I know…it’s not a word. But it should be. Especially if you have CF and you deal with the ups and downs of exacerbations followed by hospitalizations and the frustrating loss of all of your hard-earned fitness gains, there needs to be a unique word to describe what enables you to keep on plugging away at the goal to be fit. I call it “mojovation.” I define it as the desire to get your mojo back.
I know you can relate to the following: There you are lying in your hospital bed, all packed up and ready to go home, waiting the inevitable extra hour or two for some random event to happen before you can leave (a wheelchair that you don’t need but is mandated by the hospital gods, your discharge meds that somehow ended up on the wrong floor, a nurse who needs to come in and “teach” you how to administer you IV’s even though you are 10,000 times more qualified than she is to teach this shit, etc), bored to tears wondering what to do? I have a great idea. This is the time for building your mojovation.
Face it, you lost your mojo as soon as you had to put the gown on backwards. After a day or two of lying flat on your back, your quads probably started shaking when you got up to pee, even though you squated 180 lbs the week before you got sick. You have likely lost five pounds of muscle in a fraction of the time it took to accumulate it, and your skin has taken on the color of hospital eggshell white. You want to smash the tiny mirror above the tiny sink in the tiny bathroom and scream at the unfairness of it all, but you know this would result in further delay of your discharge as you would then have to wait for the psych consult. I say, harness this anger and grab a pen and paper…or your iphone if you are younger than 40 years of age and have forgotten how to use a pen. Your mojo is not gone forever…you just need to locate it.
I learned the following exercise from Dr. Heidi Grant Halvorson, a social psychologist who researches, writes, and speaks about the science of motivation. Since we are speaking of regaining your fitness mojo temporarily lost in Tropical Storm CF, I’ll use a related goal in my example using Dr. Halvorson’s techniques. The first thing to do is write down your goal. Make it specific and make sure it is something that you not only really WANT to achieve, but also something that you are confident you CAN achieve. Then ask yourself, “how will I know when I have reached this goal?” If you don’t know, go back and work on it until you can answer this question. Assume, for example, that my goad is “I want to squat 180 lbs again.” This is specific…I will know when I’ve done it (ouch). I both want to do it (to prove I am bigger and badder than CF) and know that I can do it (I already have).
Now that the goal is defined, Halvorson suggests doing something called “mental contrasting.” I list 4 reasons this goal is important to me, in order of magnitude of importance. Then, I’m to write 4 obstacles, again in order of their obstacle-ness. New word. The hardest obstacle to overcome is number one, next hardest number two, etc. This is easy enough. Then I write a paragraph expanding on the number one reason this goal is important. I go for it and just write whatever comes to mind. Next, I do the same thing for obstacle number one. Then, again I write about reason to do this goal number two, followed by obstacle number two. So, four paragraphs in total. I can stop here. According to the research, this exercise makes my brain able to hold two ideas at once! Who knew? I am able to face an obstacle squarely when it arises, but still retain that little voice telling me why my goal is important and not run and hide at the first indication that life is not always a piece of cake.
The next idea is the gem and really the best part of this whole article. There is a very simple planning task that, if you do, increases your chance of reaching your goal (assuming it is a goal that you really want and one that is achievable) by 150%, according to numerous research studies. It is so simple that when you read it, you will say, “no way that is going to work.” I know, that is what I said too. But the fact that I am actually writing this is proof that it works! The exercise is called “if/then” planning. Very simply, I come up with the time and place I plan on accomplishing the task I want to achieve, and write it down. That’s it. My first attempt at this was very small–and I suggest you do the same thing. I decided that “when (you can substitute when for if) the coffee is brewing, then I will do my morning stretching.” Morning stretching is something I know works well for me, but I often forget…or am too lazy… to do. My if/then plan worked like a charm on this first test drive. I was successful every day for a week, seemingly without any effort on my part. It just happened.
Next, I tried, “when I drink my first cup of coffee, I will write in my journal.” Again, it worked like a charm. Magic. In the past, my journaling efforts have gone roughly the same as my old Buick Skylark, which tended to die every time I turned left. Suddenly, I now automatically sit down with my Bulletproof coffee and write away.
My current if/then strategy is, “if I am Vesting, I will also be writing something in my blog.” Oddly, this works in the morning (now), but I am having trouble with it at night. So, this will be the topic of my next blog post…willpower, use it and/or lose it.
So now, back to the exercise goal you want to create while you are waiting to rolling out of the hospital. First, try the mental contrasting writing exercise about why you want to regain your lost fitness, and what obstacles you will need to overcome. Then, use the magic if/then technique. Remember to start very small…test the waters a bit. Take a tiny baby step in the direction incredible Superman/woman fitness levels. Something like, “when I wake up in the morning, I will do ten pushups,” is a great example. Remember, make it very easy! Then, after it becomes automatic, add something that is a bit harder…just a tiny bit. These little steps build confidence in yourself, which remember is very important when it comes to setting and achieving goals.
Give it a try, and let me know how it works for you!
I’m currently reading a book called “The Slight Edge,” by Jeff Olson. The basic message is that significant change is made quite easily if taken one small and consistent step at a time. As a wellness coach, I have read quite a bit about change psychology, and the directness and simplicity of this author’s approach is very appealing to me. I’ve decided to take it on a test drive, and am trying to revive my blog with this approach. When I first started blogging, I loved doing it and felt like it was an awesome way to get my message(s) out about living well despite having ongoing and serious health concerns. Then, life got in the way, and blogging took a back seat to just about everything else that I could think of. Enter the Slight Edge. I will be posting more.
It seems to me that life is somewhat unfair in that good habits seem to require effort to develop, while bad habits form quite easily simply by being unconscious about choices we make. The Slight Edge basically refutes this, by making the very obvious point that over time, simply taking one small action each day will compound into huge and lasting change. On the other hand, not taking that one action will also compound. Unfortunately, compounding in this negative sense can be disastrous.
A very clear example for the cystic fibrosis peeps out there is doing your daily aerosol treatments. These are very easy to do (note that I didn’t say “convenient” or “pleasant”). Seriously…you just sit and inhale stuff. It’s not like you aren’t going to inhale anyway! And sitting in a chair holding a nebulizer is not exactly manual labor. So it’s easy to do treatments.
But it is also very easy to blow them off. There are a myriad of things that, in the moment, seem way more important than that hypertonic saline, right? Sleeping in, stopping for coffee before work, playing with your cat, browsing favorite websites, cleaning your closets, plucking your eyebrows…you name it. Who wants to sit and cough?
But now imagine what happens if that decision to blow off your treatments is compounded, day after day. Then compare that image to what it looks like if you make that simple decision to do the treatments every day. Stretch your imagination out to a month or two (here is where I wish you were a pathologist, because my mental image is a slide of healthy, pristine lung tissue vs. nastiness on a slide). Two very, very different images as a result of two sides of a decisional coin, compounded over time.
Of course, this relates to just about any area of life…not just medical treatments. Decisions about fitness habits, what you eat or drink, how you relate to people, how you work, and how you deal with stress all compound over time this way. On a day-to-day basis, it doesn’t matter in a huge way whether you take your daily walk or sit for your meditation. Not doing them ONE day is easy, and it won’t make a dent in your overall fitness or stress level. Alternately, actually doing these things probably aren’t going to matter a huge amount on that particular day. But compound these decisions over time and see what happens.
What one life-enhancing thing, something that is both very easy to do but also very easy to blow off, can you to do, today and every day? Gotta go do my saline now.
One of the drawbacks to not digesting nutrients very well is that people with CF are often small. Male or female, we tend to run on the petite side if we are pancreatic insufficient. With earlier diagnosis and better enzyme replacement therapy, this is slowly improving, of course. But for those of us who are already full grown, it can be a constant struggle to keep weight on. Not only do we want to maintain weight, it is often encouraged to have a few extra (I said, “a few”) pounds on board to stay strong and resilient to lung infections.
I don’t know about you, but when I need to gain weight—which is pretty much always—I would rather put on lean muscle tissue than fat. This is not just an aesthetic issue, either. The amount of lean body mass (LBM) you have (this includes everything but fat and water) correlates with disease severity. The less LBM a CF patient has, the more severe their disease tends to be. Additionally, LBM decreases with age, so as we get older it becomes more and more important to try to increase muscle mass.
So, what does it take to gain muscle? Three things, well…maybe four. If you are pancreatic sufficient, it takes doing three things, regularly. If not, it takes four (the fourth being, obviously, sufficient supplementation with pancreatic enzymes). This post is all about thing number one: Resistance Training.
First, you have to lift weights. Muscle tissue does not grow unless you impose a stress to it that it cannot handle. When you do that, the muscle adapts by healing and coming back bigger and stronger. In my opinion you should lift weights at least three times per week if you are serious about gaining muscle mass, and it is everyone’s opinion that you must lift heavy weights (for you). So ladies, forget about the purple Barbie weights. Soup cans will not work for long. Sure, you may have to start there, but within a couple of weeks, you will be strong enough that you will have to put some energy into finding heavier resistance. I realize most people are not training program junkies like me, and that you might not have a clue what to do with those heavy weights. One great resource is The New Rules of Lifting for Life, by Lou Schuler and Alwyn Cosgrove. You can probably find about a million training programs online, but the reason that I like this one is that it is scalable…you get to decide what level you begin at in each of the basic movements, and progress from that point. So, brand new lifters or old pros have something to gain from this book. I am also working on my own CF-specific training program, which will hopefully be available in a couple of months. Don’t wait for me though…get started now.
So, in summary, if you want or need to gain weight, do it in style—by adding muscle. There are three keys to doing this. First, find a weight lifting program that works for you, and commit to it for at least three months. If you do this, in addition to the two remaining steps outlined in the following posts, you will increase your lean body mass, and with it, your chances for a longer and healthier life. When you see the progress that you have made in the three months, I’m betting that you will be hooked for life.
Nobody wants to walk into a gym to lift weights knowing nothing about weight training. First of all, it is obvious, and who wants to look as clueless as they feel? But you are not clueless if you have read my “perfect workout” series. You know to immediately roll and loosen up your joints, to then move into some corrective work, then to do movement preparation drills. Now you are ready to lift…
Let’s start with my basic “Rules of Lifting”
First, begin by working the biggest muscles first, then moving to smaller ones. If you are going to include your legs into your lifting that day, start with squats or deadlifts. If you are giving your legs a day off, start with back exercises.
Second, focus on complex moves. Complexity is in…isolation is out. A “complex” lift is one that uses several muscle groups, and as a consequence, movement occurs at multiple joints. A squat is a perfect example of a complex lift. In the squat, you not only use the gluteals and hamstrings to extend the hips, but you also use the quadriceps, hip flexor group, and the stabilizing muscles of the entire core. Compare this to the knee extensor machine, a classic isolation movement occurring at a single joint. In this move, you sit on a chair, hook your ankles under a pad, and extend your lower legs. This is an isolation move occurring across the knee..not only that, but it is an isolation move that you almost never do in real life. Below is a sampling of both types of lifts. An isolation move or two won’t hurt, but focusing on the complex moves is better overall approach. Additionally, if you are going to do both types of lifts, do the complex moves first. The biceps curl can wait till the end (for all of you mirror gazers…).
Complex lifts (multiple joints move): Squat, Deadlift, Lunges, Bench press, standing military (overhead) press, Horizontal rowing, pull ups
Isolation lifts (single joint movement): biceps curls, adductor/abductor machines, triceps extension, leg extension, seated hamstring curl
Third, learn perfect technique. If you do this first and foremost, and you focus continually on technique (even when you fatigue) you will not get injured. On the other hand, if you are sloppy, it is very possible that you will hurt yourself as you lift heavier loads. This cannot be over-emphasized. We are not talking rocket science, though. I learned by reading books and watching others. These days, not only can you read, but YouTube makes it easy to learn the basics. Just make sure you are watching a trained professional, not an actor/actress from a reality TV show (you know who I’m talking about).
Begin lifting light. For the first few weeks, you get stronger NOT by lifting heavy, but simply by training your nervous system how to do the moves. Once you have good form and the movement patterns are grooved into your brain, it’s time to get serious. Begin light for a warm up set or two, and then work hard! You will not “bulk up.” The last repetition of your work sets should be difficult. If the final repetition is easy, or even moderately easy…go heavier!
Take a day or two off between lifting for the same muscle group. You have made teeny little tears in the muscle fibers by asking them to lift heavy weights. But don’t panic…this is good. If you feed your muscles and rest them appropriately—they heal and come back even stronger. This is the whole point of weight lifting. It is called Specific Adaptation to Imposed Demand (SAID principle for you exercise physiology nerds). Your body adapts to what you ask it to do. If you want it to get stronger, you must ask it to lift heavier objects than it is used to lifting. It then adapts, and, poof, you are stronger.
Now that the basics are covered, how about the more specific questions of what moves, how many exercises to do, how many reps and sets to do, with what frequency should I lift, and how hard should it feel. How will I know if I am doing too much? Too little?
A beginner should try to work every muscle group at least twice a week. Once a week…not good enough unless you are just trying to maintain the muscle mass you already have (and even then, twice/week is better). Three times a week is even better, but only by a little bit, so if you are really working hard to fit it in, at least get in two workouts per week. What are the muscle groups to target?
Legs: Both front (quadriceps) and back (hamstrings) of the thighs. Think lunges, squats, stability ball hamstring curls, step-ups, and more lunges
Hips: Extensors (that would be the butt, Bob), and flexors (these are usually very tight and mostly need to be stretched). Think squats, more squats, deadlifts, kettlebell swings, lunges again
Back: Huge muscle groups! Latissimus dorsi is the big one (lat pull downs, pull ups, rowing movements), anything where you pull something toward the center of your body either horizontally or vertically
Chest: Pectorals and anterior shoulder: Think push ups, bench press (flat, inclined), dumbbell flies
Shoulders: Three heads to your deltoid muscles, so they like to be worked at different angles. Exercises here include vertical pressing moves like the military press, with bar or dumbbells, lateral raises (bend over an inclined bench for a different angle), dumbbell forward raise, and my favorite, kettlebell clean and press.
Abdominals: Plank holds (front and side), bicycle, stability ball curls, regular curls, dumbbell or kettlebell renegade row (killer), Russian twist
Arms: both front (biceps): rows, pull ups, biceps curls, and back (triceps): triceps press or kickback, pushups, horizontal and vertical pressing moves
Is your head spinning? Like I said, it is NOT COMPLICATED! Pick one move from each group (some exercises overlap groups because they are complex, and therefore work across multiple joints). Study the precise form from books, YouTube, friends who know, or a trainer before you try each exercise. Start light. Warm up first. Then gradually add weight until the last repetition is fairly difficult. In the beginning, strive for two sets of 10-15 repetitions of each exercise. In exercises where you hold for time, aim to increase your time by 5 seconds each time you do the move.
KEEP TRACK OF YOUR PROGRESS. I know it looks silly. But if you don’t know what you did the last time, how can you progress? You have to challenge yourself by doing a tiny bit more or holding for a few seconds longer than the last time. I carry a workout log around with me. I look to see what I did on that exercise the last time I did it. Then I will either increase the weight, or the number of reps, or decrease the rest between sets. Only a tiny bit. It’s all about baby steps and consistency.
I knew that would get your attention!
Let me start by saying that by some grace of God or Universe or Source or whatever you want to call it, despite being a DD508, I have decent PFT’s at age 51. I know that part of that is because I am now and always have been (since age 13 anyway) a total exercise fanatic-bordering-on-nerd. There is rarely a day where I don’t do something…even if it is only a walk with my dog…as long as I am not on IV’s. In fact, even when I am on IV’s, I have been caught jogging or at least doing leg weights. My motto has always been, If You Can Breathe, You Can Exercise, which by the way, was the tagline of a CF Exercise Program I helped design and run at Stanford Medical Center.
But today in clinic, my FEV1 was down 15 percentage points from the last visit. Bummer. I’m not sick, but this is not my Cayston month, and it shows. In addition, I’ve been on a major weight gain kick, which has involved eating a ton and lifting very heavy weights. Almost all of my exercise time, except for dog walking, has been spent in the gym, not on machines, but doing deadlifts, bench presses, kettlebell squats and presses, etc. I leave exhausted and feeling great. Indeed, I have gained 6 lbs in two months. But I could tell yesterday while playing tennis with my son that my aerobic conditioning was off. I was sucking air and dreading today’s pulmonary function testing.
Isn’t it ironic that I actually started to write this article before the clinic visit? Subconsciously, I must have known that I was going to have to revisit this issue, as I have done so many times in the past. That’s just the reality of CF, as I’m sure you all know. For me, return to the land of living (and breathing) after an exacerbation always begins first with a heavy sigh, and then a muttering of something along the lines of, “Ok, Julie, here we go again. Back to Day One of getting back into shape.” So far (fingers crossed), I’ve always been successful. This article is a chance to remind myself (and you) how I’ve done it.
But before that, I know there is more to the fact that I exercise that has lead to my luck with the disease. Exercise is absolutely necessary! Don’t get me wrong. But it is not sufficient. Although most of this article will deal with the types of exercise that I think are the most important, there are two more areas of self-care that cannot ever be overlooked if you want your lung function to improve:
1) Be absolutely unrelenting when it comes to treatments, including aerosols (antibiotics, mucolytics, and hypertonic saline) and airway clearance techniques (for me, the Vest). How many times a day? As many as it takes! For me lately, it has been two. After my experience today, that number is going to increase to three for as long as it takes to get those numbers back up.
2) Keep your weight up, no matter what it takes. This has been my Achilles heel, but it is very clear to me that I am healthiest when I am heaviest. I’m not talking Biggest Loser heavy here, obviously. Overweight is as bad as underweight, just in different ways. But then, I don’t know too many people with CF who are overweight.
Now on to the NUMBER ONE WAY TO RAISE YOUR PULMONARY FUNCTION TESTS: EXERCISE
I used to think you couldn’t really increase your baseline PFT’s. As a pathologist, it made complete sense to me that once your lung was scarred from chronic infection, there wasn’t much you could do. In medical school, we learned that in CF, PFT’s just go down, and the goal is simply decrease the rate at which they go down.
You know what else we learned? We were told that the brain could not make new neurons; that after losing neurons to stroke or injury, the patient was destined for life to be disabled. This is completely false, as the evidence over the last two decades has shown that the brain is “plastic” and forms new cells and new connections throughout life. Now I don’t really think scar tissue is turning into lung tissue, but something vitally important is happening in the lung tissue that remains with exercise. We don’t know exactly how, but it gets better at what it is supposed to do.
My epiphany about exercise and PFT’s came after a round of P90X, and has been confirmed by many people I know who have raised their PFT’s with exercise. I’ve written about my P90X experience elsewhere on my blog, so I won’t go into detail here, but after one round of this 90 day program of intense exercise, the volume of air I blew out in one second (FEV1) increased by 39% since the previous, and the small airway number (the FEF25-75%) improved by 70%! As I said in the blog, I didn’t believe it at first, so I went home and compared the actual volumes of air blown with previous tests. At age 47, I was suddenly blowing what I blew in my 20’s. Weird…and definitely not what I learned in medical school.
Since then, I have seen similar results after hard-core training with kettlebells, in combination with starting Cayston. Yes, Cayston is a miracle drug, and I’m sure I would have improved immensely with it alone. But you can’t convince me that my VO2 max training with kettlebells didn’t provide a major assist.
THE BIG FIVE
Even though this can be somewhat boring, it is important to establish a good aerobic base before moving on to more challenging interval and plyometric training. This simply means that you are able to maintain an aerobic exercise (walking, jogging, cycling, swimming, etc) continuously at a moderate exertion level of 6-7/10 (where 10 is how you would feel if you were sprinting as hard as you can, and 1 is how you feel sitting on your couch) for 20 minutes. As I’ve said before, it doesn’t matter what it looks like to be at this exertion level (a 6 for me would involve doing what would feel like a 2 to my son). What is important is getting to that feeling of a 6-7.
Training for this base simply means starting where you are, whether that is walking around the block or cycling for a mile, and gradually building distance or time at a moderate exertion level.
Once you’ve reached the point where you can exercise continuously at a moderate pace for 20 minutes, you can add some excitement to your training. Interval training is very simple. You simply increase the intensity of whatever exercise you are doing for a given amount of time (i.e. 30 seconds), followed by a much slower recovery period for as long as you need it, and repeat this cycle several times. When I am starting to jog again after a break (for IV’s or while dabbling in another form of exercise), I will begin with a jogging interval (very short at first) followed by a walking interval (until I can breathe relatively normally again) and repeat this five or six times. In the beginning, my work:rest ratio will be at least 1:2 (for example one minute jogging followed by two minutes of walking). Over time, I will increase the time of work and slowly decrease the time of walking. This takes a lot of time (and patience), but it works every time.
If you haven’t checked out P90X, allow me to provide a short description. It’s home based program where you watch and follow along as best as you can to a DVD showing unbelievably fit people exercising their a*^&’es off. Three of the days per week, you do a DVD of circuit weight training, using weights or bands and bodyweight only exercises. These are tough, but there are rest breaks (thank God) and each of the three “weight days” you work different muscle groups, so you have time to get over being sore before you do the same DVD again.
Another day is devoted to a Kenpo karate workout (my favorite), and another to a 90-minute yoga practice.
None of these are easy, but the real killer day (and the one that I think popped open my airways the most) is the dreaded “plyometrics” day. Plyometrics is simply jump training. So, you jump around…a lot…without much of a break…for a solid 45 minutes or so after the warm up. This, of course, causes big time airway clearance. It’s a bit like riding a racehorse while wearing the Vest, and being the racehorse at the same time. Never once could I do this without stopping before the maniacs on the screen did. But I know that this day was the one that did the trick for my lungs.
Are there less masochistic ways to do plyometrics? Of course. Jumping rope or jumping on a trampoline (mini or full size) is a start. Of course, if you have arthritis or another contraindication to jumping, don’t do it. But if you can, pick just one day a week, and do some jumping!
I don’t really know if weight training can improve lung function. My guess is that it won’t. Apparently, my experiment of the last two months doing predominately weight training confirms this.
But I still include weight training as a valuable tool to increase lung function because, in my opinion, the results it brings provide important positive reinforcement and motivation to keep exercising! Think about it, you don’t see the end result of your aerobic work, when it is by far the hardest to do. You may see it on your next PFT blow, but those are few and far between.
On the other hand, weight training provides visible results (in addition to simply getting stronger). You also can train just like anyone else, as the anaerobic exercise of lifting is not limited by oxygen supply. You are in control here…not cystic fibrosis. This is rewarding, motivating, and, for me at least, makes me feel somewhat normal.
I’ve written quite a bit about this before, but in brief, if you are slumped forward at the shoulders and have a rounded back (a position many with CF assume after years of coughing), you are not able to use all of the available lung tissue. Simply put, increasing the flexibility of your thoracic spine has the potential to improve lung function. Read here how to do this.
That’s it! That’s all you have to do to know that you are doing everything you can to increase your pulmonary function: 1) treatments religiously, 2) maintain a good weight, 3) achieve a good aerobic baseline and then start with some interval training, 4) throw in some weekly plyometric training to shake it up and out of you (gross), 5) work to increase strength and watch your body morph before your very eyes, and finally, 6) work on good posture.
Easy peezy, right?