepts from physics and biology provide the science behind yoga that explain how it works to keep the body and mind clear, balanced, and strong.

Everyone knows yoga is “good for you,” but not everyone knows why. The common assumption is that yoga is a great relaxation technique or a fabulous way to get a good muscle ‘stretch’. We also hear many other ways that yoga will make life better, solving all of our physical, mental, and spiritual problems; claims so broad they invite skepticism. Many people have asked the valid question: “What could yoga really do for me as a cancer survivor? And why should I believe you, the yoga teacher?” A trained yoga4cancer teacher can reply: “Explore the scientific, fact-based principles and benefits of yoga, and your experience will provide the answer.” But before we explore the benefits, let us more closely define yoga. What is it? How does it work?

Yoga is ancient, and it is widely practiced in India and other countries where people use it daily to maintain health and spiritual well-being. Until recently, little research or interest has come from the West about this long tradition of physical and spiritual practices. The y4c Methodology introduced here will help ground this ancient practice in Western scientific principles and draw upon empirical research.

Yoga can be defined as a way to position the body for the purpose of practicing patterned breathing and movement. The goal is to bring balance and alignment to all body parts and systems: muscles, bones, organs and the mind. Yoga is a holistic path to wellness, focusing on the interconnection of all body systems. To help survivors heal as whole persons, yoga seeks to strengthen all the systems, both individually and collectively. Let’s break down exactly

The Physics and Physiology of Yoga

There are five fundamental principles involving physics and physiology that the y4c method builds its foundation upon. These principles are the science behind why yoga is so effective for cancer patients and survivors. They are:

1. Gravity 2. Movement 3. Compression and Restriction 4. Resistance 5. Relaxation Response

1) Gravity: Mysteries of Nature Unveiled by Yoga

Gravity is the force that pulls our physical bodies towards the earth. The force of gravity has a profound impact on our bones, muscles, and body fluids. Thus, gravity plays a role in our practice of yoga, and our practice of yoga has a direct impact on our bodies and bodily fluids. Lymphatic drainage, venous return, and bone building are not commonly associated with yoga, but are important biological functions in the pursuit of good health.

Understanding how the human body works and how yoga helps to make it work better, easier, and more efficiently is the beginning of a healthy partnership and unveils some of the mysteries of yoga as well as our bodies.

When body fluids (blood and lymph) are flowing properly, we strengthen the immune system and aid in the expulsion of waste and potentially harmful toxins. Lymphatic drainage and venous return are two important body functions that keep things flowing using the natural tools of muscle movement and gravity. Yoga can assist.

Our hearts pump oxygenated blood through arteries to every part of the body, and the deoxygenated blood back to the heart through veins. When we are in an upright position, deoxygenated blood must travel upward through veins from the lower body to get back to the heart. Like water being pumped uphill through a hose, the venous return of blood is slowed by the pull of gravity. Extended inactivity can cause blood and lymph to pool in the legs, potentially causing swelling, blood clots and varicose veins. Yoga inversions use gravity to help aid venous return to the heart from the lower body, and more efficient recirculation of oxygenated blood.

Lymphatic drainage

The lymphatic system is much more dependent on gravity than the circulatory system. Inversions, or a simple positional shift such as lifting our arms, can be very effective for improving lymphatic drainage, reducing the risk or symptoms of lymphedema.

Bone building

Resistance against the pull of gravity puts the stress on our bones that is needed to keep them strong. Osteoblasts and osteoclasts are the specialized bone cells responsible for bone mass. Osteoblasts produce bone matrix, which results in increased bone mass. Osteoclasts reabsorb bone matrix and result in decreased bone mass. Osteoblasts and osteoclasts maintain a dynamic balance in response to the mechanical needs of the bones. Just as movement increases muscle strength, resistance against gravity increases the activity of osteoblasts and strengthens bones. Yoga poses that involve weight bearing on the bones, such as standing and balancing poses, increase the active resistance of our bones against gravity, improving bone health. Additionally, as our muscles pull on our bones in order to move them, this stress also aides in the strengthening of bone.

Physical Forces Involved: Gravity, Resistance, Movement

Benefits: Strengthens legs, feet and core, improves balance, builds bone mass, releases tension in the hip of the swinging leg, and creates confidence especially in those suffering from neuropathy.

2) Movement: The body is built to move.

Our job as teachers is simple: help students to keep their Immune System healthy! Movement is one essential, natural way to get that job done and to keep the body unfriendly to cancer. Our bodies were designed to move and, when we do so in a healthy way, we massage organs and detox body systems such as the heart, lungs and lymph nodes. Lack of movement endangers both the body and the mind.

The human body exists in an ongoing and natural process of growth and decay; our bones are losing mass and being re-built, old cells are dying and new ones are being born, dividing and growing. Without movement, decay occurs faster than growth, and the body begins to break down. For instance, extended bed rest causes muscles to atrophy and bones to thin. Movement, even a tiny amount, can help to reverse both. It helps to keep body systems in a state of balance or homeostasis.

Let’s define ‘Movement’ Motion is simply a change in position. Staying healthy involves moving many things into, out of, and with our bodies. For example, we move our bones to take our bodies from one place to another. Within the body, there is constant movement of essential body fluids (blood and

© yoga4cancer 2018 85 lymph), oxygen and other material (food and fecal matter). Voluntary movement is movement that we initiate and control; for example, moving our legs to take a walk, or the jaw to chew food. Turning a walk into a runner’s pace is a decision-controlled movement––it is voluntary. Other things are not as controllable; for example, increasing the blood supply to muscles that elongate our stride to a running pace, or moving that bagel through the digestive tract. However, these involuntary movements can be influenced, assisted and enhanced by specific movements of a yoga practice.

Voluntary movements in yoga, such as manipulating breath, or rotating the body into a twist, are natural and familiar to a yoga teacher. Less obvious may be the internal involuntary movements that occur due to the manipulation of the breath and body. For example, holding Warrior 3 Pose for 60 seconds is a voluntary action. However, while in this pose, gravity places stress on the bones of the standing leg. As a result, the leg bones will begin to make themselves stronger, an involuntary action inspired by the decision to hold Warrior 3 pose for 60 seconds.

A Closer Look at Movement Movement happens when muscles alternate between contraction and relaxation, or shortening and lengthening. To lift an arm bone, some muscles must lengthen while others shorten; a heartbeat is muscle contraction and relaxation to move blood; and the diaphragm muscle draws air into our lungs in a similar movement pattern. A muscle is body tissue designed to lengthen, contract, twist, and activate all parts of the body.

Types of Movement:

Movement, voluntary or involuntary, can describe almost every action in the body. Let’s look at all the movement that is happening at any one time in the body, and with this understanding, we can better predict what is happening when we practice yoga.

• Cardiovascular Movement When we use active yoga poses or sequences, we are engaging our skeletal muscles to move. All muscles consume large amounts of oxygen. Because oxygen and nutrients are delivered to muscles through the blood, this causes the heart to pump faster and the circulation rate to increase in order to support the metabolic and contractile activity of the

© yoga4cancer 2018 86 muscles. Exercising our heart makes it both stronger and more efficient, improving cardiovascular health. Increased circulation also aids in the movement of lymphatic fluid throughout the body.

• Muscle Movement We have various kinds of muscles in the body, including skeletal muscles, smooth muscles, and a cardiac muscle (the heart). Smooth muscles line our gut and other internal organs, and are responsible for involuntary actions, such as digesting food. Our diaphragm muscle is considered a skeletal muscle, although it can function involuntarily in order for us to breathe, and we can also manipulate this muscle in order to adjust our breathing pattern.

Moving our skeletal muscles maintains and improves strength and flexibility, which allows us to perform the activities of daily living essential to our quality of life. The ability to bend down and tie our shoelaces, carry groceries, and put food away on a top shelf without pain, discomfort or exhaustion are all forms of independence that we may take for granted until we encounter the physical challenges that come with surgery, illness, inactivity or old age.

Both strength building and creating flexibility involve the fundamentals of skeletal muscle movement. Muscle groups work together by contracting alternatively in order to move our joints. As we repeatedly perform demanding actions, such as lifting a bag of heavy groceries or holding a strenuous yoga pose, we create miniscule tears in our muscle tissue. When the body repairs this tissue, the muscle becomes stronger in order to better perform the strenuous movement. This is how our muscles become stronger over time. The strength of our muscles is tested by many factors including gravity, resistance and weight.

Flexibility is the ability to move in all the directions we desire in order to accomplish daily activities. It refers to the range of movement in a joint or series of joints. Stretching is the effort to expand, making space between two points, as in moving point A away from point B. In the effort to stretch a muscle, you are trying to lengthen it by working it in two directions simultaneously. There is a directional quality to movement different from the effort. Extension is movement in an outward direction with the goal of expanding the space between two points.

Perhaps the most popular reason people begin practicing yoga is for a “good stretch” or to gain flexibility. The following link is to an interesting article and research that will shed light on a long-held assumption about what happens to muscles when we stretch: “Why Stretching Doesn't Make You More Flexible” - http://huff.to/1uoPnau

A twist is a spiral movement around an axis. The action of twisting is created with two opposite directional movements. For example, in a closed seated spinal twist, the right shoulder moves away from the left hip in one rotational direction. At the same time, the opposite rotational direction is created with the left hip moving left away from the right shoulder. The many muscles involved shorten or lengthen around the spinal axis to create the twist. To be safe and receive all the benefits, the spine must be fully lengthened and held upright during a twist.

• Breath Movement

Everyone has a first breath. Everyone has a last. Breathing fills every second of our lives. Yet, most of us take breathing for granted, as if it is totally automatic. We think we do not need lessons in how to use it. But to make breathing healing and to improve its quality, there is much to learn. When explored in the context of cancer survivorship, breathing is much more than life sustaining. Breathing with awareness – a mindful breathing - will be a vital tool in cancer recovery for your students. All breathing, but especially the kind of mindful breathing done in yoga, is made possible by the contraction of the diaphragm, the muscle located horizontally in the base of the chest cavity. So, while breath does feel automatic, it is a muscular movement like any other, and can be consciously strengthened and trained.

© yoga4cancer 2018 88 By our simple definition of movement, breathing is the exchange of air coming in and out of the body. The gas changes location and so do many other body parts. Consider all the different body tissues, muscles and bones that change location with a single breath. This is yoga in action, yoga in motion.

• Lymphatic Drainage Unlike the cardiovascular system, the lymphatic system does not have a pump to move the four liters of lymph fluid daily through the body. Consequently, the lymphatic system depends on physical movement and gravity to keep things flowing or prevent buildup of unwanted waste (toxins, cells, or other waste). Lymphatic drainage is the continuous one- directional movement of lymph fluid from all parts of our body through the lymph channels toward the thoracic duct, the principle cleansing station of the body. This drainage process is created by several different kinds of movement.

Internal movement of lymph fluid created by:

§ Muscle Contraction § Muscle compression creates the squeeze and soak effect (See discussion on the Squeeze and Soak concept) § Increased heart rate moves blood, lymph fluid, and breath § Breathing moves the diaphragm and massages the thoracic duct

External movement of lymph fluid created by:

§ The natural pull of gravity § Lymphatic massage or brushing

Lymphatic massage is a technique developed in Germany for treatment of lymphedema, an accumulation of lymph fluid that can occur after lymph nodes are removed. Because the lymph nodes and channels are close to the skin, this simple gentle technique is a manual directional movement to follow the lymphatic channels and designed to increase flow of lymph fluid. See M. Földi and R. Strobenreuther, Foundations of Manual Lymph Drainage, Elseuier Mosby Press, 2003

© yoga4cancer 2018 89 • Elimination Excretion is a natural and essential process in all forms of life. Waste, toxins, dead cells and other non-useful materials are all eliminated from the body, which is critical for a healthy body. This is accomplished primarily by the organs of the lungs, kidneys and skin. When we exhale, the air depleted of oxygen is eliminated. You do not need it any more. Waste elimination, such as discharging feces and urine happens with the smooth muscles of the digestive tract and the urethra.

3) Compression and Restriction

Equally important, although not always recognized, is the science and significance of the prevention of movement. This statement may sound contrary to what we have learned about the necessity for movement. Let us explore a specific phenomenon that occurs during the prevention of movement, and how this action can deliver powerful benefits to the body.

Squeeze and Soak Compression

The term “squeeze and soak” was coined by B.K.S. Iyengar to describe the process by which poses that create physical compression, such as yoga twists, affect blood and lymph circulation. Iyengar teaches that twists cleanse internal organs in the same way that a sponge discharges dirty water when squeezed, and can then absorb fresh water and re-expand. Blood, lymph fluid and, for that matter, air, are squeezed out of the target area—and as compression is released, the area is soaked with fresh, oxygenated blood to fuel healthy organ and muscle function.

The health benefits of the “squeeze and soak” action in relationship to blood circulation have not been scientifically proven. However, recent studies have shown that lymphatic flow can be improved by compression. For instance, lymphatic massage therapy with its stretch and release rhythm, and compression stockings or sleeves are common methods to aid lymphatic drainage, using the principles of compression.

EXAMPLE: Crunch Twist

Physical Forces Involved: Gravity, Movement of legs, Restriction and Compression of abdominal organs when twisting. Benefits: Builds core strength and stabilizes lower spine, promotes lymphatic drainage from legs, improves venous return from lower extremities, provides stimulation of abdominal organs to encourage elimination.

4) Resistance The pull of gravity is an excellent example of our body’s use of resistance. Our skeletal structures stand in resistance to the pull of gravity, which means that by merely standing, we are already keeping our bones and muscles strong. But resistance is broader than gravity’s pull; it is movement against any opposing force, such as a wall, the floor, or a table.

In the science of physics and yoga, holding the body in stillness—resisting movement—can require as much muscular effort as propelling the body into motion. There are two kinds of resistance effort: active and passive. An example of active resistance would be holding a standing pose for a length of time, or for several breath counts. In this situation, muscular effort maintains the pose. The body is still, yet muscles are working.

© yoga4cancer 2018 91 An example of passive resistance would be removing muscular effort and allowing the force of gravity to hold the body in a stretch or twisting pose—a fundamental concept in restorative yoga.

A less familiar, but powerful, technique is to use an external force, such as a strategically- placed hand, yoga strap, or weight to assist in creating an inwardly-directed squeezing force. The goal is to gently guide body fluids in a specific direction. This technique is used successfully in lymphatic massage therapy to manage conditions such as lymphedema. Compression garments such as compression sleeves and stockings also create a similar, yet passive, force.

EXAMPLE: WARRIOR 3 AT WALL Physical Forces Involved: Gravity, Resistance Benefits: strengthens the whole body, improves balance and builds bone mass, stimulates the lymph system.

5) Relaxation Response Perhaps only second to achieving a ‘good stretch’, relaxation is one of the most common expected benefits of yoga, but it should not be underestimated or undervalued. The physiological benefits of relaxation are well researched and universally experienced.

The chronic stress of daily life can over-activate the sympathetic nervous system (the “fight or flight” response), potentially causing a wide range of effects including high blood pressure, headaches, fatigue, insomnia, anxiety and depression. In the 1960s, Dr. Herbert Benson of Harvard Medical School proved that the brain can be stimulated to create relaxation. He called

© yoga4cancer 2018 92 this the Relaxation Response, which is described as a physical state of deep rest that changes physical and emotional responses to stress. Relaxation occurs when the parasympathetic nervous system is activated – the opposite of “fight or flight.”

There is no single method of eliciting the relaxation response; however, practices that include these techniques are usually successful:

1. Slow your breathing 2. Focus the mind as if in meditation 3. Release muscle engagement

Meditation and restorative yoga poses can be particularly effective in eliciting the Relaxation Response.

EXAMPLE: LEGS UP THE WALL

Physical Forces Involved: Gravity, Resistance (passive) and Relaxation. Benefits: lymphatic drainage from legs, increases venous return from the lower body, activates the parasympathetic nervous system promoting physical relaxation and stress reduction.

Note: It might seem that legs up the wall create a risk rather than a benefit for lymphatic drainage. It has been argued that this action could create a problem with lymphatic flow (i.e., too much lymph moving towards the upper body). However, the lymph that flows from the extremities of the legs into the chest with the help of gravity then pools itself in the chest, heading for the thoracic duct where it will re-enter the cardiovascular system for cleansing.

© yoga4cancer 2018 93 This in no way puts the lymphatic flow from the extremities of head, chest and arms at risk, because lymph flows in only one direction, and once it arrives at the thoracic duct, it will not reverse that directional flow.

Conclusion: Scientific Foundation of the y4c Methodology

First, physics is at work on the biomechanics of the body in every pose or sequence when we do yoga. Second, whether in dynamic stillness or vinyasa sequence, these activities directly affect biology on a cellular level. Finally, research from every discipline says that regular exercise improves physical health as well as mental well-being. Movement strengthens bones, muscles, and provides benefits to essential body fluids like blood and lymph. The mechanics of movement in yoga poses is the foundation of the scientific explanation of how yoga works to assist the immune system in its job of protecting the body and decreasing the risk of cancer.

© yoga4cancer 2018 94 #3.2 - YOGA BENEFITS Now that we have discussed the basic scientific mechanisms by which yoga impacts the body, let’s explore the specific benefits of yoga on cancer patients and survivors. These ten benefits from yoga that address common side effects are just a sample, but it should awaken your curiosity and understanding. At the end of this section, we have provided a bibliography of relevant research to substantiate these claims and provide you with further information. Later in the training, specific poses, sequences and practices will also be provided to help you apply these benefits to your classes and put the science of yoga to work. Here are ten yoga benefits to have in your toolbox when someone asks, “Why is yoga beneficial for a cancer patient or survivor?”

Benefit # 1: Yoga Detoxifies the Body Detoxification is the metabolic process by which toxins, or harmful things, are changed into less toxic substances to be excreted. This is a vital process for everyone; but for cancer survivors undergoing treatments such as chemotherapy, radiation, hormone treatments, alongside a weakened Immune System, this is essential. Whether the goal is to remove environmental toxins like a flu virus, rotten food, or potential pathogen, detoxification should be part of every cancer survivor’s Wellness Plan. As we just discussed, yoga applies the science of physics by using the principles of movement, gravity, and resistance to help detoxify the body’s systems.

These yoga principles utilize and activate the lymphatic system—the body’s plumbing and trash removal system. As we learned, the lymphatic system has no muscle system like the heart for the cardiovascular system that circulates its fluids, so it depends substantially on the movement of muscles—especially the heartbeat and the diaphragm muscle—to flush waste from body of any toxins or potential cancer cells. Yoga increases lymphatic flow by placing the skeleton in certain postures, then moving them in specific patterns with our muscles. Because muscles need more blood flow when moving than when resting, movement increases the heartbeat. The demand for more blood results in a greater quantity of blood being pumped through the cardiovascular channels located throughout thebody. Since the lymph system parallels the cardiovascular system, lymph fluid also flows better when blood flows.

© yoga4cancer 2018 95 The largest lymph “waste” collector is the thoracic duct located in the body’s center as discussed in Module 2. It starts at bottom of the sternum, below the navel, reaching all the way to the base of the neck. Body movement, including diaphragmatic breathing, helps move the lymph fluid from the arms, legs, and head toward the thoracic duct. From there, lymph fluid is routed into the cardiovascular system through the liver, kidneys, and finally the bladder for discharge. So the aim of a yoga practice should be to flush all the lymph canals and nodes and aiding lymph fluid to flow in the direction of the thoracic duct.

Gravity also plays a role in detoxification. Inversions of the body such as a modified and supported Shoulderstand are a fundamental part of a strong yoga practice. Inversions utilize movement and body positioning to reverse the effects of gravity on our body, especially the cardiovascular and lymphatic drainage process to your central lymph collector, the thoracic duct. This use of gravity is essential to expelling toxins from extremities.

Another way yoga detoxes the body is through compression. We spoke earlier about Iyengar’s “squeeze and soak” idea that body twists cleanse internal organs in the same way that a sponge discharges dirty water when squeezed, then to absorb fresh water and re-expand. A common utilization of this technique is through abdominal twists that activate internal organs, driving the release of toxins into the lymphatic system. For all these reasons, detoxification is one of the most important benefits of yoga.

Benefit # 2: Yoga Strengthens the Body Cancer treatments such as chemotherapy and radiation weaken the body in the process of eliminating cancer as a life-threatening disease. These treatments seek to attack fast-growing cells, but unfortunately, healthy cells, such as bone cells, muscle cells, and the cells of most organs, are also affected. Additionally, during active treatment, people face fatigue that makes normal activity challenging and contributes to further muscle atrophy.

Many methods of building strength exist from weightlifting to vigorous walking to running. For a cancer patient and survivor, these forms of strength-building may be challenging or harmful during and after cancer treatments, or for other reasons unrelated to cancer. In the y4c Methodology, safety is a primary concern and our goal is to build strength in a gentle and effective way. For example, yoga uses a person’s body weight as resistance unlike

© yoga4cancer 2018 96 weightlifting. The y4c method eases the body into positions or using support systems, such as yoga props, to enable people to build strength over time and without harmful pressure on weakened or vulnerable areas of the body.

Bone Strengthening. Individually, bones are rigid organs; linked together, they form the skeleton, our internal support structure. Bone is living tissue made of calcium and collagens, and it is constantly changing—just like all body parts. New bone cells are always replacing old ones. Two bone cells are responsible for maintaining proper bones and density known as osteoblasts (which build bone) and osteoclasts (which diminish bone). As we get older, this balance gets disturbed and having thin, weak bones is considered an inevitable part of aging— especially in post-menopausal women. An overlooked side effect of cancer and its treatment is bone thinning; a reduction of bone density, which happens because the balance between these two bone cells is disturbed. Remember that chemotherapy is designed to interrupt the activity of cancer cells that are building abnormal tissues. Unfortunately chemotherapy affects the osteoblasts in much the same way it targets cancer cells.i

When bones and muscles are not made to work by using them every day, they do not build. Worse, deterioration can start quickly, especially as we get older. Research has shown that an excellent solution for weak bones is weight-bearing exercise. In a study conducted at the Hong Kong Polytechnic University in China in 2004, regular participation in weight-bearing exercise was beneficial for building peak bone mass and optimizing bone structure.ii Weight-bearing exercises, however, are commonly limited to the type done with barbells, so the common recommendation to build bones is to lift weights. A recent pilot study of osteoporosis and osteopenia sufferers suggested that 85% of the yoga practitioners gained bone density in both the spine and the hip, while nearly every member of the control group either maintained or lost bone mass.iii

I believe yoga is safer for bone-building than many gym routines because it stresses bones (or puts weight on them) in a precise, deliberate way. Through y4c Methodology, we use our body weight and focus on alignment through simple activities such as balancing on one foot.

Cardiovascular Strength and Fitness. Running is a popular exercise to improve cardiovascular strength and fitness. The goal is to enhance the body’s ability to deliver larger amounts of

© yoga4cancer 2018 97 oxygen to working muscles along with burning calories for weight management. Cardiovascular fitness such as running, walking, yoga or aerobics lowers the resting heart rate and improves oxygenation throughout the body. A 2013 study showed that yoga improved several cardiovascular health advantages, such as heart rate and respiratory function, at the same level as running.iv However, running and other high impact exercises may sometimes be risky for cancer survivors if they have weakened bones and joints. Therefore, a regular yoga practice can provide the same cardiovascular benefits as running without risk to joints and pain. Furthermore, heart disease can be reversed, or at least managed, through diet, meditation, and yoga, as reported in Dr. Dean Ornish’s Program for Reversing Heart Disease (Ballantine, 1992). Interestingly, Dr. Ornish is now studying whether prostate cancer can be reversed by diet changes and yoga.

Research shows that yoga helps keep a heart healthy and strong, and this is where the y4c Methodology is different from other approaches to yoga for cancer patients and survivors that focus only on gentle and restorative yoga. We teach patterned movement, ranging from slow and gentle to active, which sometimes may appear similar to cardiovascular exercise—heart rate and breathing increase and people sweat! An example is the inclusion of a modified Sun Salutations, which is a sequence of yoga poses designed to move the spine, arms, and legs in precise directions combined with deep breathing. The body moves, the heart beats, blood flows, and the breath deepens—all combining to build a strong heart muscle.

Benefit # 3: Yoga Increases Range of Motion and Flexibility As yoga teachers, we hear one thing all the time: “I can’t do yoga because I’m not flexible!” People say this before they’re diagnosed with cancer, or even if they do not have a cancer diagnosis. A flexible body is a useful body because we can do more with it, moving bones freely and without pain. We want to be able to reach for that shoebox on the top shelf, or bend over to tie our shoes.

Cancer treatments, however, can reduce flexibility because surgeries and radiation create scar tissue around organs, muscles and joints. The scarring can make the body stiff and painful to move. Other treatments such as chemotherapy and hormone therapy can and often create joint stiffness, which decreases the body’s ability to bend, limiting the muscles and bones’ ability to work together efficiently. All of these problems make life’s daily and necessary

A yoga practice will improve flexibility, making movement easier. Like a parked car that will not move after it sits on its wheels for eight months, we must keep the joints moving and the muscles stretching, or they “rust.” (Actually, if we do not use muscles, they deteriorate more rapidly than we imagine.) y4c Methodology looks at body movement in a logical, patterned way. Movements are slow and gentle, supported with careful attention placed on where the bones are moved and with what muscles. Increasing range of motion happens by alternating the extension and flexion of muscles combined with patterned movement. The goal is to help students explore their range of motion and give guidelines to help them through their various stages of recovery to regain range of motion, strength, and flexibility. You will also use passive, restorative poses and gravity to increase flexibility, as these use well-supported poses to soothe muscles.

Benefit # 4: Yoga Keeps the Spine Strong Having correct posture not only makes you look younger, but it keeps you healthier. Posture is the position in which we stack the bones of the spine (vertebrae) and use our muscles to keep them in place. When we properly align the body, the spine takes on a beautiful, natural ‘S’ curve. When we let the body slump, we change the spine’s shape and restrict body systems such as breathing and digestion, causing us to look and feel unhealthy. Bad posture limits and crowds the space necessary for lungs, stomach, intestines, and even the heart to function. We need oxygen to feed our cells, and we need our gastrointestinal system to be unrestricted so it can remove potential carcinogens from foods we have consumed. With good posture, adequate space exists for all the organs to work together. And, in this way, good posture aids detoxification.

Yoga works to align the bones of the spine to create good posture in every pose and movement. We also learn to use breathing to strengthen the spine as well as the rest of the musculoskeletal system.

The y4c Methodology employs deliberate exploration of the body’s skeletal structure to create proper alignment and good posture. We move the spine through five natural and healthy

© yoga4cancer 2018 99 directions in order to work the whole spine and keep it strong. They are: lengthening upward and downward, bending forward, bending backward, bending sideways, and twisting around the spinal column.

A recent study confirms the benefits of yoga for vertebral fractures and osteoporosis. But the research warns that too aggressive a practice could be harmful, leading to compression of the spine. The study recommended “mild spinal flexion and extension” and “moderate weight- bearing.”v This is why y4c Methodology focuses on supported poses and deliberate alignment to ensure that the spine is not put under too much stress. For example, we encourage a Supported Forward Bend with blocks in order to protect lower vertebrae while enabling a student to gain the benefits of a forward bend. Additional research, including examples of beneficial yoga postures, is detailed in Dr. Loren Fishman’s book: http://www.sciatica.org/downloads/YogaOsteoporosis_PilotStudy.pdf/

Finally, developing back strength for correct posture is essential for breast cancer survivors after axillary node surgeries or breast reconstruction surgery. (Details of these surgeries are discussed in Modules 2 and 5.) These procedures leave women (and some men) with significant scar tissue, reducing strength on both sides of the torso. Women who have undergone reconstructive surgery can face months of rehabilitation, pain and restricted movement. Without careful focus on and consistent management (maintenance) of abdominal and back muscles, the spine can become compromised, thus impacting other functions such as balance, breathing capacity, circulation of blood and lymph fluid, and proper digestion.

Benefit # 5: Yoga Strengthens the Immune System Many people make the claim that if you practice yoga, you will strengthen the Immune System. Often these claims are not, however, substantiated by knowledge of what the Immune System is, or how it works. Y4c teachers need this knowledge.

As discussed earlier, the Immune System is not a single, tangible part of the body like the lungs, heart, brain, or stomach. These parts are organs of, and represent, specific body systems. In one sense, the Immune System includes all the body’s parts and systems, being the interaction and union of all these systems. The goal of strengthening the Immune System is to keep all the systems working together like working families in a large, healthy village.

© yoga4cancer 2018 100 Remember: the failure of any one system threatens the health of the whole community. Because yoga’s goal is to strengthen all body systems, the end product is an improved Immune System.

Why is a strong Immune System important to a cancer survivor? One answer is that chemotherapy and other cancer treatments can compromise the Immune System’s efficiency because they disrupt the development and balance of all cells, therefore stressing the body’s systems and increasing the risk of infection or other diseases. This is why it is so critical for active cancer patients to keep on “Immune System alert.” The second answer to why an alert Immune System is critical to cancer survivors is to avoid recurrence. This is of paramount importance for cancer survivors for the rest of their lives: Will it come back?

Benefit # 6: Yoga Helps Manage Weight Gain When people think of cancer patients, they imagine skinny, fragile bodies. And yes, this is often the case during active treatment, prolonged treatment, or late stages of cancer. But for many people weight gain is a common side effect of cancer treatment. Weight gain has significant impact on both physical and psychological aspects of a survivor’s life. However, an additional great concern associated with weight gain is the increased chance of recurrence.

Obesity is a key indicator of both cancer incidence and recurrence. The American Cancer Society recommends that obese individuals increase the standard weekly exercise from 150 minutes to 300 minutes per week to reduce the chances of cancer or recurrence.vi Thus, managing one’s weight should be a focus of any cancer patient or survivor (and all people).

Yoga provides a safe, gentle way to manage weight. But not all yoga is the same. And I would not argue that all styles will help you manage weight gain. Often, yoga for cancer survivors is focused on gentle or restorative yoga methods, which are necessary and beneficial approaches. But they are not an active yoga practice. Many yoga teachers are afraid to make cancer patients and survivors move and be active in class.

It is a mistake to coddle survivors, treating them as sick. I remember this from my own days of attending a yoga class with my bald head where the teacher encouraged me to lay in restorative poses, and not to participate in the active yoga class. I felt isolated, ashamed and

© yoga4cancer 2018 101 annoyed. Worse, if I had listened to my teacher, I would not have benefited fully from the active yoga practice. Therefore, including an active practice is the foundation of y4c Methodology. Active does not mean aggressive or strenuous. We just want the body to move.

Yoga for cancer survivors can be active, therefore calorie-burning; and it can be safe, physically accessible, welcoming and inclusive. Yoga can help cancer survivors manage weight gain that will improve self-esteem, improve ability to function normally and ultimately reduce the risk of recurrence.

Benefit # 7: Yoga Helps Manage Pain It is not easy to listen to the body. We get so many aches and pains before, during, and after cancer. Most are not caused by cancer, but that is the fear. Survivors tend to be hyper-alert to new body sensations, and naturally, they worry. The nervous system is a tricky alarm system, sending signals that are sometimes confusing, false, or misunderstood.

Up until the advanced stages, most cancers are not the cause of pain. More often, the treatments and their side effects can cause pain and discomfort, rather than the cancer itself. Studies have concluded that yoga can help reduce pain for both non-cancer and cancer populations.vii y4c Methodology modifies traditional yoga poses so that students can practice with less pain. You will help your students to manage body sensations and to modify poses according to their body needs and the changing circumstances of their recovery.

Benefit # 8: Yoga Helps Manage Fear and Anxiety Fear is one of the most common and overwhelming impacts of those three little words: “You have cancer.” For most, if not all, it puts a person into a tailspin of fear of the many possible results; pain, impact on family, loss of income and ultimately, death. As a cancer survivor adjusts to a life-threatening disease, an additional alarm system emerges: uncertainty. From now on, every tweak, pain or twitch one has, even old familiar ones, create anxiety. Anxiety about what is and is not cancer becomes a new threat and constant companion. This undercurrent of anxiety and fear impacts moods and causes depression, and reduces sleep quality and duration. These then disrupt our body’s natural systems to heal and restore, further weakening a survivor’s physical and psychological status. It becomes a nasty downward spiral.

© yoga4cancer 2018 102 Yoga is well known for its powers of relaxation. Other benefits are not as easily understood and recognized in popular and modern culture. As teachers, we should know the fact-based reasons for why yoga can help reduce anxiety and fear to essentially calm the nervous system.

The nervous system is a complex network of trillions of cells and countless communication pathways throughout the body. Information is delivered to the brain in the form of sensations: sight, hearing, tasting, smelling, touching and feeling. And the body responds to these sensations, or signals, with pleasure or discomfort/pain. All responses are interpretations made by the brain to protect us from harm, maximize health, and enhance well-being. Without the nervous system, we would not know what is happening in the body, and it would be impossible to take care of ourselves. Research on yoga’s positive impact on the nervous system, especially reducing anxiety and fear, is plentiful. In 2013, a study conducted by the University of Calgary showed improvements in mood disturbance, stress factors and health-related quality of life (HRQL).viii Participants saw an improvement within the seven-week trial and then in three- and six-month follow-ups. Another study suggests that yoga can be more effective on one’s mood than walking, which is a common recommendation for cancer patients and survivors. Yoga participants reported greater improvement in mood and reductions in anxiety levels than the control group who walked.ix

Anxiety causes sleep disruption. It’s estimated that between 30% and 90% of cancer survivors have problems sleeping. A study published in the Journal of Clinical Oncology in 2013 reported that 90% of cancer survivors who participated in a yoga program saw improvement in their sleep patterns; they had better sleep quality, less daytime sleepiness, better quality of life and reduced use of medications.x

Finally, the Relaxation Response, the power of positive expectations, and pranayama, controlled breathing techniques, all contribute to anxiety reduction. This is the science behind yoga, that invites the student to enjoy safe and relaxing positions, to respect their body, settle the monkey mind, work past the normal distractions of daily life, better manage fears and anxiety. All of these will help make time for healing.

Benefit # 9: Yoga Enhances Body Image I believe yoga makes us feel good from the inside out. Yoga does not just help the body get

© yoga4cancer 2018 103 strong, flexible and detoxified, it aids the perception of the body and improves self-esteem. Cancer survivors, especially those who have survived breast cancer, have the same desire as everyone else: To look good! Yoga isn’t just for the lean, limber, youthful bodies seen on the covers of magazines; it is for ordinary bodies. However, when baldness is not a fashion statement and makes us look sick, or when we feel weak, have gained twenty pounds from medical treatments, or have lost body parts, feeling good about how we look seems out of reach. Encouraging survivors to find a way to feel good about their appearance may sound unrealistic.

Some survivors feel shame or embarrassment by their disfigurement. Some say their body has “betrayed them.” Survivors might also blame—falsely—their willpower, instead of their body, and think that they did not eat enough organic food, or take enough vitamins and supplements, or use enough alternative therapies. Feelings of failure are not helpful and only add stress to understanding a terrifying, mysterious disease.

Research on stress and emotion suggests how a negative attitude towards oneself causes the cortisal-based stress hormone to rise, thus increasing risk for cancer.xi Even as research progress is being made, we know less than we should about what causes cancer. Almost always, it is not possible to identify the exact cause for an individual cancer. Rather, the best we can do is to manage risk. What we do know for certain though, is that having positive thoughts cannot hurt us.xii

So, a y4c yoga practice seeks to free the mind of negative thoughts and feelings about our bodies. Instead of looking into the mirror and making poor comparisons to magazine cover models, yoga teaches students how to turn the mirror around to find what is hidden on the inside. When we do something every day, even if it is a simple stretch, breathing exercise, or correcting our posture while walking down the street, we develop a healthier, positive image of ourselves. This is how yoga starts to work and, over time, will enhance your body image. Using a daily yoga practice, either alone or with others, survivors see what is good on the inside. A virtuous cycle of positive benefits results.

Benefit # 10: Yoga Enhances Empowerment and Well-Being Many have heard of post-traumatic stress disorder (PTSD), which is experienced by some

© yoga4cancer 2018 104 soldiers returning from war, or by people suffering a life-threatening accident. Cancer patients and survivors experience similar stress. They feel bombarded by frightening information, subjected to invasive procedures, and must endure cold clinics and blank stares.

Not everyone, though, manages stress with the same success, and a 2009 study by Costanzo, Ryff and Singer developed and tested a concept that measures how we respond to stress known as post-traumatic stress growth.xiii The researchers categorized survivorship in three ways: survive with impairment, survive with resilience, or survive by thriving. Surviving with impairment causes the survivor to blame their trauma on everything wrong with life. Surviving with resilience causes the survivor to recover from trauma and live a serviceable life. Surviving by thriving, though, occurs when people make the traumatic event a pivotal point in life, changing their situation by making lemonade out of the cancer lemon. The thriving survivor enjoys her/his blissful moments, which can lead to further change and to finding positive ways to manage stress.

About managing stress and cancer, Suzanne Danhauer of Wake Forest University says, “Given the high levels of stress and distress that cancer patients experience, the opportunity to feel more peaceful and calm is a significant benefit.”xiv She goes on to describe results of random trials studying the effects of yoga on emotions. Her research, conducted in 2009, found an increase of positive emotions such as calmness and a sense of purpose in over 50% of her subjects.

So, a growing body of research shows that yoga provides emotional benefits. Whether students use yoga to lose weight gained by taking medication, to detox the body following chemotherapy, or to regain use of their arms, practicing yoga helps them feel better. As these benefits become more apparent, they experience increased well-being and, more importantly, feel more empowered than before. A positive upward spiral toward health results—as they continue to feel better, they make still more positive decisions on how to bring balance and ease to their lives.

Often, survivors with a yoga practice are surprised to find self-healing and empowerment in addition to their newfound well-being. Yoga empowers students to define life on their terms. A solid practice can help reduce drug dependency, or a class can leave one feeling like they had

A final point: the first obstacle to exploring the great promises of a yoga practice is accepting that things are never going to be the same—and that is okay. Learning how to practice self- compassion is the most important benefit of all, what I call the bliss benefit.

© yoga4cancer 2018 106 #3.3 –WARM UP VINYASA Vinyasa yoga is a dynamic style of yoga that involves linking movement with the breath in a mindful way. A warm-up vinyasa is a sequence done at the beginning of class, and it serves some important functions:

1) Links movement, breath, and attention. The warm-up vinyasa helps cultivate an awareness of sensation and the breath that will hopefully carry through the rest of class. To develop this, the movements should be simple, accessible, and repetitive. The sequence should form a loop and be easy to follow. The simplicity, repetition, and clarity also help build confidence and give students a sense of accomplishment and empowerment early in class.

2) Increases mobility and warms up the body for bigger, more demanding movements. A warm-up vinyasa includes four or five types of spinal movement: extension (back bending), flexion (forward rounding), rotation (twisting), lateral extension (side bending), and sometimes a fifth type, axial extension (lengthening). In addition, a warm-up vinyasa often helps to begin warming up the shoulders, arms, and other parts of the body.

3) Provides an opportunity to introduce anatomical principles, themes, movements, or language that will come up later. A warm-up vinyasa may introduce individual components of poses that will appear later. For example, if the class includes a version of eagle, the warm-up vinyasa may include a variation of eagle arms, so the arm movement will already be familiar to students when they encounter the pose.

4) Allows the teacher to observe students and notice range of motion limitations (possibly due to surgery/treatments), or other issues that should be considered, such as difficulty paying attention. While information may be gathered during the intake, certain limitations may not be apparent until students start moving, and a warm-up vinyasa includes safe, simple movements that allow the teacher to assess students’ needs and modify the class if needed. Typically, the teacher demonstrates at least the first round, but the teacher should also observe while demonstrating.

© yoga4cancer 2018 107 Warm-up Vinyasa Guidelines: • Usually done seated in a cross-leg or virasana seat, though a warm-up vinyasa can also be done lying down, standing, on hands and knees, or in another seat. The position shouldn’t require special flexibility. • Include spinal flexion, extension, rotation, lateral extension, and axial extension. • Link breath and movement in an anatomically appropriate way. Typically, each phase of the breath is matched with a new movement or new cue. For example: − Inhale and reach your left arm up, exhale and side bend to the right (matches each phase of the breath with a new movement). − Staying in your side bend, inhale and reach through your left fingers, exhale and drop more weight into your left sit bone to deepen the side bend (matches each phase of the breath with a new cue, while position is held). • Work both sides of the body evenly. Repeat asymmetrical movements on both sides of the body in the same way, and if doing a cross-leg seated warm-up vinyasa, switch crossing of legs between rounds. • Use clear, precise, simple instructions (though language/cues may vary), and keep the movements accessible. • Form a loop - have the vinyasa end where it began, so the second round begins cleanly. Do two or three rounds. Use the first round to teach the movements, taking it slowly if needed, and move fluidly following the breath for subsequent rounds. • Be prepared to modify for range of motion limitations (such as difficulty lifting the arms overhead due to recent surgery). • Set your theme and intention for the day and utilize it within the sequence. For example, if you are focusing on breast cancer or lymphedema, be sure to include poses and asana that will address this and verbally explain why and what you are doing.

Introduction This is where it starts to get fun! In the following module, we start to apply your newfound knowledge of cancer and yoga and put it into practice. We will explore how these insights encouraged me to modify, expand and evolve my training to develop a unique methodology for cancer survivors and patients.

This y4c Methodology is a specialization—for experienced yoga teachers, healthcare workers and fitness professionals seeking to design a safe, healing yoga class for cancer patients and survivors. It is applicable to help cancer patients of all ages, all cancers and at all stages of recovery to lessen the side effects of treatments, and ultimately live longer, healthier and happier lives.

The aim of this module is to provide you with the insights and tools you need to create an effective and appropriate class. I will talk you through both the pragmatic elements (props and poses) and the more theoretical or subjective advice based on my years of working with the cancer community with thousands of survivors, testing, adapting and modifying to make the approach effective and enjoyable.

This Module is divided into 4 sections:

#4.1 – Defining the y4c Methodology

#4.2 – y4c Poses – the good, bad and the ugly!

#4.3 – y4c Tools

#4.4 – y4c Class Plan

#4.1 - Defining the y4c Methodology What is a methodology? How is it defined? Miriam-Webster’ states: ‘methodology is a set of methods, rules or ideas that are important in a science or art: a particular procedure or set of procedures.’ That definition works for me. The y4c Methodology is a set of guides that can be

© yoga4cancer 2018 109 applied to any yoga practice or teaching to the cancer community. It is both a science (fact- based approach) and an art (teaching style and the beauty of yoga). However, it is not ‘rule’- based either, it provides support on how best to optimize any existing practice or teaching style.

The y4c lineage is grounded in vinyasa. From this yoga philosophy and foundation, unique sequences or vinyasas are carefully constructed with modifications and cautions addressing the needs of cancer survivors. Over the years, I have added research (desktop and in-studio) with the cancer community to build a set of pillars and then poses that best support the needs, hopes and challenges of a cancer survivor or patient. I would argue that the methodology is not fully ‘complete’ as we are still developing and learning the benefits of yoga to help with cancer recovery and maintaining optimum health while undergoing treatment. But the concept and the practical guidance provided will remain.

Five Pillars of y4c Methodology The methodology of y4c is based on five pillars. In addition to giving guidance, these pillars are “envelopes or sheaths” that protect and embody our physical and psychological experiences throughout life. Their content is knowledge and shared wisdoms that guide through challenges such as cancer and support any practitioner to replace ‘chaos’ with balance.

Pillar 1: Using the Breath to Heal Everyone has a first breath. They also have a last. In Sanskrit, the ancient language of India, prana translates to breath. According to yoga traditions, prana metaphorically means the vital life force that flows through, enlivens, and maintains all our physical systems. Breathing fills every second of our lives. Yet, most of us take breathing for granted. We think we do not need lessons in how to use it. But to make breathing a healing activity and to improve its quality, there is much to learn. When explored in the context of cancer survival, breathing is much more than life sustaining. Breathing with awareness—mindful breathing—will be one of your most vital tools in cancer recovery.

Mindful breathing can be used to reduce the anxiety and stress that come with cancer and its treatments. It is a way to feel safe and hopeful rather than challenged. Personally, I learned mindful breathing to reduce the fear I felt when getting prepped for chemotherapy. The

© yoga4cancer 2018 110 antihistamine administered before the chemo made me anxious, but my healing breathing calmed my nerves and allowed me to set aside my fears without the use of drugs. If you incorporate a conscious breathing routine into your practice, it may also improve your body’s reaction to treatments, reducing the potential for harmful side effects.

Previously we explored how the breath functions mechanically in the body, making it a tool for healing and for staying healthy. Mindful breathing will aid in cultivating a cancer-unfriendly environment in the body, which is your best tool to prevent a recurrence—the ultimate goal of every survivor.

Pillar 2: The Moving Body The physical body was designed to move. In the second pillar of y4c yoga, this is where we start movement of the physical body in the practice of yoga. Just as our breath gives us energy and life from outside the body, movement creates an energy level starting inside the body and keeps us alive. After treatments, patients are told to go home and take it easy. I know I was. Caretakers and family members coddle the patient into a sedentary attitude without recognizing that the body has evolved to move as well as rest. Our job as survivors is simple: Keep the Immune System healthy! Movement is one essential, natural way to do that and to keep the body unfriendly to cancer.1

As I mentioned earlier, our bodies were designed to move and when we do so in a healthy way, we massage organs and detox body systems such as the heart, lungs, and lymph nodes. Lack of movement endangers both the body and the mind. Yogic movement will lead to a healthy body. Research data is conclusive that exercise can modify human emotions, creating feelings of well-being. So, a strong body and a positive mind together become the healing power of the second pillar.

Cancer survivors need to be aware of specific movement in response to treatments, surgeries, and other changes in the body that have taken place. The yoga poses presented in the y4c Methodology have been tailored to provide a structure for overcoming the many obstacles associated with these changes and side effects, both short- and long-term.

The patterned movement and simple, straightforward instructions of the y4c Methodology

© yoga4cancer 2018 111 through each pose ensures confidence and new ways to overcome any fears and misconceptions about movement. ______1 Strong research supports the benefits of exercise/movement for cancer patients and survivors: Starting with MSKCC Blog about Dr. Lee Jones’ Research on exercise for cancer patients: https://www.mskcc.org/blog/field-motion-fighting-exercise http://well.blogs.nytimes.com/2016/02/24/how-exercise-may-lower-cancer- risk/?emc=edit_tnt_20160224&nlid=46111969&tntemail0=y&_r=0 https://www.mdanderson.org/publications/cancerwise/2013/06/exercise-for-cancer-survivors-a- great-way-to-boost-your-health.html#more

The body absorbs, processes, and interprets input from the physical world around us. Through our five senses, we experience everything we know. Through the senses, your mind is stimulated by a continuous stream of sensations all day and night. It fluctuates among these many sensations, trying to make sense of them. Is it raining? Am I hungry? What is that tingle in my left toe? As a cancer survivor adjusts to the news of a life-threatening disease, a new alarm system emerges in relation to sensations, especially pain. Every type of pain that the survivor has—even old and familiar ones—becomes a new fear of having cancer. Uncertainty becomes a new companion.

The third pillar recognizes that cancer leads to emotional side effects, not just physical ones. Yoga will teach you to observe sensations in your body, how to resist being distracted by them, and how to monitor them.

The word mindful comes up frequently in my book and in the yoga community where it can have different meanings.2 I use it to mean that the mind is full... full of something, full of thoughts and ideas. That is all it can contain—thoughts. Because we know the world through the body, the third pillar draws attention or awareness to the ability of the body to control the mind. We need to cultivate a mind full of properly placed thoughts. We can place thoughts in our mind and we can take thoughts out of our mind. For example, a thought that causes anxiety, such as fear of a cancer recurrence, could be replaced by a thought of well-being by taking five slow calming breaths every time that thought places itself in your mind. And we need to have a mind determined to use that information to heal. Yoga will help you train your mind to be mindful about everything you do and think.

The best use of the mind is having questions about anything. In relation to yoga and cancer, questions such as, “Why is yoga beneficial to cancer survivors?” and “How can yoga heal or make our bodies more resistant to cancer?” are helpful. This is how we want the mind to work rather than having fear of developing a new cancer.

The answers are found in learning how to listen to and observe the body. In yoga, we sometimes do things that seem unfamiliar, maybe slightly uncomfortable. Listening to your

© yoga4cancer 2018 113 body in those situations— at the same time, knowing why you are doing so—will make the experience more empowering, meaningful, and positive. This is how yoga trains the mind. If you are able to quiet your mind and hear your body speak, then a healing process unfolds that is empowering and life preserving. The mind will give witness to the information your body gathers. Together, they will be wise and potentially healing. ______2 Different definitions of mindfulness exist as well as growing empirical support for its benefits in healing and education. Mindfulness in the Buddhist tradition has been written about for hundreds of years. For an introduction, read Thich Nhat Hanh’s The Miracle of Mindfulness: An Introduction to the Practice of Meditation. Recently, mindfulness has become a popular topic for Western clinical researchers like Jon Kabat-Zinn and social psychologists such as Ellen Langer who refer to a flexible way of thinking about the world without preconditions.

Pillar 4: Connecting Wisdom – Community

As the mind guides and integrates our experience of the world around us through our body’s sensations, it also leads us to the next level of human consciousness – reflection, protection and connection. These give rise to fears, doubts and awareness of vulnerabilities. Great emotional challenges naturally arise with potential to throw us off the path to recovery even after the treatments are finished and the body is nearing ‘normal’. The fourth pillar is ‘the other’. Being with others takes us out of that emotional container.

Cancer can be a lonely, long path. You feel, look, and think of yourself as different. Family and friends treat you that way. Before diagnosis, you may not have known others who have been on the cancer path. But taking this trip alone is unnecessary. This pillar of y4c is about learning ways to connect with other people in order to feel part of a community.

There is a benefit to interacting with other survivors living with and overcoming similar challenges. Connecting with others helps us understand ourselves, and helps us heal both emotionally and physically. Embarrassed by disfigurement, hair loss, weight gain, or weight loss; feeling fatigued, scared, and alone—this is a small sampling of the emotions we share as cancer survivors.3 Support groups are a way of creating community that can enhance the quality of life of survivors, including pain reduction and positive mood. Community protects and

© yoga4cancer 2018 114 allows us to understand our emotions. Learning with, and from, others makes us stronger. ______3 Depression may make the effects of cancer worse, according to David Spiegel. For more information, go to: http://med.stanford.edu/ism/2009/august/depression.html.

Pillar 5: Self-Compassion and Contentment

The world is full of suffering. And the world puts obstacles in our paths–with or without cancer. It is continuously jabbing us with expectations and illuminating all the ways in which we need to improve, have more, look better, and be worried about the future. All of these are obstacles to feeling happy, safe and content. Cancer only adds more obstacles.

The fifth pillar of y4c Methodology is the act of being kind to yourself—self-compassion. How to practice self-compassion to experience contentment and well-being is a fundamental pillar to a yogic path and essential to life after a cancer diagnosis. Everyone comes to yoga seeking something. I believe survivors come to yoga seeking comfort and hope as well as strength and health. Frequently, they leave feeling good and empowered. Yoga promises and usually delivers all those, in my experience. It also suggests something more is possible beyond the sensory experience of poses, breathing practices and community. There are those who call that something a ‘yoga glow’ or happiness. In my teaching, I call it bliss, a feeling of contentment and joy which unmistakably indicates ‘aliveness’. It gives hope because it begins with the gesture of love towards oneself. Loving yourself enough to go to yoga just to feel better after is reason enough. And it is not selfish love, it is life-giving love. “While yoga is not a cure for a cancer, nor a definitive way of preventing it, yoga increases physical, emotional and spiritual wellness, and brings about a certain peace, of which many cancer patients desire.” 4

Whatever label we use—bliss, contentment, joy, aliveness or happiness—having any one of these feelings of being well is essential to hope, managing a longer healthier life and making sense of the cancer chaos.

The subtle, hidden gem of yoga is contentment. The y4c Methodology seeks to cultivate the conditions that allow survivors this experience of contentment, encourage self-compassion and leave with that ‘yoga glow’.

4 As yoga participation rates continue to increase, it is important for healthcare professionals and yoga teachers to be informed of the evidence of its many therapeutic effects. This is comprehensive review of the benefits of regular yoga practice. * http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193654/

© yoga4cancer 2018 116 #4.2 - Y4C POSES I am curious to see how many people jumped to this section... as frankly, I am so often asked ‘What types of poses are good or ‘counter-indicative’ for cancer survivors and patients?’ And as you might expect, there is no simple or quick answer. Yes, there are examples, but the y4c Methodology is about understanding the science and facts first, then being able to modify any poses, asana or yogic principle. But the information below will provide you with an overview along with the sample poses provided in the Appendix at the end of this manual and as explained in the Yoga for Cancer book.

There is nothing really new in yoga. What is new is how the yoga is applied. Starting with curiosity and a deep investigation of how the Immune System works, I selected from recognizable yoga poses and sequences and modified them considering the known risks and limitations caused by cancer treatments’ side effects. Some will look familiar while others are unique variations of classic Hatha poses and Vinyasa style sequences. After years of development in the y4c laboratory (e.g. my classes), I discovered some yoga poses and techniques need modifications, some deserve special awareness and others that generally, but not always, I avoid.

In terms of poses and sequences, what to do and what to avoid falls into three categories:

• Category #1 – Poses we like but use with care • Category #2 – The y4c method • Category #3 – Poses requiring special awareness or to avoid

Another aspect of teaching yoga is pedagogy – the art and skill of teaching that involves voice, language and use of metaphor. This is part of every teacher’s style. In the y4c Methodology, we consider these to be important aspects of teaching and adapt them to serve the needs of this community with sensitivity. My approach and suggestions may differ from what you have been taught or practice. The rationale behind the differences and their practical application also defines the methodology. Some have already been discussed in the ABC’s, for example, using the C-word and avoiding a ‘coddling’ voice are good pedagogy skills and included in the

© yoga4cancer 2018 117 list of what is defined as y4c Methodology. Some are discussed in Elements of a Class Plan (Section #4.4) and Tari’s Advise/Cautions (Section #5.1). Of course, voice inflexion and intonation will be a major topic and exploration in our training class.

Category #1: Yoga poses we like but use with care. y4c methodology believes that almost any yoga pose has a positive benefit for cancer survivors but some must be taught with attention and purpose within this community. The key to modifying any practice or lineage is to use the facts of cancer and its treatments discussed throughout this training to make the pose more comfortable, safe and effective for any survivor or patient. Below are some examples of poses we love but use with care:

• Forward Bends are a staple of most yoga styles but a hallmark of potential risk for the cancer community. Be aware that bending forward places extra pressure on the front bone tissue of spinal vertebra. This is a special concern for cancer survivors because their bones may be more fragile as a result of chemotherapy. Students having had recent surgery or existing abdominal tumors should be cautious about doing deep forward bends. Therefore, we modify forward bends with bent knees, blocks and chairs. The y4c Sun Salutation is modified by moving through Chair pose to step back into a lunge, while keeping the chest lifted. This means the chest remains above the level of the hips. It also means the chest remains open and actively reaching upward. With this intention, even as the knees bend and hips are lowered, the chest continues to lift and expand. [See Chair Pose in Appendix.]

• Cat/Cow – Hands and Knees Survivors may experience pain or have concerns about weight bearing on the hands and wrists (for instance because of Lymphedema). An alternative is to place hands under shoulders, support on the elbows and forearms. To set this up properly, you need four blocks. Line up the blocks like parallel railroad tracks, with two blocks end-to-end on the left, and two blocks end-to-end on the right, all blocks on the lowest level. The distance between the “railroad tracks” should be the width of the shoulders. Support the elbows, forearms and palms on the two parallel lines of blocks, with elbows directly under the shoulders, so forearms are now parallel to each other. [See Cat/Cow Pose and variations in Appendix.]

© yoga4cancer 2018 118 • Standing Poses build strength and confidence and are easy to modify with supports such as chairs, blocks and walls. You now know that weakness and fatigue are common side effects that can discourage survivors from exercise. Along with loss of muscle strength and range of motion, standing poses may be challenging. Making standing poses accessible with the use of props is the goal. That will cultivate confidence. During Sun Salutation lunges, Warrior poses and Side Angle, keep the bent knee directly above its own ankle. Bending the knee past the ankle in weight-bearing poses such as lunges and Warriors causes instability in the knee joint and can potentially lead to injury. Keeping knee above ankle helps to properly engage the leg muscles and evenly distribute weight into the foot from heel to toe, improving balance and stabilizing the alignment of the whole body in the pose. If it is too strenuous for your students to bend the knees over their ankles, bring the feet together in these poses to achieve this alignment. How far apart should the feet be in standing poses? The answer depends on the body – length of the legs, flexibility, and comfort level. Lengthening the stride is suggested. If it is a struggle to bend the knee deep enough for ankle above knee alignment, shorten the stride.

• Breath Exercises (including Pranayama, such as, Bhastrika and Kapalabati; Engagement of Bandhas) – Breathing is fundamental to the y4c Methodology and all yoga practices. The health benefits are profound and necessary for cancer survivors, as explained throughout this training. And there are many wonderful breath awareness practices in yoga that can be adapted to cultivate natural healthy breathing patterns in survivors. However, there are several commonly used yogic breathing principles or practices that can be challenging or uncomfortable for survivors and should be used with caution.

1. ‘Breath of Fire’ or Pranayama - The practice of ‘Breath of Fire’ (Bhastrika and Kapalabati) or any pranayama that uses forceful or sharp muscular movements and retention can be harmful if a student has recently had surgery or has existing heart disease. In general, these techniques are designed to create body heat and to prepare for an energetic practice by quickly increasing the supply of oxygen in the blood. There are warnings noted by both B.K.S. Iyengar in his book, Light on Yoga (page 450), and William Broad in his book, The Science of Yoga (page 86).

Iyengar states that pranayama can increase blood pressure levels, causing stress on the heart rather than relaxation. As common side effects from some cancer treatments

Additionally, temperature sensitivity is an ongoing side effect for both patients in treatment and survivors. This will be discussed in various parts of the training. Breath of Fire’s goal is to create heat in the body quickly. In my experience, a safer and equally healing way to reach that goal is with warm-up arm vinyasas from any position and modified sun salutations. I do not advise Kapalabati for class situations. Perhaps in private sessions this could be explored with care.

Finally, Broad explains that the repeated exhalation and lack of inhalation can ‘rob the brain of oxygen’, causing dizziness. Cancer patients undergoing chemotherapy or receiving brain radiation treatments frequently experience dizziness. In addition, patients and survivors suffering from neuropathy can experience loss of balance. Under the above circumstances, the benefits are far outweighed by the dangers.

2. Long Breath Retention and Counting are normal parts of some pranayama practices and the practice of Bandha Engagement. Breath retention is used to produce various patterns and sequences of breathing. The resulting therapeutic effect of increased lung capacity often creates a sense of relaxation. However, long retention between inhale and exhale, requires a great deal of muscular resistance and strength, which can be both physiologically and psychologically uncomfortable. As mentioned in other sections, chest muscles tighten and skin can have scar tissue due to surgeries or other treatment side effects (e.g. radiation burns and lymphedema), so retention of the breath can be painful and uncomfortable.

Additionally, some of your students may have experienced many treatments and diagnostic tests that require breath retention for long periods of time. This could have caused pain or discomfort at the time of treatment, and carries forward fear and anxiety - not unlike the experience of Post-Traumatic Stress Syndrome. Similarly, the y4c Methodology discourages counting the breath and encourages observing the natural length of inhale and exhale. That pace will naturally vary for all participants, but enable them to achieve the benefits without unnecessary discomfort.

3. ‘Deep’ Breathing - Take care with the word ‘deep’. When the chest becomes compressed due to scar tissue, shoulder tension, poor posture and/or stress, breathing is limited and not free. So just breathing consciously can be surprisingly challenging to a cancer survivor. Therefore, ‘deep’ breathing can be impossible or painful.

Suggestion: y4c Methodology suggests slow, gentle, natural breathing exercises to provide just the right amount of heat, oxygen and energy, and they are a better approach for the same goal for survivors. Be especially aware of your words and pace when directing or describing a breathing sequence. Avoid the word “deep.” Instead, use directions that encourage a gradual increase in the length and volume of an individual breath within the range of comfort for the student. Utilize the directive to “follow your breath” during a yoga movement sequence means the breath leads, setting the pace for the rest of the body to follows. To be safe, avoid ‘Breath of Fire’ or similar intensive pranayama work with cancer survivors.

Sources: The Science of Yoga, William Broad, Simon & Schuster, 2012, page 86. Light on Yoga, B.K.S. Iyengar, Schocken Books, 1979, page 450

• Chest (Heart) Opening Poses. y4c Methodology prefers to use the term Chest Opening rather than Heart Opening. This common yoga term describes poses that stretch the muscles across the front of the chest and expand the front of the rib cage. This happens in coordination with the shoulders moving back as the shoulder blades draw towards each other on the back. There can be many reasons to teach chest opening poses. After surgery, primarily breast surgeries, the chest muscles become tight - scar tissue forms, which can restrict and limit movement. y4c Methodology offers unique and accessible poses and sequences to guide gentle recovery and development of these specific muscles by cultivating the use of other muscles.

• Restorative Poses. Yoga physics is constantly at work, even when the body is at rest. Restoring and finding balance by aligning the bones and redirecting muscle tension can be the first step to eliminating discomfort. Ultimately, we want to redirect the “muscle” of the brain to find relaxation and to learn to manage distractions. What’s not to love about restorative poses?

© yoga4cancer 2018 121 And how wonderfully healing they can and will be for the cancer community. However, teaching them is the hard part. Experienced restorative yoga teachers know the essentials: adequate and proper props, precise set-up and demonstration, thoughtful language to guide students into the pose and time for assisting/adjusting once there. I consider the latter an art form of teaching yoga. The difference between assisting and adjusting will be discussed at length in the hands-on portion of this training.

• Why, when, how much to vary from pose to pose, class to class and person to person. Once in the pose, a general awareness and caution is needed. Less effort and more support do not necessarily mean that the poses are easy. Due to limitations beyond the scope of cancer, a restorative pose can be difficult to get into or to hold comfortably for a long time. The position of the head and neck in Rest and Restore poses may determine whether the rest of the body is able to fully relax. Notice if the chin is jutting up toward the ceiling, and/or the back of the neck feels shortened or compressed. If so, you can use additional props such as a folded blanket or small pillow to support the head and neck so the forehead is slightly higher than the chin. This can sometimes also be achieved without any additional props, simply by adjusting the alignment of the head so the back of the neck elongates and the chin drops.

Lying on the back with arms in a cactus shape, like Knock-Kneed Cactus Twist, and many of the restorative poses, often requires extra attention to supporting the arms in a comfortable position. In the Cactus Pose, the elbow, forearm, wrist and back of the hand should all be supported by a folded blanket. Often, shoulder tightness causes the wrist and hand to be higher above the floor than the elbow, requiring additional support. If this is the case, fold a second blanket and place it under the wrist and hand, so that the props under each arm make the shape of a triangular wedge (lower at the elbow, higher at the hand), rather than a flat surface.

Please note that Child’s Pose is not considered a resting pose in the y4c Methodology. See explanation in Category #3. Refer to the benefits and proper support of other Rest and Restore poses illustrated in Yoga for Cancer. [See Restorative Fish in Appendix.]

• Partnering is an effective way to create community, while also bringing stability and depth to

© yoga4cancer 2018 122 certain poses. However, we avoid partnering exercises in traditional y4c classes because patients undergoing treatment have compromised Immune Systems, and for obvious reasons, need to avoid contact with others who may have this year’s flu virus, for example. Even long- term survivors can have a high awareness and sensitivity about being exposed to germs. This can be disconcerting and make them feel uncomfortable when partnered with another student. Being respectful of that possibility is the responsibility of a yoga teacher. In addition, the varying yoga skill levels found in a y4c class and non-cancer related pre-existing conditions makes partnering students appropriately a challenge.

For these reasons, partnering is not common, and if done so, only very selectively. For example, a group tree or Warrior 3 can be fun and safe. These are situations where the teacher maintains constant visual contact with all the students and can support those who are the most needy.

Category #2: The y4c Method

To answer the question highlighted in the introduction: ‘What is good yoga for cancer patients and survivors?’ Here is a list of poses, sequences and other teaching tools found to be effective and safe. General-purpose advice and some examples are listed and these will be expanded in further discussions and assignments. The following three charts are a visual outline of the y4c Methodology elements designed to give you an overview of purpose, provide important details and specific examples.

Language Skills Purpose Sample Minimize use of Cancer is a world full of strange ‘Chair Pose’ instead of Sanskrit and difficult words to learn. Using ‘Utkatasana’. ‘Stand Tall’ Sanskrit can add an unnecessary instead of ‘Tadasana’. level of complexity for some students. Use the ‘C’ words at Use the word ‘cancer’ at least once C-words we like to hear: Calm, least once during class. Don’t avoid it- your Comfort, Confidence, Curiosity,

© yoga4cancer 2018 123 students can’t. But also use other Courage. ‘C’ words. Refer to known side Builds confidence in you as a ‘If you have concerns about effects teacher who has been educated Lymphedema, weight-bearing and trained in the y4c methodology activities like hands and knees poses, have been shown to reduce symptoms.’ Address common fears It will reduce stress levels. When a ‘Standing and Balancing poses or concerns student trusts you, they are more help us build bone mass that likely to relax. can be lost or weakened by Chemotherapy.’ Metaphors that relate Find the dualities between yoga ‘Yoga and Cancer are both life- to cancer and caner to create relevant changing.’ metaphors. Avoid using a coddling Make your students feel like yogis, ‘You are strong, you are voice not ‘sickies’. courageous, you are beautiful.’

© yoga4cancer 2018 124 Finding Stillness Purpose Sample 1. Taking your Your introduction and Welcome. Make Can be in a chair, cross- seat everyone comfortable. Find the proper, legged, or in Hero Pose. Also neutral alignment for the spine, body use this time as an opportunity awareness, breath awareness, to learn how to use props and focusing the mind. sit properly and comfortably. 2. Create a Use ‘C’ words. Address common fears ‘Fear is normal. How we connection or concerns, and illustrate that you manage this fear is where we understand and can offer find control, confidence, modifications. Use metaphors or comfort and community.’ examples that can relate cancer and Use other examples from the yoga. Language Skills matrix. 3. Breath The first y4c Pillar is Using the Breath Equal parts breath (avoid Awareness to Heal. Developing breath awareness counting) naturally helps to utilize the breath with Smiling Buddha Eyes Breath movement. Introduce the powerful tool Meditation of the exhale to physically and Belly Button Breath emotionally begin the healing process. Alternate Nostril Breathing Developing breath awareness helps focus the mind with a few moments of simple breathing. 4. Moment of Practice how to quiet the mind as well Practice in a comfortable, Quiet as the body. Meditation is an essential seated position, and develop a survival tool for cancer survivors commitment to being curious. because we learn how to control, calm, Promise not to judge what and clear the mind of thoughts and comes up, or what happens. ideas that are not useful. Developing Avoid long periods of time, and breath awareness is an ideal point of limit ‘moments’ to one or two entry. A few minutes of breathing can minutes. help focus the mind. Repeat a mantra, similar to “I

© yoga4cancer 2018 125 am happy, I am at ease.” Watch the mind and what thoughts ‘float’ by, or travel to a specific place or idea within the mind. Practice doing ‘brain laundry by thinking of nothing. 5. Opening OM Chanting the sound of OM helps to Chant the sound OM three focus on the power of the exhale. It times. also cultivates a sense of community and helps to signify the beginning (and ending) of practice.

© yoga4cancer 2018 126 Poses and Sequences Purpose Sample Warm-up Moves the spine in all 5 directions. Seated Cat/Cow Pose, Cactus Clap, Vinyasa: 5 Links movement, breath and Twist, Side Bend, Gather and Hold. ways attention. Increases mobility and Hands and Knees Twist, Leg -Seated warms up the body for bigger, more Extensions, Side Angle and Slumber -from Hands demanding movements. Provides an Party. and Knees opportunity to introduce anatomical -Supine principles, themes, movements, or Supine Full Body Stretch, Leg Rocking, -Standing special language. Allows teacher to Crunch Switch, Crunch Twist. observe students, especially during a seated warm-up. Standing Tall, Chair Pose, Swaying in the Wind. Swan Wings. Step Back Provide safe and accessible ways to The y4c modified Sun Salutation uses Vinyasa build muscle and bone strength. blocks and starts from sanding or Sequences Cultivates self-confidence and body hands and knees. It moves through a awareness. Raises heart rate slowly modified chair pose keeping the head

and steadily. Promotes Lymphatic lifted to avoid a deep forward bend. It Drainage. Makes everyone look and does not include Downward Dog, feel like they are doing yoga! Upward Dog, plank or Push-up pose, but still accomplishes the purpose of a vinyasa to move the spine through all directions with proper break cues and moves safely to other poses. It starts and ends in the same place.

Examples include the Modified Sun Salutation, Step Backs for getting up and getting down, and Step Backs into standing poses. Standing Activating bone-building cells to Stand Tall on One Foot. Balances maintain strong bones as a Tree Pose with variations and

© yoga4cancer 2018 127 foundation of a healthy body. modifications. Improves concentration as well as Eagle Pose with variations and balance. Can build confidence and modifications. assist in managing feet neuropathy.

Warrior 3 variations. Lymphatic Lymphatic Massage and brushing is Half Cow Face Pose Lymph Brushing. Self- a manual technique that directionally Ed’s Stool. Massage moves and increases flow of lymph fluid. Breathing moves the diaphragm Squeeze and Release. and massages the thoracic duct, increasing the flow of lymph fluid. Gentle Pranayama.

Full Body Stretch with diaphragmatic breathing. Rest and The natural pull of gravity detoxifies Restorative Bridge, Fish, Cobbler, Restore the body passively. The spine can be Shoulderstand, Restorative Side placed and supported in 4 of 5 Stretch, Restorative Twist. distinct healing positions. Initiation of the Relaxation Response.

There are several poses commonly used in most yoga styles that, while not entirely discouraged in y4c Methodology, should be used with great care. It is important to understand the reasons as they are commonly part of yoga classes for ‘general’ populations. Plus, there are often modifications and/or other poses that have the same benefits but none of the risks. So I do not use these poses or breathing techniques in my methodology for cancer survivors. Here is why.

• DEEP Forward Bends and Folds – Don’t be confused with ‘Forward Bends’ in general. Indeed, in Category #1, ‘Poses we like but use with care’, Forward Bends are listed. The difference is adding the operative word ‘deep’. Deep forward bends are designed to stretch the hamstring muscles. Simultaneously, this action lengthens and strengthens the muscles of the lower back. These poses are beneficial for the general population, but a yoga teacher must be aware that bending forward places extra pressure on the front bone tissue of spinal vertebra. This is a special concern for cancer survivors because their bones may be more fragile as a result of chemotherapy. In addition, students having had recent surgery or existing abdominal tumors should take care in deep forward bends or folds.

It is not unusual for some yoga styles to start a practice session in a deep forward bend, using it as a warm-up, giving the hamstrings a good stretch before starting sun salutations. However, even for advanced healthy yoga practitioners, a deep forward bend should be done with care.

Suggestion: When done gradually, slowly and properly, benefits result from forward bends. When rushed or attempted too early in a practice, unsupported pressure is placed on front bone tissue of spinal vertebra. Keeping knees bent, moving slowly, and using blocks under hands to decrease the depth of the bend will help to keep forward bends safe and approachable.

A healthier way to approach any forward bend is to replace ‘bend’ with ‘fold’. Rather than rounding the spine putting pressure on frontal spinal vertebrae, keep the front and back of the spine parallel or the same length and fold over the legs. For most of us, in order to create that ‘taco’ effect of resting the abdomen on the thighs, it helps to ‘bend’ the knees not the spine.

• Downward Facing Dog – Often considered a resting pose between other poses, like other forward bends, Downward Facing Dog is a powerful pose for stretching the hamstring and abdominal muscles while strengthening lower back muscles. It also builds upper body strength and flexibility.

However, for those diagnosed with cancer, this pose can be uncomfortable and anxiety- producing, largely because breast cancer patients and survivors may have been told, erroneously, that this pose places too much downward pressure on the arms, causing lymphedema. The real threat is that this pose can cause discomfort due to the inverted positioning of the torso, which puts gravitational pressure on incision sites, especially abdominal body parts that are missing, tumors that are not removed, or breast implants.

Just because this pose is not recommended in y4c Methodology does not mean you should never use it. Yoga practitioners who understand how to relax and enjoy this pose, how to breathe and stretch gaining its incredible benefits, and understand how to protect vulnerable body parts while doing it, can teach this pose safely.

However, the best reason to build a practice without including this pose applies to all cancer survivors: Downward Facing Dog is actually a half inversion. Almost equally divided, neither body half has the benefit of gravity to move body fluids towards body center, which is critical to our major goal of creating and maximizing lymphatic flow. Also, diaphragmatic breathing from this position can be strained, neutralizing a significant benefit. Inversions are valuable to assist the flow of lymph and blood to detoxify the body’s Immune System when they are done supported, or in their full expression.

Suggestion: If you love Downward Facing Dog, instruct students to use proper alignment. Build their strength slowly by holding for no more than five breaths in the beginning. “Puppy Down-Dog” can also be done by keeping the knees on the ground and using the forearms to carry more upper body weight. Downward Facing Dog at the wall or from the back of a chair is also a great alternative with all the benefits and minimal risk. Please see the illustrations in Yoga for Cancer.

© yoga4cancer 2018 130 • Plank- Plank is normally done as a major strength-building pose for upper body, abdominal, and lower extremity strength. It increases awareness and encourages spinal alignment, and can also bring awareness to breath as you maintain the pose. Used as a transition between Downward Dog and Upward Dog, plank is not generally a long-held pose unless the goal is to build endurance. Plank pose can be problematic for cancer survivors because, first, it requires a tremendous amount of strength and endurance (it is singularly focused on these things), which survivors are not always ready for. Second, plank could cause alarm for those who experience or are concerned with lymphedema. The y4c Methodology is based around student success, and there are many more attainable poses that achieve plank’s objectives without stressing the body or causing concern.

Suggestion: One leg extensions from Cat and Cow, which are essentially half a plank pose, will address strength-building, spinal alignment, and focus on breath. Please see the illustrations in Yoga for Cancer for see-saw poses, lunges, as well as hand and knee leg extensions.

• Jump Backs- Jump backs are an extremely vigorous transition through various positions that require good body awareness, proper placement of body parts and plenty of strength and confidence. Jump backs are generally used as a way to transition from Mountain Pose to Downward Facing Dog. The jump back is an ambitious transition, even for advanced yogis who can use their body strength to lessen the impact involved. This pose’s purpose is easily accomplished in other ways, avoiding the potential jarring that may result in injury or discomfort for a y4c student.

Suggestion: The y4c Methodology uses step backs in place of jump backs, which serve as a gentler transition and allow the student to remain focused on breath and movement. If your student is an advanced yogi with past experience in doing jump backs, it is important to ensure that they are accurately confident that they have the strength to do a jump back before it is attempted, IF it is attempted.

• Child’s Pose - Child’s pose is commonly used as a resting pose. Some find it comfortable and relaxing, but a surprising amount of people do not. In my classes for cancer survivors, I rarely use Child’s Pose for resting because for many survivors, this pose is not comfortable

- First, it requires a level of flexibility in the spine, hamstrings and feet, which cancer patients and survivors may lack due to inexperience and/or fitness. - Second, it puts pressure on the lower vertebrae which can be compromised due to osteoporosis or weakened bones from chemotherapy and other cancer treatments. - Third, cancer survivors can have sensitivity in the abdomen due to scar tissue, surgical sites, or even existing painful tumors. Forward bending and folding can exacerbate that condition. - Finally, having the head below the heart restricts breath (to some extent) and can feel claustrophobic, which may be a particular point of sensitivity for cancer patients who have often been required to hold breath and remain still in small spaces (e.g. MRI machine) for long periods of time during treatments or diagnostic tests.

For all these reasons, Child’s Pose is not necessarily relaxing or comforting, which defeats its purpose entirely. Breast cancer patients who have recent surgery or expanders, and long-time survivors who have had reconstruction or implants are particularly uncomfortable and cautious about this pose. Of course, for some survivors, this pose is wonderfully relaxing and helpful. It’s just important to understand the potential challenges and modifications that can be done to make it comfortable for all.

Suggestion: Modify the child’s pose by placing a blanket under the knees and a rolled blanket under the tops of the feet. Once that is set up, place a block between the thighs, with one or more blankets or a bolster on top of that block and across the thighs. Construct a support for the chest and the head using blocks and blankets so the bend is less extreme and the head remains at the same level as the heart. For breast reconstruction situations, create a support for the head and abdomen but that leaves the breasts suspended. Place a clean towel on the head support.

• Advanced Inversions such as Headstand, Shoulderstand, Full Wheel/Back Bend and Arm Balances require great muscle strength, flexibility and a careful balance of effort and ease. Like Downward Facing Dog, they form the core of many fine yoga traditions, and invert the body to detoxify fluid-based systems. We endorse all of these benefits in a full yoga practice,

© yoga4cancer 2018 132 and they can be accomplished by a more advanced student who is well prepared and confident. However, many students are lacking in the strength, stability or endurance needed to achieve more advanced inversions. For these students, there are several options that are less vigorous, easier to attain, and still effective in creating homeostasis or balance of the body’s fluids.

Suggestion: Any modified inversion such as Supported Shoulderstand, Supported Fish, Supported Bound Angle, Supported Bridge Pose, or Legs Up the Wall. For arm balances, you can do hands and knees leg extensions, standing split from blocks or a modified table top.

• Plow Pose - This pose puts a tremendous amount of stress on the cervical spine, creating the same forward bend issues as Child’s Pose. It is considered a foundation in many practices, but for the reasons explained in full inversions and Child’s Pose, it is not taught in y4c classes. The great benefit of Plow Pose is passive engagement of the throat lock and compression on the thyroid gland. A Supported Shoulderstand can achieve a similar benefit.

Suggestion: Same as Child’s Pose and inversions.

• Classic Sun Salutation including: Downward Facing Dog, Four Limbed Staff Pose and Upward Facing Dog. Sun Salutations are like a choreographed dance rather than a healthy dose of exercise designed to flex and revitalize the body and unites it with the mind. This ancient sequence seems like something that should not be changed. However, we can use parts of it, making it accessible for those in the early stages of recovery. When you’re not at your strongest, using modifications such as blocks can provide all the benefits of a classic Sun Salutation.

Suggestion: The y4c Modified Sun Salutation and Step Back provide stability, give students at all levels more range of diaphragmatic breathing and access to all standing poses.

Yoga Props Yoga Props are important tools in the y4c Methodology. In preparing to teach, start with proper props because they provide the necessary support to individuals and enable you to create the most healing environment possible. Of course, not all props are needed for every pose or student but it is important for a teacher to understand and use them. That being said, there are some poses and sequences for which props are always used in the y4c Methodology. Recommended props are: • Sticky Mat, usually made of textured rubber or PVC, provides both comfort and stability. A yoga mat offers safety and steadiness by ensuring your feet and hands don’t slip during practice, and the mat doesn’t slide on the floor. Mats come in varying degrees of thickness, which provide a cushion between your body and the ground. However, there is a trade-off between comfort and stability when choosing the thickness of your mat, as a thinner mat means a firmer connection to the earth. Too much cushioning will make balancing difficult.

• Chair. There may be times when a chair is more useful. This will depend on the student, of course. You will assess this need after an intake. But, in general, a chair can be an excellent way to practice standing and balancing poses. Always place it well on a sticky mat.

• Yoga Blanket. Can be folded into various sizes and shapes for specialized support, or used for warmth. The yoga blanket is a multifaceted tool for supporting the alignment of the body, and providing extra cushioning, particularly for the knees, hips, neck and shoulders. A blanket may help you perform poses that might otherwise be overly challenging or uncomfortable due to range of motion or flexibility. It can help keep your body in balance, if one side is less mobile than the other, and encourages relaxation. Don’t have a yoga blanket? You can use any blanket of substantial thickness and size. Towels are generally too thin to be a good substitute.

• Yoga Block, usually made of foam, wood or cork, is a solid, rectangular object designed to support the weight of your body for improved stability, alignment and ease. The yoga block

© yoga4cancer 2018 134 serves as an extension of your body to the floor. For instance, blocks are often used under the hands in standing poses so the hands can be supported on a stable, flat surface if they can’t reach the ground. Blocks can improve body alignment and create extension in the spine, provide support during balancing poses, and help you to move safely into and out of a posture. Don’t have yoga blocks? You can also use a stack of books, a chair, and a counter. Ensure the support structure is stable enough and the correct height to meet your student’s needs.

• Yoga Bolster, a large, firm pillow, usually cylindrical or rectangular in shape, used to support the bodyweight so students can experience the benefits of a yoga pose without exerting effort. Most often used in restorative poses, the bolster promotes complete relaxation. It will hold the body in a posture while encouraging deep muscular release. Don’t have a yoga bolster? You can use several folded blankets, a narrow couch cushion, or a stack of firm pillows.

• Yoga Strap, usually 6 to 8 feet long, with a belt at the end, connects one part of the body to another for an intensified stretch, improved alignment, or deeper relaxation. Don’t have a yoga strap? You can use the belt to a bathrobe, a necktie, or any strap made of material that is durable, and smooth so as not to be abrasive to sensitive skin.

• Eye Pillow. Why use an eye pillow? Darkness promotes rest. In all ‘Rest and Restore’ poses, using an eye pillow to cover your eyes can be beneficial, offering soothing darkness, helping the eye muscles to fully relax, and putting gentle pressure on the eyes and forehead that can help to quiet the mind.

Yoga Blankets Yoga Blankets

Bolster

Strap Eye Pillow

Yoga Blocks

Getting to know your students quickly is probably the most challenging but crucial element of being an effective teacher. I call this finding out what’s ‘under the baggy t-shirt’. As discussed previously, cancer and the side effects of treatment manifest in extremely different ways in each individual and this can be the most challenging aspect of working with the cancer community. Also, often a student will not know what aspects of their physiological or psychological state you need to know in order to teach a safe yoga class. Or, understandably, they are shy about sharing their details, so it can be more difficult to understand what is going on ‘under that baggy t-shirt’.

Fast Facts is an intake tool created for y4c Methodology. This is the tool that will give you the required information on the individual and what physical or emotional challenges they might be facing. This, with your newfound awareness of the facts, will help you provide any student a safe, healing yoga experience.

Fast Facts has been constructed as a question-by-question guide on how to gather information from your new or returning students in a non-intrusive way. Start with asking for their name and yoga experience because that is polite and yoga is what they have come to do. The sequencing of the questions is important, the answer to one leading to the next. For example, the answer to “What cancer has ‘touched’ you?” could spontaneously give answers to the next three questions. “I am on chemotherapy for stage 4 pancreatic cancer.” If, however, the answer is “I had thyroid cancer” your follow up would want to be the date of diagnosis. It could have been one month ago, or ten years.

Please note that I do not use, nor recommend, a written in-take form because that is too clinical. Clipboards with sheets of paper taking medical history happen too often to cancer survivors – we want to create another type of healing environment. But after a personal interview and after class, I make notes on my new students to aid my memory and to keep track of progress.

Next is the Fast Facts form but it also can be downloaded at y4c.com Online Learning site.

Fast Facts !

1) Yoga experience: 2) Cancer type: 3) Stage: 4) Date of start or completion of treatments: 5) Treatment Protocol: SURGERIES CHOICES: • Single or double mastectomy and lumpectomy • Sentinel node biopsy or axilliary node surgery • Breast Reconstruction (Type of reconstruction and any long-term side effects) CHEMOTHERAPY & RADIATION: • There are over 50 kinds of chemotherapy drugs and endless combinations. You need not know all the names of the chemo, only the names of your students. • Treatment time frame • Treatment side effects BREAST RECONSTRUCTION CHOICES: • Implants • Tram Flap or Free Diep Flap • Latissimus Dorsi Flap • Other Host Site

6) Other Healing Surgical Sites: • Post Surgical Drains • Chemo Ports 7) Do any of these conditions exist? • Neuropathy • Lymphedema • Dizziness 8) Other non-cancer related conditions? 9) Is there Doctor’s permission to exercise?

Let’s start to construct an y4c class. There is no prescribed plan for every situation, every individual or every class; there is only a structure of a plan by using the following outline of essential elements. An intelligent, well-planned y4c class includes all of the elements listed but remains flexible. Your planning starts with determination of these variables: • Time you allow for class • Number of students • Yoga-specific levels • Student-specific physical and emotional needs • Teacher’s theme or intention for the class • Availability of props or specific situations of the location of the class

The y4c Class Plan has 7 Elements: Finding Stillness, Warm-up Vinyasa, Movement Module, Balance Modules, Dissolving Body Awareness, Sunset, and Closing OM.

Each lesson plan is different, just as each day is different. However, they both have a beginning, middle and end. You will select appropriate poses and sequences to fill the time and a definition of each element. • The elements of the beginning are Finding Stillness and Warm-up Vinyasa, the essential elements that introduce quieting the mind, breathing and beginning simple links of breath and movement. This is the part of the class plan that allows for the most variation of time, level and intention to address specific cancer-related benefits. • The middle of the plan consists of Movement and Balance Elements. • The ending elements are designed to dissolve the body into rest, with Restorative Poses and Shavasana/Sunset.

Seven Elements of a Class Plan 1) Finding Stillness: This element includes several important parts that all work together to quiet the mind and begin a yoga practice. The sequence of these parts can vary, but should have a logical path between them. The first element should be first! • Introduce yourself and state the name of the class you are about to teach.

© yoga4cancer 2018 139 • Teach how to sit—how to place the bones and use props to sit upright and comfortable. There are three ways to sit: In a chair, cross-legged on a bolster or cushion, or on a yoga block, cushion or stool, with legs folded. The y4c Methodology does not rule out variations starting prone or standing. A teacher should clarify the purpose of this variation and accordingly explain the proper positioning. • Create and introduce a theme, or metaphor that sets your intention as the yoga teacher. • Opening OM (chant) • A moment of Meditation: Meditation is essential for survivors because this is a way to learn tools to control the mind. Many different meditation techniques and styles exist. I recommend simple ones! The length of time is not as important as the quality of calmness one can create in the nervous system. Start with one minute. It should be an active practice and requires three things: − A comfortable seated position − The promise to yourself that you won’t judge what happens − A commitment to being curious as to how it feels when your mind is not thinking • Breath Awareness practice - The breath nurtures and detoxifies our organs and cells, strengthening our Immune System and keeping the body resistant to cancer. Discuss the muscles used in creating the breath. How to control, strengthen and even enjoy the breath. Introduce a simple pranayama, or breath awareness.

Tips: ü Check the arrangement of room: mat orientation, spacing. If students are close together, take time to alternate their positions before beginning Warm-up Vinyasa. ü Make sure everyone has proper props. ü If starting seated, use yours to demonstrate the most accessible posture to all levels. This will likely not be your personal version of the pose. This is not a time to show what you can do, rather what is possible for others. ü Use a crisp and audible voice. ü Make general welcomes to new and returning students. ü Do not ask for current concerns, injuries or updates on treatment in an open environment, this should be part of your individual in-take process.

© yoga4cancer 2018 140 2) Warm-up Vinyasa: This Element is the arising body awareness linking breath and movement. See the section “What is a Warm-up Vinyasa”. The structure of the sequence must move the spine in five ways using a vinyasa pattern linked to the proper breath. Because this is a warm up, begin slowly and make simple links of breath. A Warm-up Vinyasa can be done from many positions: • Seated Arm Warm-up vinyasas • Supine Warm-up vinyasas • Hand and Knee vinyasas • Standing vinyasas

For me, the Warm-up Vinyasa is key to the success of the whole class and is the element that I work on hardest in preparation. It grounds the theme/metaphor/intention for the class. And intrinsically, everything flows from this first Vinyasa. When I have the kernel of an idea for a Warm-up Vinyasa that combines my theme and moves the spine in all directions, I write it down and then practice it many times at home on myself. And then I review it mentally on my way to class. Because it is simple, it doesn’t mean it is easy or should be underestimated. Because it is the beginning element, it is important to be precise in teaching it.

Please review: What is a Warm-up Vinyasa? Section #3.3 and/or the Warm-up Vinyasa video. Save and use examples of practice sequences you create in the assignments of this module—they will be the basis of our in-class training and your future teachings.

The Connecting Vinyasa: .... Getting up and getting down Whether the Warm-up Vinyasa was seated, standing, prone or on hands and knees, continuing to the Movement Module is the next step. To do so, we use what I call the “Connecting Vinyasa”. In other words, yoga movement that gets you up and gets you down. Although not an Element itself, it is theconnecting tissue between Elements. Plan your class including smooth transitions between Elements.

This is extremely important when a survivor is not yet back to ‘normal’ due to surgeries. It can also be a challenge for many other reasons, some unrelated to cancer. For example, if someone is overweight, has had knee or hip replacements, or muscle strength has atrophied. If a person lacks coordination, body awareness or is fearful to moving from the floor to sitting,

As teachers, we want to provide safe transitions between poses. We also want the students to feel confident making those changes of position without struggle or pain. Equally important is making the instructions easy, special and memorable so that students will be empowered to use these techniques in everyday movement, not just in yoga class.

Examples of “how to get up and how to get down” have been discussed or will be demonstrated in other parts of this training. However, two examples are clearly illustrated in Yoga for Cancer. In an assignment in this section, you will be asked to integrate the movements and language queues that you will use. This then becomes the connection vinyasa or connecting tissue to other elements of your class plan. The y4c Methodology uses the following poses to create that connecting tissue between poses and elements: • Hands and Knees • Chair to Blocks • Knee-Down Sun Salutation • Lunge to Stand • Toe Massage to Stand

3) Movement Module ‘Move to live, live to move.’ – Tari

A cancer survivor wants to keep the Immune System healthy and alert. Many ways exist to maintain a strong system, but the most critical and natural way is through movement. By mobilizing muscles and bones, we massage the organs in our body that are otherwise inert. In fact, lack of movement can be as harmful as cancer. Movement improves circulation and mobilizes fluids such as blood and lymph, which keep organ tissues nourished, and movement allows the body to detoxify.

The core of a class plan is constructed to move the body safely with ease and confidence through classic yoga poses. How do you do that? y4c Methodology has not re-invented yoga, rather it focuses on how to make these poses/asanas accessible to students who are in

What poses to include and how many? The next step in planning is choosing which poses you want to teach. Which classic yoga poses you include depend on two variables you have already established: your theme and the Warm-up Vinyasa. And the factors you cannot always control and/or know prior to class: the students in your class and how they are feeling that day. How many poses to include is also determined by the length of class you want to create and/or the level of challenge you feel your students will find most beneficial. There are more than 200 poses in Mr. Iyengar’s book, Light on Yoga, and perhaps hundreds more. In my book, Yoga for Cancer, I detail 53 unique poses. You have lots to work with. Choosing which poses to teach is the art of yoga teaching.

Here is how I start making a Movement Model Plan. 1. Select several standing poses that match my theme and class level. 2. Begin with Step Back to Modified Sun Salutation. 3. Continue with Step Back to a standing pose(s).

You can guide your students to almost all standing poses from the basic y4c Step Back. Those poses can include: Lunges, Side Angle, all the Warriors, Triangle and standing poses, such as Side-chest Stretch with blocks and Wide-leg forward bend with blocks. From each standing pose you choose, you should include and create Vinyasa variations of: elongation, forward (flexion), back (extension) side bends and twists.

4) Balance Module The Balance Module teaches yoga poses that help us do just that—balance on one foot. One leg/foot standing poses are frequent in yoga. Any that can be taught safely and lead to success are appropriate to y4c Methodology. As with the Movement Module, time available and level intended challenge are variables to consider, along with the particular phase of recovery. However, include at least one balance pose in each plan. Tips: ü Give warning you are starting a one-leg balance. ü Demonstrate on a student or assistant, not yourself.

© yoga4cancer 2018 143 ü Suggest using a wall or chair. ü Build the pose slowly from the simplest expression. ü Alignment makes balancing easier, so does breathing. Bring attention to both. ü Hold without counting. ü Rest and explain benefits between sides.

Why is balancing on one leg so good for cancer patients? Here are reasons and benefits: • It is healing to know how to clear your body and mind of anxious moments by standing on one foot! • Challenging your balance challenges your connection to the Earth. • Practicing balance poses increases your ability to focus. When this happens, it is easier to do the same when it comes to the other things in life that are important and not so easy, such as going to a cancer treatment. • Weight-bearing exercise strengthens bones. • Good balance helps protect you from falling and breaking bones. • One-footed poses teach us proper alignment of the spine and gives us better posture. • Good balance improves your posture, which, in turn, cultivates breath awareness. • Overall, practicing balance helps keep the Immune System well.

Remember, just as in standing poses, the Balance Element can become a vinyasa sequence including small movement and breath awareness. Include at least one of the following: • One-leg Balance (Start with simple variations of Padagusthasana) • Tree with simple modifications and possibly the support of a wall or chair. • Eagle with block modifications and possibly the support of a wall or chair. • Warrior 3 variations with block or the support of a wall or chair.

5) Dissolving Body Awareness - Rest and Restore Poses The science that led to the development of Restorative Yoga defines it as “resting with purpose” literally meaning to balance the body’s architecture, organ functions and mind. I find it helpful to define the purpose of a restorative pose as different from active poses, yet having all the benefits with less student effort. The effort is on the part of the teacher and the props. Most rest and restore poses are done lying down with bones properly placed in one or more of the

© yoga4cancer 2018 144 five spinal positions that are the foundation of every yoga style: elongation, forward (flexion), back (extension) side bends and twists. When the body’s architecture (skeleton) is properly aligned, deep rest begins.

Restorative Yoga uses props such as blocks, blankets and bolsters to completely support the body. The only movement for a student should be arranging the props as directed (That is the challenge for the teacher, you!) and getting into the pose. However, the teacher is responsible for making sure that every ‘body’ is properly aligned and supported to the purpose of the pose.

It sounds easy, but teaching restorative poses is hard work. Also, restorative poses can be more challenging physically for others then they may be for you as an experienced yoga teacher. Choose your restorative poses based on the yoga for cancer benefit you want to achieve, not on what restorative pose you love most in your personal practice. See notes on Restorative Poses in Category #1 – Poses we like, but teach with care.

The suggested time to hold a restorative pose is 5 minutes or less. Poses can be held for longer depending on the student’s comfort and/or the teaching situation. The length of time will vary most when teaching single students, privates. Ok, I know that gives you a wide range of time. Trust your experience, familiarity with your students and watch for the ‘fidget’ factor clues. Always suggest a student come out of the pose at the first sign of discomfort.

Cultivating attention and focus on the breath can be included with a restorative pose, making it a simple gentle breath vinyasa or breathing awareness. The mind tends to wander during these poses, so encouraging a breath awareness exercise is a great way to induce calmness and rest. This is the only movement allowed! Each exhale is an opportunity to release distracting thoughts as well as muscle tension.

Dissolving Body Awareness element using Rest and Restore Poses is wonderful, if used to follow the more vigorous, energizing Movement and Balance elements. It could also be done alone. This may be appropriate at some stages of cancer recovery, depending on your student’s mood or feeling that day.

© yoga4cancer 2018 145 Tips: ü Be prepared with the proper props. ü Demonstrate on a student, not yourself. ü Offer modifications rather than alternative poses. ü Once each person is settled and comfortable, do not readjust. ü Once calmness is achieved, talk about the benefits.

In your class plan include at least one of the following: • Rest and Restore Poses(s) • Rest and Restore Poses(s) (with gentle breath awareness)

The y4c suggested and illustrated restorative poses are: Restorative Bridge, Cobbler, Fish, Shoulder Stand and Legs up the Wall.

6) Shavasana The ultimate goal of Shavasana is sealing in all the work on the mat. The restorative poses paved the way. Take care: The word Shavasana (shah-VAHS-anna) has one meaning in Sanskrit, and that’s Corpse Pose. It also has other labels: Deep Relaxation Pose (or sleep), Final Resting Pose. In y4c Methodology, we like to call it Shavasana or Sunset Pose. It is the most essential pose of a yoga practice, especially for cancer patients and survivors. It is super- duper restorative with a slight difference: It is always at the end—and it should never be skipped! It has no muscular effort, no thinking, no conscious moving. It is sunset ...

Sunset Pose is complete and utter relaxation. Even so, it might just be the hardest pose to practice for a cancer patient, or even a long-term survivor. Remind your students that everything has a cycle, be it a single breath, a life, a human cell, a yoga practice. Everything has a beginning, middle and end point, like the vinyasa sequences in the movement module. As things begin to end, the anticipation of the new beginning arises. The natural closing of each day with a sunset is necessary to make way for the next sunrise. Teaching the body to relax is not easy, nor is it fast. Like all yoga poses, it takes practice! We have to learn how to do it.

© yoga4cancer 2018 146 Tips: ü Fewer props are needed, but make sure they are available. ü Suggest a blanket for warmth. ü Often students experience discomfort in the lower back. If so, place a rolled blanket or bolster under the knees. ü Observe and offer a folded blanket under the head, if the neck is tilted back.

Instruct students to rest comfortably on the mat with arms slightly away from the body with hands opened gently to the sky. Breathe naturally. Allow ten minutes. ü Shavasana/Sunset Pose

7) Closing OM: Close the class with the chant of OM, one or more times depending on your lineage, from an upright position. It is the salutation and can include hands in prayer and eyes closed, once again, depending on your lineage. • Slow careful instructions to sit—in a chair, cross-legged on a bolster or cushion, or on a yoga block, cushion or stool, with legs folded. • Reference to the theme can make the complete vinyasa loop. • Instruct a comfortable inhale. • The teacher leads the exhale with OM.

Cancer survivors come with high expectations of yoga. I have learned many things during the years of development, testing and observing in the y4c laboratory of weekly classes. Before this work, no existing protocol or guidebook existed. To follow are some of my key findings to aid you in providing the best yoga support to cancer survivors everywhere and support the development of your yoga teaching skills for this special community. Here is my best advice and cautions.

1. Safety First Healing begins with feeling safe. Awareness of the limitations imposed by surgeries, chemotherapy and the various life-long side effects and vulnerabilities of cancer treatments and reconstruction are not covered in most yoga teacher training. Most yoga teacher training does not provide an awareness of the limitations and vulnerabilities imposed by chemotherapy, surgeries and other treatments; not to mention reconstruction and the many life-long side effects possible. Conditions for safety start with a teacher’s willingness to learn about cancer, to be properly trained to teach yoga for cancer survivors, and to take the time to understand each student’s needs and concerns. You have done this, and now you will teach the yoga that is informed by that knowledge.

2. Risk Factors I am asked questions about yoga benefits all the time, but rarely asked about its risks. Survivors expect teachers to understand the effects of cancer treatments on the body, what poses have most benefits, and what poses can be potentially harmful.

As a teacher, you must be ready to adapt your teaching to the changing needs of students. The difference in teaching yoga to cancer survivors is that the risks are higher and a teacher should know what they are.

3. Who’s Responsible? When offering a class for cancer survivors, a teacher is saying, “I am responsible. I know what

© yoga4cancer 2018 148 yoga is best for you and I will protect you from further discomfort, injury - plus calm your doubts or fears.” Students expect yoga teachers of cancer survivors to have that expertise.

Cancer survivors may be reluctant or embarrassed to talk about their concerns. They may not even know some conditions can put them at risk in certain poses. The yoga teacher needs to know the risks if such conditions exist and to adapt the yoga for these life-long conditions and side effects accordingly.

Teachers need to ask the right questions and to gather this important information carefully, in most cases, privately, and with great sensitivity.

4. Facts Motivate Survivors want to know why something works for their condition, not just that it is good for them. They come with curiosity and a desire to know how and why yoga will help them be healthy and stay cancer- free. Use research facts about yoga. Your students will listen attentively to every fact and suggestion on how to fight cancer using yoga. They will feel and see the benefits. They will remember and thank you. Then, they bring this information and good feelings back to their doctors.

5. Feelings Matter Your feelings come first. A yoga teacher has so many things to be aware of during a yoga class. The first one should be the fluctuation of her/his own emotions. It is easy to feel overwhelmed with the suffering of others. Inexperienced teachers may be inclined to treat students with hesitation based on their unrecognized fears about cancer and dying or a lack of confidence in teaching survivors. Hesitation is neither helpful nor healing for the student. Authentic, open teaching starts with recognizing and acknowledging everyone’s emotions, not just the students’ hopes and fears.

6. Who’s the Teacher? A life-threatening illness can help us all learn how to live fearlessly. If faced directly by both the yoga teacher and student, remember this: Cancer is everyone’s teacher.

• Use slow transitions between poses. Dizziness is a common side effect during some forms of cancer treatment, largely due to anemia and low granular red blood cell counts (GBC). Some heart medications used in conjunction with certain cancer treatments also affect blood pressure causing dizziness and fatigue.

• Alternate standing poses with restorative poses. Keep a good flow without exhausting the student. Giving the body time to relax between standing postures creates positive muscle memory and can assist in teaching body awareness. Use variation rather than repetition.

• Symmetry is important. While our bodies are never perfectly symmetrical, moving the body in a symmetrical way, or using props to support the body in a symmetrical position, promotes muscle relaxation and balance. If one shoulder is more mobile than the other, you may notice in a pose such as Swan Wings that one arm is able lift higher than the other or, in Restorative Fish, one arm easily rests on the blanket while the other hovers above. Similarly, if one hip is more flexible than the other, in Restorative Cobbler one knee may easily rest on a low block, while the other does not. However challenging it may be to accept what we see as our limitations, try to align yoga poses in a symmetrical way, especially in restorative poses. Most often we find and create symmetry by providing support and comfort of the less flexible side of the body.

• Switch legs in cross-legged seat pose. When sitting in Cross-Legged Seat, notice how one habitually places the same leg in front. During seated practice such as warm-up arm vinyasas, be sure to switch the crossing of the legs to spend an equal amount of time with the right leg and left leg in front. This will help to balance the flexibility and alignment of the hips.

• Use caution with physical assisting. The goal is not the perfect pose, it is SAFETY. Gentle hands on adjustments are useful as long

Hands carry germs. Because patients undergoing treatment have compromised Immune Systems and long-term survivors can have a high sensitivity to being exposed to germs, you should always ask first if it is ok to touch.

• Avoid heavy scents, incenses or oils. Be sensitive to the fact that chemotherapy side effects may include a heightened sense of smell and nausea.

• Support students by asking, not telling. Find out who your students are before class if possible. Ask questions. Avoid giving advice right away. Find out about recent surgeries or treatments, if any. This is key to allowing the student to remain safe and comfortable in the class. Memorize and use the y4c Fast Facts.

• Build realistic goals. Many students will never do the perfect handstand, nor should they. The primary goal should always be SAFETY, whether in a pose or in the community. There may not be visual improvement from week to week. There may be a shift in spirit unseen by an outsider. Let the students set their own goals and help your students attain them.

• Keep it fun and light whenever possible. Chances are that students participating in y4c class may already feel heavy with fear and despair. They don’t need further “judgments” or expectations put upon them by a yoga studio. Offer them ninety minutes of relief from the daily stresses that a cancer diagnosis can bring.

© yoga4cancer 2018 151 Cautions due to Treatments That long list of individualized side effects we reviewed in Module #2 can make it seem like a herculean task for a yoga teacher to know and be prepared for all possibilities. However, as teachers we can be aware of what is appropriate for our students, by understanding and being sensitive to their situation at any given time.

Here are important y4c Methodology cautions to keep in mind relative to different cancer treatments. Following these are important to provide a safe experience for your students.

1. Cautions due to SURGERIES: It is advisable to get a written doctor’s permission to exercise. Post-operative pain is common in the surgery site. The resulting scar tissue from any surgery can cause long-term discomfort, pain and limit functionality. Beware of host sites used for reconstruction (e.g., abdomen, back, legs). Mastectomy, auxiliary node and all reconstructive surgeries can cause nerve damage that results in numbness and almost always limits range of motion.

Surgical Drains - most people leave major surgeries with a surgical drain that stays in place until the surgical wound is healed. This is a normal post-surgery procedure. It is imperative that these surgical drains have been removed and doctor’s approval has been granted before a student practices yoga, as they can become dislodged and also be a major source of infection.

General Suggestion: The most important thing when dealing with students who have undergone surgery, is to find out exactly what the surgery entailed: • The first question is, “What was the surgery?” • Learn how much time has passed since the surgery. • Ask if they still have a surgical drain. • You should know what side effects, if any, they are experiencing. • Ask if they have a doctor’s permission to do something as physical as yoga.

2. Cautions due to CHEMOTHERAPY: A reduced red blood cell count can cause dizziness, fatigue and bruising. Meanwhile, at the same time, a reduced white blood cell count compromises the Immune System’s efficiency and increases the risk of infections. Chemotherapy can bring on premature menopause and

© yoga4cancer 2018 152 corresponding symptoms, such as hot flashes and osteopenia (loss of bone density). Abnormal blood cell counts also cause systemic imbalances that affect heat regulating hormones. Neuropathy in the hands and feet is often caused by chemotherapy. This is experienced as numbness that can affect one’s ability to maintain balance or it can cause pain and sensitivity to weight-bearing pressure.

General Suggestions: • Be sure to find out if a student is currently going through chemotherapy; if they are, ask when their last treatment was and if they are experiencing any side effects. If a student has recently undergone chemotherapy, this should not be a deterrent from attending class; even if side effects are experienced in class, they are generally manageable and hopefully even reduced by a yoga practice. • You will also want to be aware if they have a chemotherapy port and where it is located. It is OK for them to practice with a port; there may be some sensitivity in certain poses (e.g. prone poses or upper body twisting) and teachers should be cautious about adjusting in the area near the port.

NOTE: Chemotherapy Ports under the skin in the chest may be sensitive, but are not necessarily a hindrance to doing yoga. These may not be visible. You will need to ask to know what movements/poses to avoid or modify. • Be observant and careful about hygiene. Make sure the props are clean. Encourage students to bring their own props or bring their own towel to cover provided props. • Be aware that individuals will have sensitivity to a room being too hot or too cold. Be sure the room is kept at a moderate temperature. • Avoid use of anything that produces a strong odor, such as candles, incense, or aromatherapy oils.

Modifications: • Make sure a wall is available (and offered) for students to use during any balancing poses. This reassures students experiencing neuropathy and/or dizziness. • Make suggestions of how to take a time out OTHER than child’s pose (e.g. knocked knees or reclining on a bolster with the head slightly elevated)

© yoga4cancer 2018 153 3. Cautions due to RADIATION Skin sensitivity, radiation burns and fatigue are the most common side effects while undergoing radiation treatment. In time, post-treatment, this sensitivity often dissipates.

General Suggestions: • Because of the daily routine of radiation treatments, suggest frequent time-outs and easy comfortable ways to rest during class. As was discussed in Module 2, radiation is often contiguous treatments given daily for as long as 30 days—this daily routine can be fatiguing. • Bone loss also can occur as a direct result of radiation to the bone, resulting in osteopenia, weak bones and risk of fracture. • It may be a surprise to both the yoga student and the teacher that reaching this last step of treatment can cause negative rather than positive emotional reactions. What seems like a wonderful thing to celebrate can often be a source of anxiety for the survivor.

Modifications: • Exercise gently and slowly to avoid irritation to burns. • Avoid touching the radiation site while adjusting.

Appendix

• Poses: Illustrated Poses, Sequences of the y4c Methodology • General Sources and References • Endnotes for Section #3.2, Yoga Benefits

Illustrated Poses, Sequences of the y4c Methodology 20 - Glam Gal Twist Extention Part 1

13 - Leg Rocking 3 - Gather and Hold

9 - Seated Cat and Cow

15 - Crunch Twist

5 - Seated Cactus Clap

6- Cactus Twist 21 - Slumber Party 39 - Stand Tall

7- Cactus Teapot

12 - Full Body Stretch / Part 1

19 - Hands and Knees Leg Extensions 28 - Cha;ir

12 - Full Body Stretch / Part 2

26 - Sway in the Wind 14 - Crunch and Switch / Part 1 18 - Hands and Knees Twist

Part 1

30 - Down Dog at the Wall

24 - Getting up to Stand Sequence

32 - Knee Down Sun Salutation

41 - Free Warrior 3

42- Restorative Supine Shoulder Stand

43 - Restorative Cobbler

Research and resources on both cancer and yoga are evolving – both fields are still in their infancy. So I encourage you to embrace the curiosities that led you to this training. Learn the facts, dispel myths and gain knowledge to be truly compassionate to yourself and others.

To provide a comprehensive or timeless resource list would be impossible as research is actively being conducted and new findings identified on both cancer and yoga. So I am going to provide you a list of resources that I used to develop this manual, my methodology and others that I consult daily. This is not an exhaustive list, but I hope it fuels your curiosity.

One more piece of advice, on my journey, I have encountered tons of articles, research findings and studies that were outstanding and intriguing; and potentially would have led me down other paths. If I had not ‘dug’ further into the basis of the premise, who was paying for the research or interrogated the hypothesis with an eye of fact-based information, I could have potentially been misled. I strongly urge you to use that curiosity to ask and interrogate everything you read and find. Look for randomized, double-blind and controlled studies and research by neutral and well-known medical or research journals. Use the resources below to verify or challenge any learning.

Cancer Information: • American Cancer Society - cancer.org • National Cancer Institute – cancer.gov • Cancer Research UK – cancerresearchuk.org • PubMed.gov – US National Library of Medicine – The ultimate resource for the latest scientific fact-based research. • Breast Cancer Action – bcaction.org – Offers information, webinars, tools and movements to end the • breast cancer epidemic and improve the lives of those fighting it. • Breastcancer.org – Latest research, information, very helpful webinars/podcasts and other resources. • National Lymphedema Network – lymphnet.org – Provides research, resources, support

© yoga4cancer 2018 159 groups and network of professional massage and lymphedema specialists. • Cure Magazine - curetoday.com – Interprets research and latest findings in a thoughtful and pragmatic way. Easier to read!

Yoga References: • IAYT – International Association of Yoga Therapists – iayt.org • Sciatica.org – Research findings and news about Yoga & Osteoporosis and other topics

Yoga Publications: • Lilias! Yoga Gets Better with Age, Lilias Folan, Rodale, 2005 • OM Yoga: A guide to daily practice, Cyndi Lee, Chronicle Books, 2002 • Science of Breath: A Practical Guide, Swami Rama, Rudolph Ballentine, M.D., Alan Hymes, M.D., The Himalayan Institute Press, 1979 • The Breathing Book, Donna Farhi, Owl Books, Henry Holt & Co., 1996 • The Woman’s Book of Yoga & Health, Linda Sparrowe, Shambhala Publications, 2002 • Yoga for Wellness, Gary Kraftsow, Penguin Compass,1999 • 30 Essential Yoga Poses: For beginning students and their teachers, Judith Lasater, Ph.D., P.T., Rodmell Press, 2003

Additional References Cancer Statistic: The number of cancer survivors continues to increase, with estimates at 18M in 2022 according to the National Institutes of Health and Centers for Disease Control and Prevention. • http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/docu ment/acspc-033876.pdf

Cancer and Exercise: Most cancer survivors are not exercising enough to benefit. (2014) http://medicalxpress.com/news/2014-03-cancer-survivors-benefit.html

A study that a regular yoga practice improves immune function and stress hormone releases in young healthy people. (2015) http://www.ncbi.nlm.nih.gov/pubmed/26181573

A study that shows that exercise reduces tumor incidence and growth. (2016) http://www.cell.com/cell-metabolism/fulltext/S1550-4131(16)30003-1

Yoga as Complimentary Treatment: • https://nccih.nih.gov/research/statistics/2007/camsurvey_fs1.htm

Yoga Popularity • http://www.channelsignal.com/fresh-signals/by-the-numbers-the-growth-of-yoga

• http://www.google.com/trends/explore#q=yoga%2C%20pilates%2C%20tai%20chi%2C %20trx%2C%20kettlebell&cmpt=q

Common Cancer Treatment Side Effects • http://www.cancer.net/survivorship/long-term-side-effects-cancer-treatment

• http://www.cancer.net/navigating-cancer-care/how-cancer-treated/radiation- therapy/side-effects-radiation-therapy

Yoga and the Immune System • http://www.google.com/trends/explore#q=yoga%2C%20pilates%2C%20tai%20chi%2C %20trx%2C%20kettlebell&cmpt=q • http://www.ncbi.nlm.nih.gov/pubmed/26181573

Managing Chemo Brain with Yoga • http://www.ncbi.nlm.nih.gov/pubmed/26181573

Lymphedema • http://www.nytimes.com/2009/08/18/health/18well.html?_r=0

Cancer and Massage • http://www.massagetherapy.com/articles/index.php/article_id/278/Massage-and-the- Cancer-Patient

Other Referenced Websites: • http://www.cancer.net/all-about-cancer/newly-diagnosed/tests-and-procedures

• http://www.cancercenter.com/treatments/diagnostics/

• http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/detection-and-diagnosis/diagnostic-tests/index.html

• http://www.cancer.gov/cancertopics/wyntk/cancer/page6

• http://www.cancer.gov/cancertopics/pdq/screening/overview/patient#Keypoint1http://ww w.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/detection-and-diagnosis/symptoms-by-disease/cancer-symptoms.html

• http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/detection-and-diagnosis/recognizing-cancer-symptoms/index.html

• http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/detection-and-diagnosis/diagnostic-tests/index.html

© yoga4cancer 2018 162 Endnotes for #3.2 Yoga Benefits: ihttp://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Lifeaftercancer/Bone health.aspx ii P. S. Yung and others. “Effects of Weight Bearing and Non-weight Bearing Exercises on Bone Properties using Calcaneal Quantitative Ultrasound.” British Journal of Sports Medicine 39(8) (2005): 547–551. iii Loren Fishman, Yoga for Osteoporosis: A Pilot Study, 2009. http://www.sciatica.org/downloads/YogaOsteoporosis_PilotStudy.pdf iv http://www.ncbi.nlm.nih.gov/pubmed/24163186 v E.N. Smith and A. Boser. “Yoga, Vertebral Fractures, and Osteoporosis: Research and Recommendations.” International Journal of Yoga Therapy 23 (2013):17-23. http://www.ncbi.nlm.nih.gov/pubmed/24016820 vi American Cancer Society. vii BMC Cancer, 2012, Physical and psychosocial benefits of yoga in cancer patients and survivors, a systematic review and meta-analysis of randomized controlled trials viii http://www.ncbi.nlm.nih.gov/pubmed/23762132 ix http://online.liebertpub.com/doi/abs/10.1089/acm.2010.0007/ x http://jco.ascopubs.org/content/early/2013/08/12/JCO.2012.43.7707.abstract xi S. E. Sephton and others. “Depression, Cortisol, and Suppressed Cell-mediated Immunity in Metastatic Breast Cancer.” Brain Behavior and Immunity 23 (8) (2009): 1148-55. xii “Yoga as a Practice Tool,” Monitor on Psychology 40(10) (2009). Also, in one study, cancer patients receiving palliative care have reduced depression scores and lived longer. David Spiegel, “Mind Matters in Cancer Survival.” JAMA 305(5) (2011): 502-503. xiii Erin Costanzo, Carol Ryff, and Burton Singer, “Psychosocial Adjustment among Cancer Survivors: Findings from a National Survey of Health and Well-Being,” Health Psychology 28 (March 2009): 147-156. xiv Suzanne Danhauer, “Yoga Provides Emotional Benefits to Women with Breast Cancer.” Science Daily. Wiley-Blackwell (2009, March 2). Retrieved March 3, 2009 from http://www.sciencedaily.com/releases/2009/02/090224230707.htm