I’ve not been writing much lately, but that’s because I’ve been busy becoming unstressed. It’s an ongoing project, but suffice it to say, I think it’s working. I have my moments, of course. While driving with three dogs in my car and one spots another dog daring to walk it’s person on a sidewalk nearby, the uproar of barking and screaming and gnashing of teeth as they hurl themselves at the car windows can be a bit upsetting, and I may lose my equanimity for a moment, but like all moments, these pass.
I want to write a bit more about stress in the next few months, as I am taking on a new project–that of teaching mindfulness-based stress reduction to people with cystic fibrosis (and those who love and care for them) via an online portal to accommodate the need to prevent cross-infection. One of the reasons I am so passionate about doing this is that I know firsthand how stressful it is to live with CF, to watch family members and friends die from CF, and what it feels like to be depressed and anxious largely due to the toll CF plays on my psyche. As a start to the stress series I hope to write (unless it becomes too stressful), I’ll repost what I recently wrote in the CF Roundtable:
Stress is not a light-hearted topic, but given the recent findings of the international TIDES study (The International Depression Epidemiological Study), I think it is important that we talk about stress and the common effects of mismanaged stress—namely depression and anxiety.
The TIDES study spanned 154 centers; 6088 patients with CF and 4102 parents. This is a very large sample size, and the statistically significant findings are eye opening. Specifically, there are elevated signs of depression in 10% of adolescents with CF, 19% of adults with CF, 37% of mothers and 31% of fathers (of children with CF).
The consequences of depression are decreased adherence to our very complex medical regimen, disrupted family function, diminished quality of life, difficulty with sleep, impaired appetite, poor energy, and a weakened immune system. If this is not bad enough, I’m sure you can come up with a few more reasons that depression sucks.
The findings regarding anxiety in the CF world are worse. Elevations in anxiety were found in 22% of adolescents, 32% of adults, 48% of mothers and 36% of fathers.
Overall, these findings show the prevalence for both depression and anxiety in the CF community are two to three times greater than community samples. Of course, both depression and anxiety are the result of complex factors including genetics, environmental, psychological and developmental factors. But clearly, at the heart of environmental factors is the stress caused by living with CF. Knowing about the chances of a shortened life span is stressful. Not being able to do the “normal” things your peers do is stressful. Trying to fit into 24 hours all that needs to be done daily to manage your illness is stressful, because life doesn’t stop just because you have to do treatments and occasionally go into the hospital. You still have to deal with “normal” life stress. And of course, knowing that even when you do everything right, the outcome is often out of your control is stressful.
All of these stressful events are “chronic” stressors, as opposed to “acute stress” such as being chased by a hungry tiger. We have evolved to get over acute stressful events (as long as we don’t keep re-living the experience). But chronic stress is a different animal—no pun intended. Chronic stress wears on the body, physically and mentally. It is always there, ready to ruin your day if you let it. Hence the findings of the TIDES study.
So far, this has been quite a bummer of an article, and I’m sorry. But there is good news. There are quite a few things that are very effective for managing chronic stress. I’ve written about some of these before, namely getting daily exercise, proper nutrition and sleep, and finding time to relax and engage in activities and be with the people that you enjoy on a regular basis. There are also very helpful medications when these lifestyle habits are not enough. There is certainly no shame in needing additional medical attention for depression or anxiety.
But in this article, I’d like to focus on a technique that I have found extremely beneficial for handling life with CF with a modicum of balance and even occasional equanimity. Mindfulness meditation has been a practice I’ve used on a fairly regular basis for over 20 years.
I took my first eight-week course in “mindfulness-based stress reduction” when I was in my mid-thirties, very early in my career as a surgical pathologist. For some reason, up until this point I had not had major lung complications from my CF. But with the stress of a new job, a significant commute, and the necessarily busy schedule, my health began to decline. The reality of having a lung disease hit me square in the face, and I was looking for ways to help deal with it.
I saw a sign for the eight-week meditation class at the hospital where I worked, and signed up. This was one of the better moves I’ve made in my life, as I’ve benefitted from that class for the last 20 years. The practice I learned has helped me navigate through illnesses, upsetting sputum culture results, losing friends and another sibling to CF, losing my parents, and generally watching my health slowly decline. I won’t say those things have been easy, but becoming familiar with that place beyond my mind and body that never changes has proven immensely helpful.
That first class also planted a seed in my mind, though. I began to think that if it could work as well as it did for me, that maybe others in the CF community would benefit as well. This seed began to sprout about five years ago, when the opportunity to train as an MBSR teacher landed in my lap. I had a friend who had done the teacher training, and as a result, she and I began to teach a community class in mindfulness, which was a blast. That was when I knew I needed to pursue the idea of bringing MBSR to the CF world.
A brief word about MBSR is in order here. The class is the brainchild of Dr. Jon Kabat-Zinn, a PhD in molecular biology who also happened to be a Buddhist meditation practitioner. He knew the practice of mindfulness would benefit sick people, and in 1979, began to ask his colleagues at the University of Massachusetts Medical Center to send him their toughest cases, the people for whom they had no answers. People with debilitating chronic pain, untreatable cancer, horrible anxiety, or terminal diagnoses soon began showing up at his door. Of course, he knew he couldn’t begin to preach Buddhist theory…this was a hospital, after all. Somehow, he had to secularize what he did every day. He needed to create Buddhist meditation without Buddhism.
So Kabat-Zinn came up with an eight-week program where patients met as a group once a week to learn several different meditation techniques as well as practice gentle yoga. They also talked about ways of coping with reactive states of mind, and learned how to practice being mindful in everyday life. They were given homework of daily meditation, using guided meditation tapes provided by Kabat-Zinn.
An amazing thing happened. Terminal illnesses weren’t cured, of course, but people learned how to cope and enjoy what time they had left. Some people had pain reduction, but almost all improved the ability to tolerate their pain. Depression and anxiety lessened. Ever the scientist, Jon Kabat-Zinn collected the data and began to publish.
Now there are thousands of published papers on the benefits of mindfulness. MBSR programs are offered in hundreds of hospitals and community centers internationally. The science is fascinating. It appears that just an eight week intervention including meditation and gentle mindful movement at home, combined with the weekly group practice actually physically changes the structure of the brain. Areas of the brain associated with the control of empathy, emotions and compassion grow, while areas involved in anxiety and stress shrink. And these changes correlate with what patients report in numerous psychological tests.
Research, then, supports what I have discovered directly: Mindfulness meditation can benefit those of us with cystic fibrosis by changing our brains in ways that foster emotional balance and self-compassion while reducing the ever-prevalent problems of depression and anxiety.
It is possible to learn to meditate without taking a class, of course. There are fabulous books. There are online guided meditations. But every time I take an MBSR class (I’ve taken six now), I am amazed at how much being in a group helps, not just with accountability but because of how the group dynamics work. People share their struggles. We all learn that we are not the only ones suffering with…well, just about anything. Starting a habit like meditation can be hard. It may feel very awkward and discomforting at first. You will fight sleepiness. You will doubt that it is working. You will wonder if you are doing it “right.” You will want to give up and go get coffee. Your mind will wander off a thousand times. But, when you are in a group of people who ALL describe these same struggles, it is easier to stay on track.
With the amazing help of CFRI and the support of Vertex pharmaceuticals, I am beginning the inaugural online MBSR for CF (and caregivers) this spring. I hope you will join me. You can find out more, and sign up for the course at http://www.cfri.org/mbsr.shtml.
If you sign up (and Vertex has taken the financial burden of doing so down significantly) I can promise that you will learn a lot about what your mind does that is less than skillful, and this will prompt more healthy coping with life’s difficulties. It is worth the investment. You are worth the investment.
Wow, it has been so long since I’ve written anything! There are several reasons actually, but the biggest one is that I am falling apart.
Not in a bad CF kind of way. Actually, since withdrawing from the trial of the miracle combo drugs (not a miracle for me), I have felt remarkably well…at least as far as my lungs are concerned. So that’s good. I think my lung function is back to baseline for me. I would actually know that today had I not had to reschedule my clinic visit because I can’t move. But that’s another story.
When I say I’m “falling apart,” I’m referring to basic body biomechanics.
The problem for me is that when I feel good, I act like a crazy person and overdo almost everything that I attempt. I got away with this habit in my twenties and thirties. And you would think that the sudden absence of this ability in my forties would have affected my decision making processes. But that is entirely too reasonable.
Alas, I am still “learning” about aging in my fifties. The first little blip in my happiness about being out of the hospital for a sustained amount of time occurred a couple of months ago, when I felt so good jogging that I foolishly thought it would be a good idea to try some short sprints. This doesn’t sound stupid, but I didn’t have on my running shoes. I had new “minimal” trainers on when I decided to try short jogging intervals, just to see what it felt like. It felt great! So jogging intervals turned into sprint intervals, and two or three jog/walks to test them out turned into ten sprint/walks.
If you run, you probably know what happened. The next morning I had searing, and I mean searing pain upon putting weight on my left foot. Plantar fasciitis. The bane of any runner’s existence. I’ve had this before (in my twenties) when it lasted for months…only to go away after I purchased several hundred dollars worth of orthotics and wore them in every shoe for weeks. I also took massive doses of NSAID’s (oh the joys of youth) and iced and stretched like a fiend. Eventually, it went away, but it took forever.
So, running was out. Actually, even walking was out, much to the chagrin of the boys, who suddenly had extensive dog walking duties. But ever the optimist, after a few days of pouting, I thought, “No problem. I can do kettlebell training for my conditioning!” Kettlebell complexes, I’m almost positive, can be just as effective at inhibiting my epithelial ENAC channels as running. This is why running works in CF (I think). Besides the obvious jarring and increased breathing that makes one…ahem…”clear” one’s lungs, it also inhibits a sodium channel that works overtime in CF and contributes to the dryness of the airways. Normal CFTR inhibits ENAC, but mutant CFTR (ours) lets it run amuk, and this is bad.
So, kettlebell complexes it was. That is…until I couldn’t lift my right arm above my head anymore.
This little issue had started to rear its ugly head in January, during 2014 Pneumonia #1, (I should call it Vertex Pneumonia #1, but I’m being nice). I had to take oral Levoquin after hospital discharge, and it left me with a touch of shoulder tendonitis. The shoulder pain was minor at the time, and mostly stayed that way, since the sudden arrival of Pneumonia #2 and Pneumonia #3 kept my right arm immobilized with PICC lines.
But with the foot problem, I attacked my kettlebells with a zeal I hadn’t approached since my RKC training three years ago. Cleans and presses, swings and snatches, Turkish get-ups before every workout. I was a maniac, certain that Pneumonia #4 would be upon me if I didn’t suck serious air with every workout.
That’s when my right arm decided that it was not going to rise above my head, or around my back, or go anywhere, really, other than beside my right hip forever more. After a steroid injection did nada, an MRI showed supraspinatous tendonopathy and a superior labrum tear. Yikes. Option one: try another shot of steroid. Option two: surgical consult. I’ll take shots with extremely long needles into my shoulder joint any day.
So that happened, and I’m not doing much with kettlebells.
My next brilliant idea was to do the Stronglifts program. My thinking was that if I couldn’t run, and couldn’t swing or snatch or press KB’s, I would lift HEAVY weights three times a week and try to make it a “conditioning” workout by using short rest periods. Not really a bad idea…if you are young and don’t already have a bulging disk between L5 and S1.
This program emphasizes squats…you squat every workout, and you increase your weight every workout until you can’t do five sets of five repetitions…then you keep increasing, but more slowly as you are able.
You would think that an educated person such as myself would not undertake such a program given my history, but hey, my back hadn’t been hurting in at least six months, so I was sure I’d be ok. Besides, I was doing front squats instead of back squats. Surely, that would make a huge difference.
And I was hanging in there…until I hit the 105 lb day. I weigh 105 (ish) so my goal was to get to this weight and be able to do the 5×5 workout without missing a rep. I had tried it for two workouts before and hadn’t been able to do it, so this was my third attempt.
Later, when I was lying on my back under the squat rack, wondering how I was going to get up and if anyone around me had heard my scream, I realized that maybe this was not a goal that a 53 (almost 54) year old woman with a previous back injury should have. I’m afraid to even know what happened to the disk. All I know is that it hurts to sit, or to walk, or to bend over the slightest amount.
What is a girl with CF to do? I would swim if I could move my arm. Without that, I’m pretty sure I will drown. I would walk fast, uphill, if I could stand up, and oh yeah, if my foot would heal. I can’t even think about a kettlebell right now, or any other heavy object, without psychic pain.
A normal person would stop exercising, right? I gotta go now. I’m off to the gym. Certainly there is something there that I can do!
Just as we all remember where we were and what we were doing when JFK died, I remember where I was in 1989 when I learned that the gene coding for CF had been identified. It was a BIG day. Everyone in the CF world was convinced that a cure was just around the corner. I was a medical student and soon to be resident at Stanford, and couldn’t wait to be a subject in gene therapy studies.
Of course, that didn’t exactly pan out as expected. Inserting a corrected version of this newly identified gene was much more complicated than anyone could guess, and gene therapy as a cure for CF is still a long way off. But, 25 years later, as a result of sequencing the gene and determining the structure and function of the protein it coded for, we are having another BIG, BIG day.
Everyone in the above-mentioned CF world has been anticipating the day that Vertex Pharmaceuticals would announce the results of their two phase 3 combination trials of Kalydeco (ivacaftor) with VX809 (lumicaftor). These were huge studies, not just in the sense of numbers of patients (1000 total), but also in the significance of the results. Kalydeco had already proven to be a huge success for a small number of people with a rare CF mutation, G551d. “Blue Lightening” as some fondly refer to it, at the cost of over 300K per year, has proven to be a literal life saver for people with this mutation. You can argue for days about the price–and many , many people have deep concerns about this–but you can’t argue that Kalydeco has been a game changer. By correcting the defective gene product itself, Vertex has proven that the long awaited CF “cure” is quite possibly just around the corner.
I put cure in quotes because taking a Vertex drug is NOT going to undo what has been done. Scarred lungs will remain scarred. Treatments to contain chronic infections will continue to be necessary. Pancreatic enzymes will still need to be replaced. CF-related diabetes will continue to need management with insulin. By “cure,” what I mean is “contained,” or managed chronically, just as diabetes or high blood pressure are managed.
But these combination studies, named TRAFFIC AND TRANSPORT, were going for the BIG money (pun intended), deltaf508 homozygotes, the most common genotype to cause CF. Yours truly is a double delta f508, and I was a subject in the study. Now that the results are published, I can talk about my experience.
I still don’t know if I got the drugs during the first six months, as I was blinded. But when I rolled over to the open label portion of the study, when i knew for a fact that I was taking both drugs, I immediately got sick and ended up with pneumonia. Then, two months later, the same thing happened. And then, the same thing happened again. In sum, three rounds of pneumonia in four months.
Coincidence? Maybe. Prior to rolling over to open label, it had been 19 months since I had needed IV’s for pneumonia. So I don’t know for sure…but I had to stop the trial, and I’m not about to take those two drugs together again until I have a LOT more information.
But my story is not what Vertex is reporting today, so I’ll stop there. Vertex says that they have achieved their primary endpoint of absolute improvement of FEV1 of about 3%. In addition, secondary endpoints of weight gain and decreased pulmonary exacerbations were statistically significantly achieved. This is big! Wall street is going crazy. Facebook is exploding. Champaign corks are popping!
A lot of people are going to make a lot of money.
A 3% change in FEV1 is not a ton. As a comparison, Pulmozyme studies showed an improvement of about 6% in FEV1. Kalydeco improved FEV1 in G551d folks by about 10%. According to Dr. Bonnie Ramsey, one of the lead investigators in these trials, patients probably wouldn’t even notice a 3% improvement. So why is 3% a game changer? And why is this a BIG, BIG day?
Today is a BIG, BIG day and I will always remember where I was (sitting on the toilet, of course) when I read the press release, because today we know for sure that it can be done! It can be done for the most common form of the disease, not just in the lucky (?) few with G551d. It’s as if we’ve been running a marathon for 25 years, slogging along, runners (patients) dying left and right, trying to cure or control this damn disease, and suddenly today, the finish line is in sight.
The delta f508 mutation leads to a misfolded protein (CFTR) which mostly gets chewed up and spit out by the cell’s quality control mechanisms before it can ever get to where it needs to go, the cell membrane. Here, even the very few CFTR that make it to the target site don’t function correctly to allow chloride ions to traverse the membrane. That’s why we need at least two drugs…one to help with the folding and one to help with the functioning.
But there are two areas within the CFTR protein that are misfolded. Lumicaftor (809) corrects one of them. Then Ivacaftor (Kalydeco) corrects the functioning (partially) of the protein at the membrane.
So 3% is not huge, but better correctors are just around the corner, including second generation correctors that fix the second misfolding site in the dd508 mutated gene product. People, the end is near, and the race is on! Vertex is madly working on other correctors, as are big pharmaceuticals like Pfizer and Genzyme. Competition is really, really good. There will now be a sprint to the finish line because everyone wants to be the big winner in CF. The game has changed. The slog is now a sprint. Everybody wants to be the company that does for delta f508 what Kalydeco has done for G551d, or better!
The race is on, and now we are going to watch capitalism work, for better or worse. CF patients and investors in the correct company will win. People who actually have to pay the astronomical prices for these medicines will lose.
My Quantified Self Experiment: Can Heart Rate Variability Be Useful In Predicting A CF Exacerbation?
There is a movement afoot. It goes by a few names; quantified self, biohacking, and biologging are a few. The quantified self website has a tagline which sums up the purpose of this movement quite well, “self knowledge through numbers.” By using technology, usually in the form of wearable tracking devices, data is acquired which allows the self-tracker to understand herself better.
A simple example is the popular Fitbit, which is a device worn somewhere on the body, depending on the model, that tracks steps taken over the course of the day. It’s fancier than a simple pedometer (the original self-tracker), in that it has a built in accelerometer, so the user can wirelessly sync to her computer dashboard and record sleep, calories expended, steps and miles walked, floors climbed, most active time of the day, and of course even connect with fellow fitbit friends. It’s really amazing what you can track these days.
My recent foray into self-tracking involves first-thing-in-the-morning measurement of my heart rate variability, or HRV. I learned about the value of this measurement through my obsessive thinking about and planning my latest “comeback.” After the third bout of pneumonia this year, I guess I needed more than the usual amount of motivation, and was looking into the latest and greatest fitness gear/technologic toys to spice up the process a bit.
HRV measurement is definitely not new, but using it to enhance one’s training is a relatively recent phenomenon. It’s been used for years in professional athlete circles, but easy to use cellphone apps for the masses are new. There are a few, but the one I chose is called “Bioforce.” Using a bluetooth enabled Polar heartrate monitor strap and this iPhone app, I’ve been watching my HRV steadily “improve” as I’ve slowly but surely increased my training intensity since rolling out of my room in the wheelchair (why do they have that rule?).
So what is HRV? In brief, there is a normal rhythm to the heartbeat that is a bit different from the constant “lub dub, lub dub, lub dub” that you might imagine. Your heart rate is under the control of your autonomic nervous system, which is a good thing or else you’d have to consciously contract your heart with every beat. The autonomic control of heart rate depends on a delicate balance between the sympathetic nervous system (think “fight or flight”) and the parasympathetic nervous system (think “rest and digest”). As you inhale, the sympathetic nervous system is more in control, and as you exhale, the parasympathetic nervous system prevails. As a result, when you inhale, heart rate speeds up just a smidge, and as you exhale, it slows down. So when a regular heart rate monitor says your HR is 75, that is just an average of what it is over a given time period. Really, it probably ranges from about 70 to 80, depending on your breath cycle.
Now it gets simpler. A given measurement of HRV is a reflection of your autonomic nervous system, the balance of sympathetic and parasympathetic input, in the moment. Increased parasympathetic function is associated with higher HRV and aerobic capacity and has been shown to correlate to increased life expectancy (in “normals,” i.e. they don’t have CF).
Why is this useful? Well, when the body is stressed, sympathetic system is more prominent. This is why your heart and breathing rate increase, why you stop digesting food, why blood shunts to your muscles to get ready to fight. It’s all automatic. When you are relaxed, parasympathetic control leads to the opposite effects. So HRV can reflect your body’s state of stress.
Elite athletes use this measurement to tell them if they are overtraining. This is why HRV apps for your phone have been created. A given daily measurement will let them know whether they should train hard that day, or take it easy because their sympathetic control is too high, warning them that they are approaching the overtrained state.
But HRV can also reflect the body’s state of inflammation, because there is a linkage between inflammation and the sympathetic nervous system. This is a bit complicated, because obviously you can have low grade inflammation and not have a flight or fight response. But remember, we are talking about measuring a fine balance here, and a significant inflammatory process (such as a CF exacerbation) could very well tip the balance a bit, and this could be picked up by a measure of HRV, especially if you are your own control. At least, this is my hypothesis.
So this is my N of 1 trial. Basically, N of 1 is a clinical trial in which a single patient is the entire trial. I am running my own case study. And N of 1 trials are what the quantified self movement is all about.
What have I learned so far? Well, for the first few days out of the hospital, my HRV was extremely low (green line is HRV, yellow line is heart rate, and blue is average). This makes sense, as I was stressed and my body was WAY stressed. Gradually, it has increased, with downward blips here and there:
The colors of the bars on the bottom of the graph have meaning if you are an elite athlete and basing your day’s training on your HRV. Green means go hard, amber means take it easy, and red means take a day off because your body is in the danger zone of too much sympathetic input.
Here is what I have learned so far: My HRV goes down (bad) if I drink any amount of alcohol the night before. This saddens me. It also goes down if I am dehydrated, which is likely related. As you can see, I am supposed to take today off from training, but my take away is that the second bottle of Fat Tire last night was a really bad idea.
Okay, so I know I’m a nerd. But I’m going to keep this up and watch what happens when I get sick the next time. Maybe I’ll have an early warning. We’ll see.
These types of experiments can be very enlightening. What would be really cool though would be if those of us with specific questions (CF related) could share with others our experiences, and get immediate feedback from others with similar questions. Do you think we could uncover some interesting results? Think of the surfers’ experiences leading to the development of hypertonic saline. More to follow!
One of my father’s favorite sayings was, “I’m in pretty good shape for the shape that I’m in.” He was being funny of course, but these days, I can totally relate. It’s all about perspective. Today, I’m thinking about what it means to be “fit” as I walk at a snail’s pace on my treadmill and suck saltwater into my lungs, which are being violently shaken by my therapy vest.
If you use the biologic definition of fitness,
The genetic contribution of an individual to the next generation’s gene pool relative to the average for the population, usually measured by the number of offspring or close kin that survive to reproductive age.
then I’m toast. These genes were surgically stopped in their tracks decades ago. On purpose.
If you get a bit less Darwinian, fitness could be described as:
The capability of the body of distributing inhaled oxygen to muscle tissue during increased physical effort.
This is getting closer to what I’m after. But living with cystic fibrosis takes a special kind of fitness not intimated by either definition. My favorite description of fitness is one I heard on a podcast yesterday, which was something like,
The ability to do what you need to do, given the exigencies of your life, and to have a little left over for emergencies.
In other words, to be in good shape for the shape that you are in.
The “exigencies” of our lives include things like constant immunological battles in our lungs, defective insulin production, and shitty (pun intended) digestion, to name a few.
To be fit with CF means to be able to thrive, given all of these complications…and then, to have something left should an emergency occur.
I have a CFit client who is a perfect example of CF fitness. This woman is a runner, and also lifts weights and dabbles in Crossfit. She’s hardcore. She related a story to me the other day which left me amazed.
She was running with a group of people crossing a bridge, when they noticed a child stuck on a log in the water below. This was in Florida, and the water was swampy and apparently the home of many crocodiles. The kid was unable to swim to safety, and was in a precarious position, to say the least.
So my client took off at a sprint, as she needed to run nearly a mile to get to where she could enter the water. Then, she had to swim to the kid and keep him/her (I’m not sure) from being swept into crocodile territory until help arrived.
Now that is fitness!
If you are reading this thinking, “that could never be me,” you are missing my point. If you have CF and are simply moving more each day in attempt to improve your health, then you are an athlete in training. You don’t need to be a child-rescuing ninja. If you don’t like to run, then walk, or swim, or cycle, or lift weights, or swing a kettlebell, or play badminton, or… something! Prepare for that emergency. It may be a kid in danger, but more likely, it’s the next exacerbation. Whatever it is, it will be in your best interest to be stronger than you are right now. Unless you are my ninja CFit client…she’s already in pretty good shape for the shape that she’s in.