Sami Papacek

Sami Papacek is a personal trainer, cancer exercise specialist and fitness educator. She has been in the fitness industry for almost 10 years. Sami works with all types of clients, but specializes in women with breast cancer. Using her experience with weight loss programs, Pilates, core conditioning, as well as general strength training, she incorporates all types of exercise in her exercise design.

Sami created the Pink T's Exercise Program, a free class for breast cancer survivors in the Kansas City area. She works with women of all levels of treatment and recovery to incorporate exercise back into their life. Her certifications include: Certified Personal Trainer, American Council on Exercise and National Strength and Conditioning Association, BOSU Master Trainer, Cancer Exercise Specialist, Rocky Mountain Cancer Rehabilitation Institute and Leading Edge Fitness, Pilates Instructor, Fitour, and CPR, First Aid and AED.

Questions & Responses:

Week 1 Question 1:

I had a double mastectomy with immediate tramflap reconstruction and will start chemotherapy next week. I have been shocked at the pain, limited range of motion, and lack of stamina I have now. I really thought all that working out would make my recovery a little easier.

I have 2 young children, a career, and a rather active lifestyle. I want be able to pickup and hold my children, work hard, and be more active when the time is right. I have asked both my general and plastic surgeons if physical therapy is a good idea. Both have advised that it is not normally needed and I should gradually be able to get back to most of what I did before. I have to wonder if that is the standard answer they give to older patients, perhaps with less need or desire to be so active.

It just seems logical to me that with as much muscle, tissue, and nerves as have been removed, severed or rearranged, having a physical therapist teach me how to best manage these changes should be standard treatment. Certainly a common knee or shoulder surgery is usually followed by physical therapy - why is mastectomy not? What are your thoughts on physical therapy and do you have any suggestions for activities I can be doing to work my way back to more activity without injury?

Answer:

I know what you are going through is very common. I'm very happy that you have decided to use exercise as a way to get through your treatment. The fact that you have not been referred to a physical therapist can be considered a good thing. Most women that are referred post-surgical have very limited range of motion and other conditions that are much more severe. Based upon this as well as what you have told me here would show me that you have a very high likelihood of being able to regain your range of motion and strength.

As far as your shoulders are concerned, range of motion and scar tissue are typically your most immediate concerns. The most important thing is to start to move! If you have been cleared by your oncologist and surgeon to exercise you can start with a general strength training program using just the weight of your arms and progressing into resistance bands or small free weights. Even through it may seem difficult at first; gradually you will feel an increase in energy and strength.

Start with 1–2 sets of 8–12 repetitions and progress from there. If you are risk for lymphedema, you will also need to monitor your arm for swelling, redness and signs of fatigue. Progress by adding repetitions up to 15, increasing weights and changing your exercise. All changes should be slow and made as you feel stronger and have more endurance. Try to find someone in your area that can assist you or email me if you have additional questions.

Here are a couple of exercises that are effective post treatment. They help with range of motion and flexibility.

Touch your heart, head, and sky

Seated or standing, start by taking the hand guided by your index finders of your affected side(s). Touch your heart, then the top of your head and then reach for the sky. As you reach up, try to straighten your arm as much as possible while keeping the shoulder blade down. If necessary, place your opposite arm across your chest to touch the shoulder blade to feel if it is lifted. This exercise is vital for the surgical side(s) but as effective for the non-surgical side as well.

Reach up and over (palms facing front)

Standing, take hold of a wooden dowel or towel palms facing in. Lift your arms straight over your head so that your palms are facing forward. As you feel comfortable lean to the side. Keep sine straight up and down, movement comes from arms only.

You will more than likely feel a stretch in the chest and armpit area. Sometimes it will feel like a ripping sensation, monitor closely, but this is typically the release of scar tissue. Go slowly and only to comfort.

Option-place one hand in an overhand grip and the other underhand as you do this. Press towards the side with your hand underhand.

Repeat both sides. This exercise is also effective for the non-surgical side to stretch tight muscles.

Chest and shoulder stretch

Using a wooden dowel or broomstick, find an area where you can sit with upright posture such as a kitchen chair. Place the stick across the muscles in your shoulders (the trapezius), not on your vertebrae. Place your arms up and over the stick, your hands should be at least 4 inches wider than your shoulders.

You may feel your hands go numb during this exercise. This is because the muscles are so tight that they are affecting the nerves causing tingling. This typically improves as the muscles stretch.

You may also feel the painful pull or pop of scar tissue. This is common in women that have had breast surgery. It should improve with time, but can still be felt many years after breast surgery.

As it gets easier, imagine you are pushing the ends of the stick together. This active stretch will increase the amount of muscles fibers that you are stretching.

Question 2:

After my bilateral mastectomies with implant reconstruction last August, my back was in poor shape. Last month I began one-on-one training with a yoga instructor and my back is beginning to get strong again. My problem is with the arm and upper body exercises. While trying to move and strengthen my upper body through weight-bearing routines, my chest muscles force my implants into uncomfortable positions, and even spasmed at one point... I hate the feeling of the implants moving around while I exercise, it's so unnatural! I'm super-aware of the movement of the implants, and think everyone can see my chest jumping around. I'm so self conscious about this. I'm 10 months post-op -– will the muscles relax with time? Will I ever regain the upper body strength I had before surgery?

Answer:

I give you a lot of credit for getting back in shape with yoga! It's so good for the mind and body. I think that you are on the right track, but modify your exercise to allow some weak muscles to start to function again and then catch up.

I have worked with numerous women that have gone through spasms of the chest muscles. This can be caused by things such as over tight muscle, scar tissue, nerve damage and weak muscles. Most of the time, this can be overcome and will subside over time. It is also possible that you are dehydrated or lacking in certain nutrients such as potassium that help muscles to fire.

I suggest that you start a flexibility program for your chest along with a very light strength training program. It sounds like you have some scar tissue that is causing your implants to be forced into positions rather than just being able to move more naturally.

There are several ways to help get rid of the scar tissue. You can stretch or get a massage from someone that specializes in this type of therapy. Sometimes light strength training with resistance bands will also help. It is important to understand that everyone is different and therefore might require a different combination of treatment.

Will you regain your pre-surgery strength? Not knowing you, that is difficult for me to answer. However, I can tell you that if you keep moving forward while retraining muscles that have been affected, the chances are good. Many times, the difficult part is understanding that you just can't go back to what you were doing. Your body has been modified and it is important to work through the changes.

Question: 3

I have metastatic breast cancer in the lungs and liver. I'm on weekly chemo and stay nauseated and fatigued continuously. I'm 60 pounds overweight and really need to lose it, but all I can do is lie on the sofa and sleep. I deal with other problems as well—arthritis, neuropathy, lymphedema, and have had reconstructive surgery with an abdominal tram flap. The region in which I live has 90–100 degree weather daily, preventing me from going outside at all. I know all about the 'weight/cancer' relationship... Is there anything I can do?

Answer:

I admire your desire to exercise even through you are going through so much right now. As far as the concerns from your physicians I can understand why they have expressed this, make sure you tell them if you start exercising.

Is it possible for you to spend some time in a pool maybe at a community center or other location? You can walk in the water; take a water class or just move. Any type would be beneficial for your body and mind. Water is 7 times more resistant than air and very effective for weight loss while being better on joints and lymphedema. You will remain much cooler but don't let this fool you. You will still sweat in the water so it is important to drink water.

If this doesn't work for you, just try to move at home. Walking up and down stairs, around your house or in place can be very effective. I also recommend that you get a stability ball to sit on. Part of why you may be so fatigued is that you have been sedentary due to treatment and have lost of lot of muscle strength and endurance, both contribute greatly to fatigue. Even sitting on a stability ball 10 minutes per day will rebuild core muscles making your body stronger and better able to support yourself.

Start small, but just start!

Question 4:

What are your suggestions for losing weight after breast cancer?

Answer:

Some of the most common questions that I receive are related to weight loss. So many women gain weight post treatment for a number of reasons. Treatments such as chemotherapy, radiation and hormonal therapies each have their own side effects. Women respond differently to treatment, but many times the outcome are still the same.

So what can we do? There are three main components to obtaining and maintaining a healthy weight. cardiovascular exercise, resistance training and nutrition. Each is vital to your success.

Cardio is important for a strong and healthy heart and lungs as well as an effective way to burn calories and combat or prevent osteoporosis. You can walk, run, swim, bike, do aerobics or any other activity that gets your heart rate up. You want to feel a little "breathy" but be able to talk. Try to work up to at least 20 minutes most days of the week.

Resistance training is exercise for your muscles. This type of exercise will boost your resting metabolism, create a slimmer and tighter appearance as well as strengthen muscles to support your joints and skeletal frame. Shoot for a full body workout 2-3x weekly. Make sure you target all of the major muscles groups such as back, chest shoulders, biceps (front of the arm), triceps (back of the arm), abdominals and lower body including both the front and back of the thighs and buttocks (quadriceps, hamstrings and glutes respectively).

Nutrition is also important component for fitness. The calories you take in both fuels your body (think gas in your car) as well as how you feel, both in your energy levels and your mind. Proper nutrition means eating from all of the major food groups in a balanced manner. For example, it is important to eat carbohydrates and protein with a small amount of fat at each meal. You can have oatmeal and eggs (try for mostly whites) for breakfast, a half of a sandwich with a side salad for lunch. Beware of "fast food." This doesn't just mean the food that you pick up in the drive through, but also anything that has a shelf life in your cupboards of over 30 days. These foods are all full of preservatives and additives. They are more difficult for your body to break down and utilize and therefore give you less fuel for your day. Everything you put into your body needs to be broken down and either used or stored. The most important equation if you want to lose weight is calories in vs. calories out. Make sure that you expend more than you take in. Be careful that you don't go to low however. This can lead to your body thinking it's in starvation and slowing your metabolism down even further.

Water also helps keep your body functioning properly. Drinking water, a minimum of 8 large glasses per day contributes to your body functioning better from your muscles (which are about 70% water) to your brain and digestive system. It will keep you from overheating and assist you in recovering faster.

Question 5:

I had a mastectomy and node removal on my left side in 2004 and have since developed mild lymphedema in that arm. Recently, I started a medically monitored exercise program, but I have to wear my compression garment while I exercise.

However, after 2 weeks of the program, I hurt my neck and left arm and had to stop for a while (I ended up damaging a nerve in that arm and now I have no feeling in my pointer finger!). I am wondering if, due to the lymphedema and less strength in my left arm, that maybe I am simply overdoing it or shouldn't be exercising that arm? Or are there just certain weight machines/movements that I should avoid?

Answer:

I'm sorry to hear that you hurt yourself. From what you have told me, it sounds like you are weaker in the left side which could have very possibly led to the injury you received. With a mastectomy and lymph node removal, I would recommend starting with exercises with free weights (1–3 lbs) or resistance bands (the lightest resistance possible). This will allow your arms to be independent and start to overcome a weaker side. Strength training machines are a little riskier for women with lymph node removal. Machine can limit your range of motion and many times the starting weight is too heavy until you get stronger. Many women feel safer on machines, but they are better once you have been back in an exercise program for several months. You should defiantly exercise both arms, but always wear your compression garment. Recent research from the University of Minnesota has shown the benefits of twice weekly weight training using very small increment increases and a close watch over possible signs of lymphedema. Researchers in this study suggest that exercise can enhance the flow of lymphatic fluid and improves protein reabsorption. Dr. Carolyn Kaelin from the Comprehensive Breast Center at Brigham and Women's Hospital in Boston suggests low, progressive upper-body weight training places a gentle stress on the channels that lymphatic fluid flows through, causing them to dilate slightly. She theorizes that the circumference of the channel may actually enlarge over time to accommodate extra fluid when there is an injury or stress.

I would encourage you to exercise, start off slowly and progress with caution. I suggest to start with one set of 10 repetitions for upper body exercises. The resistance selected should make your exercises slightly to moderately challenging. Slowly work up to 2–3 sets of 12–15 repetitions per exercise. At this point, it is okay to increase the resistance. Because acute injury often triggers lymphedema, experts remain adamant that it is possible to overdo exercise.

Question 6:

I had TRAM reconstruction after by bilateral mastectomy in February, 2005. I am back to running but would like to resume core strength exercises. Exactly which muscles am I missing and how can I improve core strength safely?

Answer:

Congrats on your running! Having a strong core will not only help you day to day but also in your running and other forms of exercise.

The core section of the body consists not only of the main abdominals and lower back, but almost 40 other muscles that make up your midsection starting just below the breast to mid-thigh, and in a complete circle around your body. It is important to work all of these muscles as they work together. Weakness can cause pain, fatigue and imbalances that can create other problems within the body.

For example, many people are unaware of the importance of strong glutteal (buttock) muscles to a strong lower back. Sitting can cause weaknesses in both the glutteal and hamstring (back of the thigh) muscles. Sitting for long periods of time shortens the abdominal muscles and creates weakness in the upper thighs which can also cause knee problems. It is important to work on the entire core region.

The good news is that there are many ways to incorporate core into your regimen. You can get a stability ball and sit on it as you watch TV, work on your computer or complete upper body exercises with free weights. You can also do crunches by rolling down onto the ball so that your lower back is supported by the ball. Standing on one leg and closing your eyes will work the smaller muscles of the thigh and abdominals as well as improve your balance.

There are many exercises that are effective. Here are just a few. Try stationary or walking lunges or floor bridges. Try doing exercises for the lower body that are unilateral which means that you work one leg at a time. For the front of the thigh (the quadriceps), you can do leg extensions or stability ball squats with the ball behind you against the wall. For the abdominal core muscles, plank, lying face down and lifting your body in so that only the elbows and toes are on the floor and holding is simple and effective. Try other exercises such as back extensions to work the lower back muscles or standing balance moves to use the small core muscles.

You might want to talk to a knowledgeable personal trainer in your area to show you exercises that will be effective for you individually. Since everyone is at a different level as far as their core strength as well as any muscular imbalances and weaknesses, it is important to find out the best level for you.

Question 7:

What kind of exercises do you recommend after breast reconstruction?

Answer:

It is important to note that the body goes through numerous muscular changes after reconstruction. Not only do you have weakness where soft tissue has been removed, moved or modified; but scar tissue can also be a concern after major surgery.

Scar tissue can cause tightness and pain in many women that have gone through reconstruction. It is common to feel a pain or popping as bands of scar tissue are broken. However, it is important to distinguish this from muscular or joint pain. Note where you feel discomfort, back down the intensity of your exercise and see if it continues or changes. Scar tissue will many times be felt during an exercise one time, but not so much the next. Other more serious types of pain will be continuously felt during an exercise and sometime after.

There are many physiological changes that the body goes through after reconstruction. After TRAM for example, most women lose at least a small part of the rectus abdominus muscle, the abdominal wall that runs along the front of the body. Because this muscle is used in many daily activities, change to it can contribute to other weakness and pain. Although it is important to weight for the surgical site to heal after surgery, it is important to start rebuilding when you can, this is typically 6-10 weeks. Make sure you find this out from your surgeon. For example, getting out of bed may require you to strain up or roll yourself to the side. By not strengthening the muscle you can create additional problems or weaknesses. After surgery, many women spend a great deal if time resting. This can lead to weakening of the smaller supportive muscles. If these muscles are not strengthened, other injuries can occur, typically while doing a simple task such as carrying groceries or picking something up off of the floor.

This is also true for other types of reconstruction such as the LAT flap, SGAP, DIEP. It is important to re-strengthen the affected sites by starting a simple exercise regimen. It is common for the larger muscles to take over and the smaller muscles to quit working. This can lead to overcompensation from some muscle and imbalances from others. To overcome this, use resistance bands, body weight exercises and individual free weights in your exercise regimen. Incorporate other types of exercise such as yoga to your weekly routine.