Despite being a nerd  who never did anything but read as a young girl, the last thirty-eight  years of my life have been marked by a pronounced exercise addiction.  As such, both good and not-so-good things have occurred.  The good is clear:  Somehow, I’ve beaten back the CF monster time and time again, and I honestly believe that my fitness level has been a huge contributor to this bit of good fortune.  It’s been known since the early days of CF research that fitness level corresponds very well with survival in CF (Nixon, 1992).  I certainly didn’t know anything about this at the time I started  running in order to be the  skinniest girl in  my high school class (thank God I didn’t win that competition), but the consequent addiction to fitness has certainly paid off.  The need to be skinny turned into the need to be in control (thank you weight-lifting), which morphed into the need to combat stress (thank you medical school), which then turned into the need to get out of the house (thank you two toddlers).  It wasn’t until my CF began to really let it’s presence be known to me in more serious ways that exercise became my need to (literally) run away from reality.

It was only when out for a run, or when strutting around in the gym looking (and actually being) strong that I forgot about those pesky malfunctioning genes that took my sister and brother’s lives, and would likely take mine.  Taking on fitness challenges and training for them was a way to beat CF, and forget about it at the same time. This is how I coped, and it worked really well.

Until it didn’t.  The wake up call for me was last spring, when I lost my mind and decided to train for, and pass the RKC.  You can read about that little escapade here.  So, at 50, I proved that I could train myself so hard that I could end up in the hospital with pneumonia.  Sure, it was a great experience (the RKC, not the pneumonia…that sucked), it was very good for my ego, and I think I even surprised a few people, but was it really worth the blow to my immune system, the chronically elevated cortisol levels, and the resulting scars in my lung tissue which are permanent?

Here is my point.  If you have CF, exercise.  Heck, if you don’t have CF exercise.  That is what our bodies need…what we are made to do.  Everyone is healthier when they move frequently.  But overdoing it is not a good idea.  Over-training is a serious stressor to the body.  It causes hormonal chaos, as the body thinks the stress is never going to stop and keeps on pumping out cortisol like crazy.  Cortisol is the body’s version of a drug we commonly have to take to dampen inflammation in the lungs, prednisone.  Remember the last time you had to take prednisone?  The shaky feeling?  The mood swings?  The elevated blood sugar?  The yeast infections?  Elevated cortisol over a long period can lead to these things and worse .  It not only turns down the inflammatory response in the lungs, but it also turns down the immune response to infections, resulting in….trips to the hospital with pneumonia.

So what is a cyster (or fibro) to do?  Moderate.  It is the best course of action.  Here is how I do it now (at age 51).  I walk every day, at least 30 minutes, usually more like 60 minutes.  This is at a moderate pace, and is usually a pretty low key event.  My heart rate is never more than 50-60% of my maximum (although this is a guess since I never take it).  There is a little bit of an upper body workout component as I am always accompanied by two dogs, one of which almost outweighs me, is horribly leash-trained, and constantly looking for squirrels.

Three days a week, I pick things up and put them back down (weight lifting).  This consists of a heavy day, a medium day, and a light day each week.  The “heavy” day means heavy (for me) weights, which means fewer reps.  This day usually consists of deadlifts and bench presses, with some ab work thrown in for good measure.  The “medium” day means not heavy, but not too light weights.  It’s a Goldilocks day.  The exercises are usually squats, military presses and rows, and the rep range is 8-10.  I may “play” with kettlebell exercises this day–but nothing hard.  The “light” day is just that–light.  I go back to deadlifts, but just practice form, and work on my pull ups.  This is the day I will “practice” my kettlebell favorites, like the Turkish Get Up or the snatch.  Again, the focus is on practicing and playing.  Currently, my weight workouts are limited to 45 minutes.  I’m trying to get them down to 30 minutes, but this is tough for me, because I always think of “just one more thing” I want to do.

I can hear you now.  ”What about cardio?”  I know, I know.  Running has saved me from the CF beast.  I can’t give it up…the beast might get me.

I’ve been experimenting with limiting my “run” days to two a week at the most.  And they are not runs anymore.  They are interval workouts, where I either run fast (I would say sprint, but that’s sort of stretching it) for short periods (15-30 seconds) and walk to recover, repeating for as long as it feels right,  OR I walk uphill fast wearing a 20 lb weighted vest, and then slow way down (and decrease the incline) to recover, again repeating the work:rest intervals for as long as seems right.  Because interval training is hard, these are short workouts; 20 minutes maximum.

So, let’s think about this:  walks daily…at such an easy pace they don’t really count.  Weight lifting 3/week at 30 minutes (that’s the goal anyway).  Interval training 2/week at 20 minutes.  Not much time, right?  Now trust me, in order to get the work done, and make it worth your time, those short workouts have to be pretty fast pace and intense (except the easy weight lifting day…don’t even consider “intense”).  This is what I’ve been doing this year.  And guess what?  I’m going on seven months with no infections and no IV’s.  My weight is up.  My mood is up.  My numbers are up. Life is good.  Compared to the times in the past when I’ve been working out like crazy, one to two hours-a-day, this is a much more sane, and healthy (I think) approach to fitness.

Here’s my final point:  This isn’t a lot of time.  So the next time you try to convince yourself that you don’t have time to exercise because you are so overwhelmed by the CF regimen,  ask yourself if you have 20-30 minutes.  That’s not even a sit-com!

Lastly,  an important caveat:  If you are just starting to exercise, or just coming back to exercise after being sick, start with the daily walks.  Get those down first, building up an aerobic base.  Next, add the lifting.  When you feel strong again, start in with the intervals.  At first, intervals may look like this: 30 sec walk fast, 1:00 walk normally.  Then maybe build up to a jog for the work intervals…then a run…then a sprint….then a sprint uphill (ok so maybe this won’t happen until the Magic Pills are approved).  Go VERTEX!

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In brief, I have quit trying to kill myself with intensely hard workouts, day after day.  You would think after living with cystic fibrosis for 51+  years, I might have embraced the wisdom of this before now, but alas…

What has caused this epiphany, you ask?  After attending a four day Z Health course last month, I’ve begun to re-train my nervous system as part of my overall exercise program.  By necessity, this means I am being nicer to myself.  I’ve learned that my brain doesn’t like to be whipped into an endorphin frenzy every single day…and neither does my body.  Oddly, I’m 1) in better shape than I’ve been in years, and 2) not injured.

“OMG,” I can hear you now.  ”First, I have to take a million medications, AND I have to do hours and hours of daily treatments,  AND I have to wear a vibrating vest for an hour a day, AND I need to go outside and walk or lift weights every day,  AND I need to get 8-9 hours of sleep, AND I need to eat 5-6 times a day (add more pills), AND I need to work, AND I need to raise kids and be a spouse or partner and dog mom, AND I have to fit in a few home (best case scenario)  IV sessions each year, and NOW I HAVE TO RE-TRAIN MY NERVOUS SYSTEM, TOO???”

Only if you want to minimize pain and injury and maximize your movement excellence.  I’ll write more about Z and what it is doing for me in subsequent posts.  Oh, and just a side note:  if you move well and without pain, you move more.  When you move more, you increase your fitness.  And when you have CF, it’s not fitness, it’s life.

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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.

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Here is why (David Letterman style) I think strength training needs to be a key component in your workout–especially if you have CF:

10) You can seriously increase your appetite, especially if you are doing a heavy lifting program.  Lifting heavy and the consequent eating like a horse is how I gained six pounds in six weeks.  Doesn’t sound like much, I know, but it’s about 6% of my body-weight (you do the math).  The only time I’ve ever been able to gain that much weight was the first year of college.  Man did I love that all-you-can-eat cafeteria.

9) It’s great to beat your son at arm-wrestling.  OK, so he’s only 12.

Maintaining bone density is pretty important, unless you want to crumble into a heap of skin and bones in your old age.  Yes, I did say ‘old age.’  It will happen.

7) In CFTR-able people (code name for those without CF), lifting weights increases insulin sensitivity.  There is no reason to think this won’t be true in CF as well.  If you CFRD or are on the verge, or, if you don’t want to develop CFRD, a little weight training can absolutely not hurt!

6) You get to buy new clothes when you ‘outgrow’ your old shirts, pants, etc.  Ladies, don’t worry–I’m kidding.

5) Who wants to be soft?  Weight training will firm up those abs and legs and arms in very little time.  Try it.  You will be amazed.  In addition, who wants to be skinny and wimpy?  This will not be the case if you adhere to a regular lifting schedule.

4) Being stronger will make the regular chores of life easier.  Easier means requiring less energy.  Requiring less energy means requiring less oxygen.  Less oxygen required means even if you have sucky lungs–that’s a technical term–you will still be able to carry on, soldier.

3) Coughing is easier and more effective if you have strong abdominal muscles.  This is just true.  Given that we cough, and the effectiveness of our coughs is directly proportional to our health…strong abs are very important.

2) Let’s face it, body image can be impaired in CF.  It’s not hard to imagine why this is true, but this is a very important issue, especially in kids. One very good way to improve body image is to develop muscle.  Development of muscle is not impaired in CF (as long as you eat and digest food).  We can ALL do it.  And when you do develop muscle that is visible to the naked eye…you feel better about the way you look.  Even if you cough.  Even if your fingernails look funny.

1)  I left this for last because it is my favorite reason to lift.  You are in control when you lift.  Not CF.  CF doesn’t affect your strength.  CF doesn’t stop you from developing strong muscles.  There is absolutely no difference between you and normal Joe GymRat, when it comes to getting strong.  Booyah.

These are good reasons to add resistance training to your workout.  The next post will discuss how to design your program.

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Remember back in the days when you would hold static stretches before you exercised?  I still see people doing this…going straight from the locker room to the stretching mat and doing seated forward bends and holding calf and quad stretches before going to the elliptical machine or treadmill. We know better now.  First, it’s not good to stretch cold muscles.  If you must do static stretches, it’s much better to do five minutes of jumping rope or fast walking first, as the increased blood flow to the muscles helps to warm them up and may increase their elasticity.  It also turns out that stretching a muscle statically (holding the stretch for 20-30 seconds) may actually decrease its ability to perform strength and power moves.  So if you are intending to lift weights, it will benefit you  to find better ways to stretch prior to your workout, and do the static stretches at the end.

A better way to stretch cold muscles and get them ready to work is to stretch them actively.  This simply means to stretch your muscles while they are in the act of moving.  This is a dynamic process. Nothing is held for time.  You simply wake your muscles up by asking them to move into stretched positions.  A great example of this is the “inchworm,” one of my favorites.  Here is a great example of this.  Notice that the hamstrings and calves get a great stretch as they are working.

Click here to view the embedded video.

Another great exercise for the upper body targets the front of the shoulders and the upper back.  This is much harder than it looks, especially when you keep your butt, upper back, head, forearms, and wrists touching the wall the entire time.  Check it out here:

Click here to view the embedded video.

Walking lunges are a great way to warm up for running or lower body weight lifting.  To increase the stretch in the hip flexors, add a twist in the direction of the forward lunging leg.  Check this out here:

Click here to view the embedded video.

These are some of my favorite movement preparation exercises.  I will also do a few sets (if I am lifting weights) or a few minutes (if I am doing cardio) at a much lighter intensity level than what I do normally as more movement prep.  After all, the best way to prepare to do something is to do it…with a very light load.  This tells both your muscles and your brain to get ready for what is to come.

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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

Aerobic Base

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.

Interval Training

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.

Plyometric Exercises

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!

Weight Training

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.

Posture Work

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?

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• Step One of Perfect Workout: Rolling

Corrective exercises are meant to do exactly what you would guess, namely to “correct” any structural imbalances which lead to vulnerable muscle groups. These types of exercises have also been termed “prehab,” with the idea that if you do them, you avoid injury, pain, and the need for “rehab.”  Why would imbalance lead to injury?  I’m glad you asked.

As I mentioned in the previous post, we all (and by “we” I mean those of us with CF) tend to develop a somewhat kyphotic (hunched forward) upper back, and usually the end result of this is an overarched, or “lordotic,” lower spine.  This lordosis combined with  hours and hours of sitting lead to tight hip flexors (the muscles that work to hinge your hips forward—think bringing your thighs to your belly-button).  Tight hip flexors tend to go along with weak gluteal muscles. This stick figure here shows the problem.  Tight low back and hip flexor muscles along with weak abdominals and gluteals.   The picture of imbalance.  This is a set up for low back pain.

These are the areas that I focus on in my “prehab” work.  I do exercises to strengthen my gluteals and abdominal muscles, and work to stretch and strengthen my hip flexor group and low back extensors.  In the YouTube video below, I go through a few of my favorite “glute” activators, and some good abdominal exercises using a stability ball.  Try these, and let me know what you think.

In the next post, I’ll talk about some corrective exercises for that pesky hunchback.

Click here to view the embedded video.

Related Posts:

• Step One of Perfect Workout: Rolling
• Almost Six Months Later….
• Step Five of the Perfect Workout: Strength Training
• Step Four of Perfect Workout: Movement Preparation
• Step Two of The Perfect Workout: Just Move It

Now it is time to move on to Step Two, which is all about improving mobility.  Mobility is becoming one of my favorite subjects lately, and I have been working diligently to improve my own.  It is not a complex subject; mobility is simply the ability to move.  As it relates to exercise, mobility is about the ability of every joint in your body to move through its natural range of motion.  Now, there are many, many joints in your body…somewhere between the mid 200’s to mid 300’s (the definition of “joint” is a bit fuzzy).  Most of those don’t need a lot of your attention. But before you stress your body with exercise, it is good to circulate a bit of synovial fluid (the stuff that lubricates joints) and wake up the millions of mechanoreceptors that live around your major joints…especially the ones you plan on taxing during your workout.

I have many tight and not so smoothly moving areas that I like to focus on, but the one area I’d like to talk about at length here, because I am certain that we all share this issue, is the thoracic spine.

Think about your posture.  Adults with CF very commonly have poor posture, and most of us with poor posture know that it is a problem.  The causes of the problem are many.  First, we are getting older, and with age comes increasing reinforcement of poor movement patterns.  The body adapts perfectly to what is asked of it.  If you start slumping your shoulders when you sit at the computer, or drive, or breathe, the body decides this is the position it is to always assume. Second, with age comes bone loss (especially in CF), which can lead to osteoporosis and subsequent hunching of the upper spine (technically called kyphosis).  Finally, as breathing mechanics change with increasing lung disease, there is consequential structural alteration of the thoracic cavity that worsens kyphosis.

Why is this?  Because the body tries to offset or balance the  increased hunching (kyphosis) of the thoracic spine with an over-pronounced swayback of the lumbar spine, also known as lordosis.  This leads to pelvic and hip problems, and the result is a mess. Sounds bad, right?  It is, and the worst part is that all of this leads to a very common problem in adults with CF, back pain.  The picture below illustrates this problem.

The thoracic spine is actually supposed to be very flexible.  It is supposed to flex, to extend and to rotate.  In contrast, the lumbar spine is designed more for stability and less for flexibility.  Sadly, most people have this backwards, and tend to use the lumbar spine more than the thoracic and hips for bending and rotating.  This often leads to pain, and commonly to injury.  Because the thoracic spine in CF tends to be even more “frozen” in place because of the above-mentioned issues, pain is extremely common.

But wait, there’s more.  Pain is bad enough, but what is worse is that the combination of poor posture and pain leads to inhibited airway clearance, less expansion of lung tissue and deteriorating lung function. Stiff and unmoving thoracic vertebrae also increase the work of breathing (isn’t it hard enough?).  None of this is good.  Not good at all.

But here is the good news:  Some of the postural problems in CF can be corrected.  Those having to do with muscle  and soft tissue tightness are reversible!  Stiff joints can be mobilized with specific exercises and soft tissues can be stretched to allow for normal alignment and movement.

This is why at least 10 minutes of your workout should be spent waking up and moving your thoracic spine.  If you are like me, you literally need to teach your brain exactly where this part of your back is, and how to move it because of something called sensory-motor amnesia.  This is exactly what it sounds like:  When you don’t move a body part much, the brain 1) forgets where it is, and 2) forgets how to move it.

I’m Convinced.  What Should I Do?

First, take a breath and don’t panic.  Then, check with your doctor and make sure these are safe for you, especially if you have osteoporosis. Next, to get a rough assessment of the amount of kyphosis in your upper spine, do this test.

Lie down on your back with your feet on the floor, knees bent to about 90 degrees.  Now press your low back into the ground and keep it there as you do the following:  bring your arms up and over your head, keeping them straight with your biceps muscles close to your ears.  Don’t move into pain, but see if you can bring your wrists and back of hands to the ground above your head.  If you have normal thoracic mobility, this is a breeze.  If you can’t, you are like me and have some pretty stiff and sticky thoracic vertebrae.  The following exercises are for you.  If you can, and want to keep it this way, the following exercises are for you.

1)Spend quality time with your double tennis ball contraption (link) every day…before your workout as I discussed in the previous article, and also throughout the day, especially if you sit at a desk a lot.  If you are bigger and have more muscle mass, you might graduate to double lacrosse balls.  This is not in my future.

2) Roll your upper back with a foam roller.  As you do this, bring your hands behind your head and keep your elbows close together (this gets your shoulder blades out of the way).  Slowly roll up and down the spine, stopping at the neck above, and the lowest rib below.  Try to “curl” yourself around the roll by aiming the top of your head to the ground.  If you have tight spots that are slightly uncomfortable, spend some time there.

3) Get on hands and knees and push your butt slightly back toward your heels.  Now take one hand (for example, the right) and place it behind your head by bending your elbow.  Now, keeping your butt back, rotate your spine by reaching the right (bent) elbow toward your left knee.  Come back up and do this several times, slowly.  Repeat on the other side.

4) Stay on hands and knees, but  this time sit all the way back onto your heels.  Take right hand again behind your head, and now rotate it up, toward the ceiling, trying to open your chest to the ceiling as well.  Don’t move your butt–this is keeping the lumbar from moving, thus isolating the upper back.  Repeat on the other side.

The sensory-motor amnesia problem is a bit more complicated, but can also be remedied with some drills taken from a system called Z-health.  I am currently immersed in learning Z-health and will write more about it in future posts, but these are some basic exercises that will begin waking up and mobilizing the spine.  Try them and then retest with the “raising the hands over the head” exercise.  My bet is that it will improve.  I don’t start my workout until I can do this without discomfort (but it has taken awhile to get there).  Start slowly, but be persistent and patient.  Your spine and lungs (and posture) will thank you.

Related Posts:

• Step Four of Perfect Workout: Movement Preparation
• First Sick and Happy Video!
• Step Three of Perfect Workout: Corrective Exercises
• Step One of Perfect Workout: Rolling
• The Perfect Workout

Unless you are a newborn, when you walk into a gym — quite a feat for a newborn — you are going to have some muscular tightness…some tension or “knots” in muscles that occur from chronic movement patterns that are less than ideal.  We all have less than ideal movement patterns.  This is not a judgment…it’s just a fact.

Those of us with chronic coughs especially develop tightness and tension in the thoracic spine, and neck.  Those who sit at work or at home at a computer for many hours a day can also develop muscular tension in the neck and back, as well as tightness in hip flexor muscles and hamstrings.  A good way to think about this is that over a long time sitting in a chair, your body tends to become “chair-shaped,” i.e. short and tight hamstrings and hips.  If that’s not scary enough to imagine (a chair-body), the ugly truth is that muscles don’t live in isolation from their neighbor muscles.  The entire soft tissue system (muscles, ligament, tendons and fascia) is all interconnected.  So a tight, knotted muscle in one area very definitely affects muscles, tendons, etc. both upstream and downstream from it.

This is why a knot in the middle of your back can cause pain all the way up into the back of your head.  Or in my case, this explains why spending a few minutes rolling the bottom of my foot around on a lacrosse ball can help me loosen up my ankles and calves.

So why do we care?  We care because it isn’t just that pain in one area leads to pain in another, but muscular weakness (resulting from those painful knotted tissues) leads to imbalance and weakness elsewhere, which leads to improper movement.  Somebody famous once said, “The body does what it does perfectly.”  So if the body moves imperfectly, it then perfectly continues to move imperfectly.  And if we, for instance, go for a walk or add resistance to imperfect movement, we solidify that pattern in our brains, and become nicely set up for injury…and more pain!

So what’s a (tight and knotted up) body to do? Well, before asking the body to work, it is nice to do whatever you can to lengthen and unknot the muscles that need attention.  This does not have to be a long process, and you don’t need to spend 30 minutes on your foam roller, thus using up your workout time allotment.

I have three favorite tools that I use for this purpose.  First, the aforementioned lacrosse ball is a must for my feet, and occasionally for very tight knots in my back.  If a lacrosse ball is too hard (and you will definitely know this), you can start with a tennis ball and move to a harder ball as your tissue gets more pliable and your nerve endings get used to the process.  For my feet, I simply stand up and put one foot on top of the ball and roll it around.  You will automatically gage how much weight to put on the rolling foot (by how much pain you can tolerate).  When I started this process, I could barely tolerate any pressure—I have very tight feet. But I persisted, 5 minutes every day.  After a couple of weeks, I didn’t mind it at all.  Now this actually feels good.  I don’t usually do this at the gym.  Instead, I have found that the easiest time to do it is when I do my treatment every morning.  It’s like giving myself a foot massage!  I also keep a lacrosse ball in the bathroom.  You figure it out.

The second tool I use is the foam roller.  You’ve probably seen these around.  Most are about six inches in diameter and about three feet long.  They are made of Styrofoam, and have lived in the gym scene for years now as a favorite instrument of torture.  I say this because they are used for “self-myofascial release,” a process that is slightly uncomfortable, especially when it is really needed.  I roll my calves, hamstrings, gluteals, and if I’m really feeling masochistic, my quadriceps over such a roller.  You will know what you need to roll by how painful it is.  The more it hurts, the more you need it.  You simply modify the move to a tolerable level of pain by taking some of the weight off the body part being rolled.  I generally spend five minutes or so rolling as the very first part of my workout.

Tool number three is a very expensive, intricate and complicated instrument.  Kidding.  It’s called a “peanut,” and is comprised of two tennis balls duct taped together to form a peanut-shaped duo.  This handy little tool sets my thoracic spine back to where it’s supposed to live every single day.  The maneuver is simply to place the peanut on the floor under your lower ribcage, and lay back on it so that the groove in the peanut is directly under your spine.  This places each ball of the peanut perfectly under the bundle of muscles that lie adjacent to your spinal column.  You simply roll back and forth on the peanut several times in the position, then move it up the spine about an inch and repeat.  Moving this way all the way up to the level of the big protuberant bone at the bottom of your neck takes only a couple of minutes, and is one of the best things you can do for knots along the spine as well as mobility of the spine (to be discussed in a later post).

That’s it!  Soft tissue rolled out…now it’s time to move on to mobility work.

Related Posts:

• Step Five of the Perfect Workout: Strength Training
• Step Four of Perfect Workout: Movement Preparation
• Step Three of Perfect Workout: Corrective Exercises
• Running From Depression
• When Less Is More

Living with an unpredictable illness is not all mirth and laughter, though.  Some aspects of getting older are a bit more frustrating, at least for me.  This is where Tonic, a new iPhone/iPad app, enters my story.  As you probably know, staying healthy with CF requires more and more effort with age.  There are more medications to take, more treatments to do, more effort is required to stay fit, to eat well, to manage CFRD, to get enough sleep, enough water, to do whatever it takes to make the plumbing system work well, remember appointments for the doctors and port flushes, to do…pretty much everything.  Yet, just as the “CF care complication” factor increases, the ability of the mind (mine, at least) to keep track of it all begins its downward descent.  This is poor design, but it is what it is.

I noticed it first with Advair.  I can never remember if I have taken it.  I don’t know… I seem to have a mental block.  The block then spread to enzymes, vitamins, children’s names, books I’ve read, etc.  While it’s much cheaper to be able to read the same book (and be entertained) multiple times, too many shots of ProAir or too many Pancrelipase capsules can be problematic.

I have officially dubbed this past winter, “the winter from hell.”  For some reason, I had three episodes of pneumonia with resulting rounds of home IV antibiotics over the span of eight months.  If this wasn’t enough, I cultured MRSA recently, so each round of IV’s included three different medications, all through IV access.  IV meds must be refrigerated of course, and when they come in Entermates (as two of mine did), they need to be removed from the refrigerator a few hours before being used.  When you forget to do this, 1) brrrr, and, 2) the infusion takes forever.  Not to mention that during exacerbations, I do three treatments per day, try to sleep, try to remember to eat (when I have no appetite), and take the usual oral meds, supplements, and vitamins.  I also have follow up appointments with doctors and need to get to the lab for blood draws three times each week.  Did I mention the port dressing changes? I literally needed a flow chart to traverse through my day, or I would forget an essential item.  Of course, most people get admitted to the hospital for this rather intensive treatment time, where, at least in theory, they keep track of these things.  Wink.  But I hate hospitals, and only go in if it is absolutely mandatory.

Enter Tonic.  As luck would have it, I was able to beta test Tonic this “winter from hell.” Tonic is an app that helps you to remember and track whatever you need to track.  Setting up Tonic is a simple task.  You simply make a list of all that you want to remember and track.  It took me about 30 minutes because my list of “tonics” was enormous.  When it was done, though, my trusty little iPad would bleep whenever I had to do something.  Take out med (bleep).  Infuse this (bleep).  Take this (bleep).  Eat (bleep).  Weigh yourself (bleep).  Eat more (bleep).  Trust me, the thing was bleeping all day, every day of each exacerbation.  But I was so completely on track!  I missed nothing.  Nor did I do or take anything more than I was supposed to, because you check off each “tonic” as you do or take it.  This is a very satisfying property of Tonic for anal compulsive people who like checking things off lists (like me).

Second, remember that the idea is to make your life easier, not to add another chore to your day.  When my life is so complicated that I really need help, I use Tonic.  But other times (like now) when things are pretty good, I let Tonic fade somewhat into the background.  It still reminds me, but I turn off the “bleep” alarm and don’t always check off all the activities or enter a lot of data.  You will find your own balance.

In summary, Tonic is just what I needed at just the right time.  I would recommend it to anyone, whether you have a complicated regimen like mine, or just want to track a few things.  If you decide to give Tonic a try, let me give you two hints.  First, use it for all of the things you do for your health.  Everything. Really.  Meds, sleep, exercise, nutrition, water intake, everything you can think of that you know you want to do to be at the top of your game.  For instance, Tonic even reminds me to journal, to stretch my hamstring muscles, and to meditate.

You can find Tonic on the web at http://www.tonicselfcare.com.

Related Posts:

• Step Four of Perfect Workout: Movement Preparation
• Step Three of Perfect Workout: Corrective Exercises
• Step Two of The Perfect Workout: Just Move It
• Step One of Perfect Workout: Rolling
• Why I Hate CF