Class #4673

Lymphedema Focus Flow

55 min - Class


This workout taught by the wonderful, Joy Puleo, focuses on supporting the circulation of the lymph. To do so, she guides you to move through opening the myofascial chains to create a flow of energy and reduce inflammation in areas of congestion. As well as, exercises to gently stimulate the lymph with circulation and neural activation. You will feel energized, renewed, and spacious.
What You'll Need: Reformer w/Box, Pilates Arc, Theraband

About This Video


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Rebecca's Story

Hi, I'm Joy Puleo and I'm here with Rebecca Phillippo. And we're here to discuss lymphedema and how to train lymphedema in clients who may be susceptible to lymphedema in your studios. Now, please, I need to start with a word of caution. Lymphedema and lymphedema research is still emerging. And what I say to you today might actually be found to be different in the future.

So I'm going to be really conservative in how I approach lymphedema in the studio, and what I think our role as movement practitioners is, as opposed to say, a physical therapist, or an occupational therapist. So, with that, I need to give you a little bit of Rebecca's history. Rebecca came to me as part of our program, Body Wise Connection. I sat with her literally across a reformer when she came in. You were newly out of chemotherapy, and headed into radiation, as I recall.

And her hair was just starting to grow back. And during this program, I worked with a lot of older clients and in walks Rebecca, young and spry and really athletic. And I said to her, "Rebecca, what are your goals?" Do you remember that? (laughing) I said, "What are your goals?" And in all earnestness, she looked at me and she said, "I'm gonna ride a 50-mile mountain bike race, single speed, by the way, in six months." And so I looked at her and I thought, "Well, let's get to work." And we did and she did that race. Sleeve and all, right? Compression sleeve and all, she did that race.

She was successful and I have a picture of her with the brightest smile on her face. And that is always my go-to, by the way, for my feel good moments, when I'm thinking I can't do this, whatever this is at the moment. And I look at your picture and it always brightens my smile and my day, so I thank you, my friend. Okay, we might have a lot of tears between us as we do this, so just bear with us. Something else I need to tell you, Rebecca, who never studied Pilates before, then went on to become a Pilates instructor, training with me through Balanced Body.

And she then worked at my studio. And when I got the tap on the shoulder to come work with Balanced Body out in Sacramento, and leave my studio in New York, Rebecca was the person that I entrusted with my clients, many of whom I've had a long-term relationship with for about 15 to 16 years and the studio. So that's Rebecca's trajectory, and how she ends up here today. What you also need to know about Rebecca is she's had a double mastectomy. The cancer was in the left breast.

She did have reconstruction. At one point, the left breast, the implant started to fail. All these words that you start to hear when you're in the medical world. When that implant started to fail, Rebecca had a dilemma before her. And that was, do they reconstruct the left breast with a lat flap or do they simply, does she deconstruct really, really were your only two options at that point.

So she had a working implant on the right side. And the left side was the one she had to maybe have be very different. Not to mention when they do a lat flap, they take this little slice of the lat, they turn it around, and they use it to fashion the breast tissue. Well, she's a mountain biker. And she has to pull up that mountain bike all the time.

And the doctors are saying to her, what did they say to you? They said the lat is an inconsequential muscle. Okay, so she was working in our studio. I had her actually doing some of the lunges that are in some of the earlier workouts. And out of my mouth tumbled the words, "When does a working muscle trump the flesh of a breast?" And I immediately wanted to put those words back in 'cause I did not wanna influence her decision.

And she decided to deconstruct. So Rebecca is one of the bravest souls that I know. She deconstructed, not just the left breast, but the right breast as well. So the tissue, you'll get an amazing perspective here because the chest wall is very apparent as she moves, and the tissue and the tissue congruency and the tissue mobility is very different left to right. And it's going to give you a unique vantage point as the viewer.

So you are by far the bravest individual that I know. And I thank you for being here, and for sharing with everybody who's gonna watch this video today. As a result of the surgeries, Rebecca is inclined to get lymphedema on her left arm. Now, it doesn't happen all the time, but when it does and when a flare happens, it can be significant. It can be somewhat debilitating, depending on the flare, how long it lasts.

When you mountain bike, you wear a compression sleeve? Am I correct? I don't insist on it in the studio. However, you may want your clients who are inclined to lymphedema to wear a compression sleeve when they're working with you in the studio. I have mixed feelings about that.

If they're gonna wear a compression sleeve, I like one that goes all the way down to the hand that doesn't stop at the wrist because sometimes the movement and the motion will start to have lymphedema pooling in the hand level, and above where the compression sleeve is. So I prefer them to have as much coverage as possible, or to use the compression sleeve once they're completed with their workout. This is something that you need to really pay attention to with your client. The other thing I need you to understand with lymphedema, lymphedema is a chronic condition. It is not always diagnosed because it can be mild.

And if you've had a surgery in your 30s, it can show up in your 50s, your 60s or your 70s. Lymphedema is part of our natural immune system processes. And once we have an infection, or once we have a trauma to the affected side, it is possible for the lymphedema to show its head. So it's very important that you check your clients, and you just ask basic questions. Does that arm feel heavy?

Do you feel puffiness in the trunk? Because the lymphedema could be in the trunk, which Rebecca also has some truncal lymphedema. It can be in the affected arm. So you can just ask simply, you don't have to alarm them like, "Do you have lymphedema in that arm?" But instead, you just ask, you know, signs of heaviness in the fingers? How does the wrist mobility feel?

When they're moving or after actually they're done, just have them swing their arms, and ask them if they feel a difference between the right and the left sides. And that will start to trigger a conversation. If there's any indication, any indication of swelling, they must see a doctor immediately. If you catch it early, it is manageable. If it's one of those nuisance little symptoms, well, my arm feels a little heavy, but you know what, I'm good and I'm gonna go shopping, and I'm gonna hold my bag, and I'm gonna throw it in the back of the car.

And I'm gonna get home and you know, ugh, that side, it's just my surgery. It's just my surgery, I've heard a hundred times. Here's the deal and I need to say this again, if they catch it early, it is manageable. But once the lymph fluid finds its way down the arm, and it starts to pool regularly, then we create a chronic condition that can be debilitating. So clients who come to you and they've just been diagnosed, gently recommend, "Make sure they give you PT and OT." It's not a requirement for all breast cancer surgeries.

Recommend that because when you recommend that, and they get the help they need, they are statistically less likely to develop lymphedema down the road. Surgeons are also much better at removing lymph nodes, which is reducing some of the incidence, and the severity of lymphedema. The less lymph nodes involved, oftentimes the less severe. Okay, so that's a little brief introduction into lymphedema. It is far bigger a concept than that.

But with that, I wanna get Rebecca moving. In my studio, what's appropriate to do? In our studio, pumping the lymph fluid through the system to try to help the venous return to try to help the return of the lymph back into the bloodstream, so that it does not pool in the extremity. That's it, I'm not gonna do any heroics. I'm not going in there with a ton of hands on.

My hands on are always light. My recommendation to hands on of the client for themselves, always light. If there's too much pressure on inflamed tissue, it responds by going, oh my God, I gotta do something else. And it inflames more, okay?

Lymphedema Movement

So this is where we're going to start.

I have Rebecca seated in the Short Box position. She has her feet in the strap. And springwise, whatever it's gonna take to keep the carriage closed. You will notice, I have the box in front of the shoulder rest because I want Rebecca to have a bend in her knees. We're not going back and having her push her legs up into the straps.

Instead, I want her to know, the strap is there for safety and security. But I'm gonna be looking at, how can we create a little, gentle pumping action? The other thing is, you have lymph nodes in your groin that are really important, a big cluster. First of all, you have lymph nodes everywhere. But you have a big cluster up through your groin.

You have another big cluster coming in under the armpit, and feeding into the breast line. You have under the clavicle. And remember, in one of our earlier workouts, we were working on moving the clavicle, yet another reason why that's really important. And you have along your sternum. So what I wanna start to do is start some pumping action in some of these primary areas where lymph collects.

We can talk another day about what lymph nodes are, how lymph circulates, it's actually really hugely fascinating, and the role of lymph in the body. But today, we're gonna talk about pumping. Pumping, pumping, pumping. And using the body and movement to circulate the lymph. Okay, so, Rebecca, even though I know your upper body has been affected, we are going to actually start with the lower body.

And we're gonna start with the groin and pumping from the groin and the legs up into the pelvis. And for Rebecca, again, I want to stimulate the hands very lightly and I wanna stimulate the lymph, so gentle, light touches. I must say that there is a method of massage called manual lymph drainage. This is not what we're doing. We're just using gentle, light touch and brushes to help stimulate the lymph system via the skin.

So I'm gonna ask Rebecca to gently with her fingertips into the mid inner thighs and as she comes up, she's just gonna brush out and around, right? Just little circular motions. So far, no movement in the spine. She's coupling her breath, good, with the brushing. Excellent, now, we're gonna add a little bit of pelvic movement over the femurs in order to get the groin stimulated as she's brushing.

So, Rebecca, as you curl back, you're gonna brush in, and around and then sit up nice and tall. So we're using that hip crease and that hip opening to start stimulating the lymph inside, or in and around the groin area. Good, good, hold it there. Now what we can also do in order to maybe use the legs, and the femur to do more stimulation is let's have you internally rotate as you go back. Come up, as your arms go around, externally rotate.

So now, not only is she going back and forth in flexion and extension over the femur heads, she's getting the femur to do this nice rolling in and out, right? Beautiful. Indirectly, we're working the upper body, both in the touch in her hands. Yep, and sit up and nice and tall and rest. Your hands should feel nice and buzzy.

And also, we're starting with the pelvis to work on up through the upper body. So we are getting the upper body, and the lymph flowing through the upper body because guess where all this lymph has to go? It has to go to the ducts to recirculate the fluid. But we are starting here at the pelvis, and really starting to use the pelvis to get that action moving. Excellent, the next thing we're gonna do is now we're gonna take it to the upper body.

And I'd like you to take your hands and cross your hands. And first, just, will you brush down, if you would, from the side of your neck down along your clavicle to your sternum and into the truck, right? Just very light brushing movements. Good, now, take your hands, and put them along your clavicle. Good, and now the elbows are gonna come up.

Inhale, and elbows down. So now we're gonna create a nice pumping action through the arm line here, and through the axilla or the armpit. Good, and really (inhales and exhales deeply). And the arms are gonna rise and fall on the breath. Good, so, Rebecca, let's take and add a rotation to it.

Your choice (inhales and exhales deeply). Good, and you'll notice what's happening, she's getting a nice reply in the pelvis. Good, three. Two and one. Good, and I don't know if you can see this but I can, her eyes have completely softened, and her smile has completely grown (laughing).

Wonderful, so that's just simple arm pumps. So we pumped the pelvis, now we have simple arm pumps. And I wanna take this now into adding a little more mobility through the spine, connecting the upper and the lower body. We're gonna go back to those brushes that we did before. But now, Rebecca, I'm gonna ask you to brush all the way down to your shins, ready?

Now, you're gonna keep your back rounded. Think of round back abdominals. She's gonna come up through her center, right? And around, yep, exactly. Here, she's gonna come around the pelvis and forward.

Good, and I'd like you to stay as round as you can in your spine, so you're going forward. There you go, there you go. You certainly can straighten the spine. But we're gonna go there next 'cause now, she's gonna go all the way up the center of her trunk. Up, lift and reach.

And now lift and reach. Now, Rebecca, when you lift, it's like taking that sternum and it's pulling that sternum up to the ceiling and presenting it forward. Sternum goes up, present it, forward. That's it, two more. And one and now hang for a second, beautiful.

Good, I'm just gonna rock you a little, and I'm gonna ask you to breathe into your back body. Super, and then come on up to sitting. Okay, in a prior workout, mat workout, we did some arching and some curling. I'm gonna ask Rebecca to put her hands behind her head, elbows in her peripheral vision. And now, here again, we have this nice openness through the armpit.

Remember, we have a lot of lymph nodes here. So when I look at this line between her elbow, all the way through to her belly button, I wanna see that line, that myofascial line, both stretching and releasing. So we're just gonna do a little bowing of the upper body. Ready, and you're gonna bow forward, release the elbows. Now, press into your head, sit up.

Open (inhales deeply) and bow forward. Good, and release and up. And what you might be seeing here is the tightness of the skin as it both stretches and releases. We know she's got some scar tissue there. I also know that she has some adhesions there, which really make, especially some of the musculature on this left side, adhere to the rib wall.

So not only is she getting stimulation in through the lymph, we're getting some gentle gliding, or trying to get some gliding, and some loosening of the scar tissue, yeah? And up, great, now you're gonna curl for me forward. You're gonna dive forward. You're gonna lengthen out of the crown of your head, and you're gonna sit up tall, and then you're gonna curl back. Yeah, now, stay rounded, ready, go forward.

Lengthen, up and tall, good. Curl, now dive forward over your thighs. Lengthen through the crown of your head and lift, good. Curl back, dive forward, lengthen out. Lift, curl back, come on up over those thighs.

Lengthen out and lift. So we just put all of those pieces together (laughing). Now, we can take these into diagonals and rotations. I'm gonna save that to your creativity, so that we can move on. I wanna use a band and I wanna show you some nice ways now to start to facilitate a little bit of rhythmic movement through the thorax.

And I'm going to ask Rebecca to put this behind her back, and under her arms. And you're going to give me the band, good. Now, Rebecca, just stand there and I'm just gonna do this. Right, and notice what's happening, right? And she's also getting that devious little look in her eyes and that smile again, she's like, "Yeah, baby, I wanna take this." (laughing) So I call these undulations.

Or if you think of the old-fashioned agitators on your washing machine, right? Where you have the central post and it agitates, right? One of the nice things we can do is by releasing some of the tightness through the back body and opening that movement, just think of what that's going to do in terms of getting us to really truly move through the thorax and creating that pumping action. This also in itself is a pumping movement. So we're gonna start here and I'm gonna ask Rebecca to start to curl back, opening up through the hip, right?

And now, come to me, me, me and I'm mirroring her. And you've gotta find your dance with your client. This is a very light resistance, so I don't want her to go too far 'cause then, she will go all the way over the box. And then come on up. Even a little less than that.

And you're going back. Now, come forward and I'm directing where I want her to feel this. By lifting my arms, she goes a little more into extension, which I know we need for that chest wall. There you go, couple more. Now, if I were a somatics instructor, I might wanna be cuing from the organs.

This is great for chemotherapy, by the way. And the sluggishness that comes along with chemotherapy, and waking those organs up, and the breath and the diaphragm. Nice and super and rest. Now, the other thing that I like about this is when I pull, you'll notice, Rebecca turns to me, not by turning her front body to me, but by really opening up through the back body, right? Opening up through the back body.

And that's going to give her better rotation. It's gonna keep her spine more central. Now, let's take that back a little bit, shall we? And curl back, back, back. Yep, go, undulate, undulate, undulate.

Now, come to me and give me the back body leads. There it is, one last time, back body leads. And there it is, super. I'm gonna give you one more. Now, remember, this is a very light band.

You might wanna double up on your bands. You wanna make sure your bands are in good shape. And you wanna make sure your client understanding exactly what you're asking of them, especially now that I have it behind me because I don't want her to take make for a ride (laughing). So, you are using me, we're going to go into, basically a roll back off the box. Bend your right elbow and then come on up, good.

Good, now, I'm gonna let go. Again, these are light bands, don't go quite so far. And focus on the opening through the back body. And come on up, good. Super and you know what, this doesn't feel half bad on me either.

Nice and rest. Do you have a preference which one you like? They both give me different feedback, so it was nice. So she said they both give different feedback, and it was really nice. Super, so, to come out of this, Rebecca, I'd like to just do some arm movements before we move on to the next segment.

And I would like to play with internal/external rotation of the arms. First, at or below 90, which is where I typically start with clients specifically if they've come, if they're too early, or if they're very early in their treatment. And I want you to internally rotate and bow toward me. And then I want you to externally rotate and open up, and let your eye gaze open up to the ceiling, good. Internally rotate and bow.

And what I'm looking for here is a softening of the sternum, yeah. And as she rises up, I'm looking for her to find that lift, and almost like that V-shape, if you can imagine, she's got a shawl that's going up, and over her shoulders and down her back. And then bow and up. And we're using the internal and external rotation here to stimulate the lymph, just as we did with the legs earlier. And one more time.

And open, great. Now, let's take it at 90. So you're gonna bring the backs of your hands together in the internal rotation, you're gonna curl back. And now take the open horizontally, yep. And curl back and take that open.

One more time and open. Now, let's take that into a Y overhead, yeah? So you're gonna come to the center and then open up, nice. And to the center and open up. Center and find that line.

Beautiful, last time and up. And now let's have you come all the way forward over your body. I love this concept of folding the body to open the body. So now the arms are gonna go out to the side. Big, open circle, big inhale.

Arms overhead, put the hands together. Pull that straight down, up, stay up. Pull that straight down through the center. Now, fold forward, open out, arms up. Hands together, come straight down, dive down, yep.

Up and dive down and up. Last one, dive down, up, hold it up there. Take all that good energy, and bring it down through your center. So there's some seated work on the short box. So think of it as short box abdominals.

But really, it's short box lymph pumping. How's that for a title? Thank you, Rebecca. Okay, Rebecca, we're gonna take you off the short box, and we're going to move into footwork and feet in straps. So I'll take the box.

And what I'll ask you to do is put on a decent amount of spring, let's minimally put on two reds. I wanna give you an idea about feet in straps, and then it's up to you to choose what you would like to do. I'm gonna move this foot bar up a second, Rebecca. And three reds, okay. So we could have her on as many springs as we want.

It's sort of not the spring that I'm most interested in. It's actually the return of the carriage that I want you to work with. I'm gonna take these straps and put them on the floor. Excuse me as I reach over you. I put on some longer straps because they're tri loops, and I like them for some of the work that we're gonna do with the feet in straps.

Here, they're just gonna clank and make noise. Now, I'm gonna ask you to stretch out all the way, Rebecca. Okay, and bend your knees and come on in. Now, here, we get this nice relationship of the knees to the pelvis, but I would like to get a deeper hip crease, if I can do it. Now, I need to be cognizant that Rebecca has a potential flare on the left side.

So I'm gonna ask you to move your tush a little bit closer to the edge of the carriage. And we may, I may not want to have her grip her hand here because of the potential flare on the left side. In which case, I'd wanna put a sticky mat underneath her in order to keep her in this position. But do you see how she's in a tighter hip crease here, where her knees are a little bit north of her pelvis? Now, could you press out and just tell me if that's too much and then come on in.

Good, now, your fingertips are just over the edge, do you wanna get a little more of a grip of the carriage, or are you okay? That's good. Okay. So I'm keeping her on the balls of her feet today. Rebecca did have, because she is super athletic, and has been running during COVID like a crazy woman, has had a little break in one of her feet.

So I don't wanna put her on the balls of her feet, but you can play with all of the footwork here and all of the various positions. I have her in this, this is really a nice, deep squat position but it's a relatively safe deep squat. And again, I'm looking at stimulating the lymph through the groin. So what I would start to do is just have this out. Press out, exhale and pull all the way in and press out.

Exhale (exhales deeply). Inhale (inhales deeply). Exhale, good. Good, now from this, we have lots of options. And again, I like to use the bone to stimulate the lymph.

So I'm going to ask Rebecca, hold, to, as she pushes out, externally rotate. As she comes in, internally rotate. So she could pivot on her heels. Nice, and now add a little more of a pump to that. (instructor inhaling and exhaling sharply) Two and one and rest, great.

We could even do a little side to side. So here, pelvis stays on the mat, and just let your legs sway. Let the femurs literally sway in the hip socket. You're gonna press out, and then you're going to take those knees, wait. You're gonna take those knees to me and come in.

Now, even less movement of the pelvis. So come back to center. Literally shift a little bit to the right. Now, go out, good. Shift those knees a little bit to the left.

Keep that hip down and then come on in, there you go. Hips to the right and to the left, good. Right, left, right, come all the way in. (instructor exhaling sharply) Last one and rest. So if you were to imagine your femurs in the hip socket, they'd be moving like little windshield wipers.

Like that, right? Good and then we can end simply with widening the stance. And now press all the way out and pull in. So first, establish the movement. Pull all the way in.

And now give me (inhaling and exhaling sharply). All the way in, yep, I'm okay if I hear a clunk. Three, two and one, rest. So legs come together. So that's just a little, little smidge.

You can get really creative with these. Again, what I did with Rebecca was I moved her so that she was closer to the edge of the carriage, which was going to bring the knees a little bit north of the pelvis, which was gonna give us more range and more travel. And give us an opportunity to close into the hip crease, and to open and extend fully to help stimulate some of that pumping action, if you will, through the groin. We then added an internal/external rotation, and those little knee sways. You can play with this any way you'd like.

You can play with the heels, the balls, the feet and the arches, and all different variations of foot placement. Okay, so that's a sample of footwork. The other thing is if you do not want your client to hold onto the edge and they are sliding, you could put a pad underneath their bum. You could also, by the way, put a yoga block here at the shoulder rest. That could keep them a little more stationary and comfortable.

Awesome, with that, you can move into the shoulder rest, Rebecca. I will take this down to two reds. And I will give you now the strap. And we're going to use the tri loops. So do you see how you have this little extra strap in here?

And we're gonna put that around your ankle. And you're going to feel the padded part of the strap around the arch in your foot. Super, okay, so let me size up where we are here. Feet in straps, we're not gonna get too fancy with feet in straps. I just wanna give you some options.

But I want you to understand that feet in straps are also a great place to start to work with a pumping rhythm. We tend to do feet in straps nice and slow, which is great to start. I'm gonna keep her in the same range as she normally does. Going to be encouraging the length of the legs into the strap. Having this little ankle piece is really just a nice, lovely little reminder, and it gives her some proprioceptive feedback.

I wanna add to this a little. Rebecca, let's pick up the pace just a little bit. And I know picking up the pace now is going to start to create sort of that whack-a-mole between the pelvis and the ribs, and who wants to get involved. And they're really trying to stay out of the equation here. Good, so once I get that piece going and I know she's good, I wanna start to use the femurs, and the stimulation of the femurs internally and externally rotating to stimulate that groin, and to get some additional pumping action, or give the lymph the idea of what it needs to do.

So let's have you externally rotate down, internally rotate up. External, internal and you could play with this, internal to external. You could play with this any number of ways. You could do opposing legs. But really, I'm just looking for the head of the femur to move in the acetabulum to start to stimulate the musculature in and around the pelvis.

High up at the level of the pelvis, not so much at the level of the feet and the ankles, great. Super and you're gonna bring your legs down. Now, let's have you pump in and out in parallel. Pump in and out. In, out, in, out, in, out.

Great, so you see again, she's creating a rhythm. Good, now, hold that, press out for a second. I wanna reverse your breathing. As you pull in, can you exhale? (instructor inhaling and exhaling sharply) I like this breathing in this instance because as she pulls the knees in, the back can yield.

When we create that space, we create more opportunity for the lymph to find where it needs to go. Let's have you open your knees and externally rotate. Let's do that same breathing of exhale, pull in. (instructor inhaling and exhaling sharply) Good, good, so parallel. You could even, if you can, internally rotate a little.

And you certainly can go, ready, Rebecca, hold on. Bend your knees in parallel, open out and press. And pull in through the center, out, in, out. Three, two and one, great. So lots of variation, variety.

Let's take this into the Peter Pan, the single-leg frog, if you will. And press down through the midline. So I love these for many reasons, and I think these are very fitting here. I do not like to go too fast with these. And really just focus on the separation of the legs and the different feedback each leg is getting.

One leg, as it bends, it needs to maintain contact with the strap. And the other as it stays straight, right? But what I do like about this even more than anything is to come to parallel with this, and do the same thing parallel. So she's gonna start slow with this and reach out. Good, and find your breath rhythm.

Now, this one is hard on the mind. So once they find the rhythm, this one, I do like them to pick up the pace. And really push to me. Me, that's your focus, me, right? You're trying to kick me, Rebecca.

Good, now, hold it. So the emphasis for her is down to me. I want you to change your emphasis, right? So as this knee bends, your right knee, you're going up and then you come, you're going up. There you go (exhaling sharply).

It's a different emphasis. It feels completely different in the body. Three, two, one. Nice, bring your feet to me. Now, reach to me so much that you unweight your pelvis every so slightly.

So lift up that pelvis, push into me a little bit. Push, push into me, push, push, push. And then lower down, good. Don't hold your breath, don't take this to the upper body. Ready, it's big exhale (exhales deeply).

And there and (exhales deeply) and there. Now, I know Rebecca and I know where her strengths are, and she wants to truly push down, and hoist herself up through her back, yeah? But I want you to think, I want you to think of the whole front line of your body. So I want you actually to reach. Reach, that's it and then come on down and then come on up.

I'm gonna give you a little more spring, so you can find that. So I'm adding a blue. Okay, just feel that spring. I have a hand here and I have a hand here. I don't want you necessarily pushing down.

I want you to feel both of my hands, and reach up to the crease in the ceiling. There you go and then down. Legs come up. Now, reach and down. Now, that pelvis does not come up until you reach.

There and down and it's even a little less. It's a little more of a hover. There and then up and reach. And up and reach. And up and you wanna hoist up with your arms.

So put your hands on you, on you, thank you. Don't want you hoisting up through your arms. I'm here. No, you're initiating with your pelvis. Lower your legs, lower your legs.

Lower your legs, feel the resistance, there. And then come up and float the legs. Lower the legs, feel the resistance, there. And up, good, lower the legs, feel the resistance. There and up, now, where are we going, Rebecca?

Single leg, whoa. Single, reach, single, reach. Give me energy. Reach, now, notice, you're letting your pelvis, yes. Let your pelvis go, there you go.

Reach, now keep that pelvis, there it is. Reach, so it floats for a moment before it comes down. Yeah, there you go. Go, there (exhales deeply). You go up, out, up, out, up, out.

Up and out, there it is, there it is. There it is, there it is. Much more fun, right? Okay (laughing). She's thinking to herself, "Ah, how am I gonna do that?" But you just have to, first, all I want you to feel...

Now, give me that float. Oh, I'll hold you for an experience (laughing). Awesome, great (laughing). So my point on that is you don't want them hoisting themselves, doing anything artificial to find that. You wanna let really the movement and the breath drive that.

But they do need to feel the concept of reaching into the strap and unweighting and feeling that pelvis, yep. Legs come up, bend your knees and come on down. Try that, if nothing else, it will start to get the cardiovascular system going and revved up in a big way. Rebecca, we're gonna take you out of these straps. And have you come to sitting.

So Rebecca, we haven't done that in a long time. So I don't know about you, but what I found really, really wonderful about that is actually, I totally lost track of the camera, and I was totally in you, and trying to figure out what was happening there. And I could see you struggling with your upper body, which is counterintuitive, or counter to what we were trying to do in freeing and opening the lymph system and getting circulation. And once we got you moving and we got that dynamism, or dynamic nature of the movement through the whole body, what happened is you let go of the upper body. And we got the pumping action of the lower body, and we've got that nice little sort of lift as you went in both directions without there being a lot of effort.

And that's something I think that's important for us as instructors is patience, trust, communication, and take the effort out and put the movement in. If they think they have to do something, actually, especially for lymphedema, we're working contrary to what their needs are. That was terrific, thank you, Rebecca, for that. I'd like to move into a version of stomach massage. Will you take those straps and put them in the well?

I'm gonna come off here, and come back with my handy, dandy arc. And I'm gonna place the arc on the reformer facing the foot bar. Sometimes, I like to get really tight. But you'll notice, oh, actually, I can do it. So there we go.

I know Rebecca's on the tighter side in terms of her hips. And I know that she's gonna have, not a hard time, but the initial positioning of this might be a little bit challenging. So I will take the foot bar down one to here. And I'm gonna ask her to sit in front of the arc, and put her feet on the foot bar. And I'm gonna close my eyes, and let you get yourself into that position however you need to get yourself into that position.

Bend your knees and come in as far as you can. Now, I have two reds and a blue a on. I think I wanna take you to a single. I mean, to two reds. But you can go anywhere from a single red to two reds and a blue with your client here.

I am looking for this deep hip crease. I think stomach massage, actually, as an exercise is a lost art, and we should all go back to teaching stomach massage. Because from a somatic perspective, stomach massage is a beautiful way to stimulate the internal organs, and get them involved in our movement. And they are involved and a very important part of it. So first, let's have you round as much as you can.

Good, and when you straighten your legs, lean back into the arc. And then reach to me and come forward. So I don't want you to go fully into the extension yet. Just feel the arc and then come reach forward. Yeah, feel the arc and reach forward.

Just easy with your breath. Good, last one. Great, now, sit up tall, Rebecca, as tall as you can. And you can push the carriage away slightly. You can also move the arc farther from the foot bar if you need to.

Now, straighten your legs, good. And stay upright and then come in. Did you see that correction she just made? Straighten your legs and stay upright. And then come on in.

So again, we're getting this pumping action through the legs, lovely. Good, but now we wanna start to integrate the upper body. So, Rebecca, when you straighten your legs, I want you to go back over the arc. You can go a little into extension, and let the arms follow your ribcage in what's natural for you, yeah? So you're gonna go back, arms are gonna go over, what's natural for you.

Exhale, now pull that all in. Go back and over and pull that in. And again, notice that pump, or that pulling in and that extending out. Pull in, up, out, in, there you go. Now, you don't have to go faster to get the pump.

I see your competitive mountain biker coming out in you. I can just get there faster if I push a little harder. But I actually want you to push, I want you to have more ease in this. So it's out, it's a big open. You know how much of a fan I am of open and close, or close to open.

There you go. Think of the rays on your shirt, right? That center ray opens out. And then it comes back in and folds into itself. Two more, try to relax your neck and your jaw.

You can let your head, yeah, your chin come down. I know this is a source of tension for her. When her arms go over, I see the neck being a little too active. Last time and rest. Now, when I want you to rest, you're gonna hold that bar.

And now let's have you go into a little monkey-esque. You're gonna send the carriage back. Good, now, don't think of bending your knees. Think of bringing your thighs to your chest. And then keep that relationship of your thighs to your chest as your knees bend and you come in.

So you're keeping this real tight ball, yeah? So now when you go forward, it's not just straightening the legs, it's actually sending your pelvis back. But you're trying as much as you can to keep the relationship between the thighs and the ribs. Bring the thighs into the ribs. Now, let the thighs coming into the ribs bring you back up.

Ah, last one, you okay in the arms there? And then bring the knees in and up. Now, sit up tall on that. Straighten your legs out, and I bet you got a better sit there. Beautiful, let's take some diagonal work, shall we?

We have our band here. I think we'll go back, because you're gonna have a little more travel, I think I'm just gonna hold the band. Yeah, and let's just do legs parallel this time instead of turned out. Bend your knees. Come in as much as you can with parallel legs.

It's gonna be a little different. Now, as you straighten out, I want you to curl back. Find the arc and open and then come on in. And then do the other side. And notice what I'm doing with my hand to try to really get her to open, and feel the relationship of the band.

And in my mind's eye, I'm thinking of the band, her arm line, all along the back line of her body. And there, sweep, sweep. Sweep, last one. Good, now I'm taking that band, okay, and you're gonna let go. I'm taking the band and you're gonna let go.

So bend your knees. Now, when you do that sweep, I want you to imagine you've got the band in your hand, and that feeling of that band around your body. Now, really sweep, sweep more. Sweep, sweep, sweep, sweep and then come back and in. Do the same side and in.

Really sweep, go and in. Slow the pace but still pump. There it is, last one. And then come back to me, great. Okay, the sweep is going to be restricted by her range of motion, especially in the rotation.

Now, what I'd like for you to do on this side, as you sweep and really feel that rotation, I want you to look on this side, and take this arm and let it work in opposition. And then come up. And what that will do is it will help you go a little deeper into the sweep. There you go. What I'm looking at is this length here, as much as the side that she's rotating toward.

Now, give me more of a pump (inhales and exhaling deeply). Doesn't mean speed. It's open, close, open, close. Last one, open and close. Great, Rebecca, we're coming through the center.

You're going overhead. So straighten your legs, go over. Big circle, around and in. Now, up, over, around and in. Now, you know how I like to collect the energy through the center.

So you're gonna go down. Around, over and dive. Two more, out and dive. Last one and dive, hold onto the bar. Breathe into your back body.

When you are ready, let's have you come up to sitting upright. Straighten the legs all the way. Great, certainly here, you can also just play with the ankle mobility if you want it. I'm not gonna have her do that today based on what I know about her foot and the break. Although, she seems to be liking this, and naturally kind of going into it.

Super and let's have you take your legs, swing them off to the side. Okay, so before we conclude, I wanna give you one more set of exercises, fairly simple, related to what you already know. I hope that you're seeing that I'm not choosing really super esoteric exercises. I'm taking what you know and I'm just changing the focus specifically for creating a pumping action and lymphedema. So I have the arc, Rebecca, we might as well use the arc.

You could use the short box again. And you're gonna come and sit right up on there on the arc. Let's have you have the straps here. One and then two. Rebecca, I'm going to take us down to a blue.

And now the reason for the blue is I want this to be really about again, opening and mobility. Less about, you know, the classical serve a tray, huge a tree but to add more of that sense of the arms overhead and opening and blossoming, if you will. So let's try this with a blue. Both arms are gonna go straight up. And then open and around, good.

And straight up, open and around. Now, when I say open, I know everybody likes to open from their hands and pull their arms out to the side, but the openness is coming from the sternum. So imagine that line from the belly button up through the sternum, out through the fingertips, as you open and down. Now, can we add what we've done before, which is a bow? Bend your elbows slightly.

And now go up, grow up, and extend slightly as the arms come around, feel okay? You really wanna see the axilla or the armpit open here as you come around and down, three more. Getting that clavicular motion is also really important 'cause we've got some lymph that live underneath that clavicle. And lift up, open and around. So now, just think, you could hug a tree, you have serve a tray.

You could do all of that work, then lighten the load, and then add these little bits of flourish in there. And it really makes a nice difference. And energywise, you will find that it's very energizing for your client. Now, let's have you put one of those down. And I will take this from a blue to a very, very, very light yellow.

So if Rebecca pulls with any kind of force, the carriage is gonna just kinda go floating out there. So this will be slower moving in order to keep you in sync with the very light spring. I'm gonna have you bend your elbow and bring it in front. Now, you could even try this, whether you're on a reformer or not, I want you to cross the midline, then take that arm up. And as that arm reaches its height, it's going to circle back and around you, and the elbow bends.

Now, let's keep your eye gaze forward for the first few because keeping the eye gaze forward means that the thorax is gonna rotate around a stable cervical spine. So it's working cervical rotation but in a different way. Let's bring the elbow across the midline. Don't move the torso, bring it across the midline. Go up and then as you reach your height, let it circle around.

Now, let the torso follow behind. Bend the elbow, bring that elbow across. And go up and circle back and bend. So it's almost like a backstroke, right? And then bring it across your midline and up.

I really wanna stress across the midline in this motion. Good, now for the next one, Rebecca, allow your eye gaze to follow your hand. So bring it across the midline, and then go up and around and down. And we'll have you, 'cause I don't know how to count 'cause I am a Pilates instructor, we'll do one more here. Cross the midline, let your eye gaze find your hand.

And up and around and down. How's that feel? Great. Awesome. All right, can we just do a few to the other side, not as many repetitions?

We know that Rebecca's left side is the side that tends to flare. As a result of the medications, Rebecca also has developed potentially RA. So we wanna keep this side, which likes to flare up, doing this to a minimum. So now that it's learned from the right side, let's go right into crossing the midline. Eye gaze stays forward.

And it's up, right, and then take that ribcage around. Keep your eye gaze to me. Around and then bend that elbow and down. Now, you can make your range smaller here. We can see that it gets really tight in and across the pec here.

So cross the midline and up. Good, now from here, you're gonna rotate. And then right here, bend the elbow and come down, right? So keep it to that range. Come across the midline and up, open and down.

Last one, come across, that range work? Up, open and down. That felt a lot better. Good, so again, with scar tissue, you've gotta be really careful not to have them go into too much stretch too fast, particularly if the resistance is pulling on that scar tissue. Always best to stay slightly inside of the range in order to cajole more movement out of that tissue.

Excellent, so let's give you now, the straps back, both of them. I'm going to take you back to a blue. All right and we're going to, we're gonna take this home. You're gonna bring the hands in front, look at your palms. And just give me a little bow.

And now you're gonna take the arms up. Turn the palms, look up, bend the elbows. Good, bring the hands in front, little bow. Go up, big inhale, turn the palms. So we're adding a little internal/external rotation to the arms.

Again, stay within a nice range on that left shoulder. And up. Good, now stop here. You know how I like to take the energy in through the enter. Ready, you're going up overhead.

Hands together, pull them down. Excellent, take those straps off. Hands behind your head. Inhale (inhales deeply). Exhale, let the elbows come forward, flex forward.

Good, rise up through your spine. Inhale, exhale. Nice, good, one last time, inhale. Send the arms up. And then just bring them down alongside your body, awesome.

All right, so there we go, some ideas on how to work with lymphedema. In your studio, please remember, refer to a PT or an OT. If there's any signs of heaviness or weakness, or just discomfort, either in the trunk or in the affected arm, please keep an eye out for lymphedema. And understand that a client who has breast cancer surgery, it can pop up anytime and that it is a chronic condition that can be maintained and assisted with exercise. In our world, pumping is appropriate.

But don't, you know, go out of scope. Keep yourself in line here with your client at all times, and always communicating. I thank you so much, Rebecca. I love you, I thank you. I love you.

(laughing) All right and that would be the lymphedema workout. Thank you so much.


Amy S
I’m so grateful to Joy for presenting this material - I am curious about one thing she said - re: number of lymph nodes involved … maybe I misunderstood, but it I heard her state  ..”surgeons are good at removal of lymph nodes, which is reducing the incidence and severity of lymphedema..”
I’ve always thought “ less lymph nodes , more chances of lymphedema”. 
I’d love clarification  if I misunderstood Joy’s statement.
Thank you,
Alexa L
This is so helpful, Joy. I love the beginning work you do with the brushing + breath. Looks like a great technique to get things moving and releasing. 
Thank you Joy.
Your caring energy is truly beautiful.
Incredible movement and thought.
Rebecca your smile says it all. You are both fabulous for the Pilates world.
Admiration from  Australia
Thank you very much for all this super important and professional  knowledge you share, its so enriching. I would love you see more of your classes here, please!
Glad the term BOW is getting a  workout. We introduced it to  limit Forward Flexion in Standing Pilates® in 2005. 
I love your energy and generosity. Thanks for sharing with us yet another form of Pilates magic :))
1 person likes this.
Thank you Joy, beautiful job! 
Brilliant Joy! Thanks once again for sharing your expertise. Rebecca you continue to inspire!
Joy P
1 person likes this.
Amy S Excellent question. The few lymph nodes doctors disturb during surgery, the better the likelihood of avoiding lymphedema. That being said, surgery to the trunk and upper arm is in itself traumatic and any trauma can trigger a lymphatic response. The good news, early intervention, OT and PT, is helpful and movement, although research is still growing in this field, is proving helpful.

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