Monday, 19 November 2012
Adaptive Physio & Why We Should All Learn Italian
When I was younger I did a lot of sport and found my lungs would naturally clear themselves. Now my FEV1 is usually between 30% and 40%, my resting SATS are 92-94% on air but they can quickly drop below 90%. I have to be careful of de-saturating as I now have mild pulmonary hypertension so I use ambulatory oxygen. I try to do as much exercise as I can (on oxygen) but I don’t always have the energy and I have to work much harder at it. So I need a Plan B (and a Plan C and sometimes a Plan D).
I tend to get a very dry, tickly cough so my challenge is to work through my physio without it degenerating into a manic coughing fit and making my airways very tight without actually clearing anything. I also find the gunk tends to be buried deep down and I have to work hard to get it out. I am interested in any techniques that help me clear a decent amount of mucus without exhausting myself too much, giving myself a horrendous headache, feeling sick or all three of these. For me, it’s all about efficiency: clearing the most mucus for the minimum amount of coughing and energy expenditure. I typically do a modified form of autogenic drainage and I also use a PEP mouthpiece. I find the back-pressure helpful in terms of propping open the airways so I don’t get too tight and wheezy (i.e. so I can move sufficient volumes of air to reach and mobilise the deep secretions).
I find my lungs are a bit like the weather - very unpredictable. Some mornings they feel very tight, dry and tickly. Some mornings they are more friendly: more relaxed, more moist, more soft feeling. Different techniques work on different kinds of “lung weather.” So I always have to be quite creative and just keep trying, adapting things until something works.
After doing Salbutamol and Pulmozyme nebs but before starting on airway clearance, I find doing some gentle stretching is very helpful. This is mostly to do with lengthening and aligning my spine and opening up my chest. I tend to find I get hunchy and this gets worse when I feel worse. It’s a vicious circle though because the more hunchy I get, the worse I breathe. A bit of work on posture each day stops it getting too bad. And I find it’s a good way to focus and relax.
When I was in the Royal Brompton once for a course of IVs there was a singing teacher called Maya walking around offering to give patients singing lessons. I had done some singing in school but that was 20 years ago and not a note had passed my lips since. I had a go though because I was intrigued and also quite bored. In fact it turned out to be a bit of an eye-opener. It was a lot of fun and it taught me some useful things about breathing and posture. I am not about to enter the X Factor but I do find singing helpful and enjoyable. I also find some of the techniques useful when doing airway clearance which for me is usually some form of autogenic drainage.
Sometimes during airway clearance, when I am fully exhaling or doing a slow gentle huff trying to mobilise secretions, I find it helpful to imagine I am singing a long deep note but without actually singing. In other words, my mouth, airways and diaphragm all behave as if singing a long deep note but without any involvement of the vocal cords. The feeling of holding the note works really well for me.
I also experiment with different mouth shapes. As I am doing these slow gentle huffs, if I find nothing is moving I try a different mouth shape. For example, I might start off with my mouth shaped for an “ah” sound but if that is not producing, I might switch to an “eeh” sound or an “oh” shape and so on until something moves.
On other recent occasions, I have found gargling gently with warm water can be effective. The combination of hydrating the throat and the “flutter” effect of the water just seems to do the trick. Then there are the old classics like slowly steaming up a mirror. I have tried using The Vest but I find it difficult to hear and feel what is going on in my lungs/airways so I prefer other methods. If I am really feeling bad and have no energy, I find some old fashioned percussion and postural drainage is the best approach.
I have had and continue to get lots of fantastic instruction, help and support from my physios. I think they are the unsung heroes of CF care. But at the end of the day, we are all unique and our lungs are capable of weird and wonderful variations.
I have learned that I have to be open-minded, try lots of different things, improvise, adapt, never give up and find something that works for me. It may be something nobody has ever thought of before!
Perhaps like learning how to sing in Italian…
An American friend of mine who is a trained opera singer recently told me this:
Listening to and thinking about how an opera singer uses their lungs might help you make your breathing work better for you. When we were babies we happily breathed through our tummy/diaphragm but as we grow older we think we have to breathe through our chest. It is good to rediscover tummy breathing and good use of the diaphragm.
As you inhale, feel the diaphragm flatten (contract) causing the abdomen to bulge outwards. During exhalation, the diaphragm relaxes upward, allowing the ribs to drop down and the abdomen to draw inward again. Feel the movement in your ribs and abdomen. You can feel the movement of your breathing by putting one hand on the side of your torso and the other hand on your abdomen. During inhalation, you will be able to feel your hands move out. During exhalation you will feel your hands move back in.
Italians singers are usually perceived to be the most "natural" sounding. Italian vowel sounds are the purest - have the fewest diphthongs – of all the Western languages. It's why one can sing so quickly in Italian (like Rossini likes to write, Mozart too, sometimes); and also why Italian opera specialized in "bel canto" - beautiful singing - as almost an end in itself. I don't know if this is true, but my old Juilliard Italian diction coach used to maintain that Italians were the most relaxed and kept their breathing channels the most open, especially while they slept. She claimed that Italians (unlike most northern Europeans, or worse still, Americans) never clench their teeth when they sleep or when they are at rest. They have relaxed jaws and open larynxs. And they sing "in the mask" - that's singer talk for projecting with an open throat, feeling like the sound is coming out, not from the mouth, but rather from an area between the upper nose and the eyes. When it doesn't work well with Italian singers, they can sometimes sound too nasal.
So while writing this note, I thought it might be fun for you to find an Italian diction coach or even take some singing lessons if it wouldn’t be too much of a strain.
Another thought: do you know something called the Alexander Method? Not really an exercise thing (it's not Pilates); it's used by lots of singers and actors to improve their posture, open up their breath canals, all of that kind of thing. When I was at "singer camp" there used to be an Alexander teacher attached. Putting one hand on your forehead and one on your belly while you breathe is an old trick, and might be fun to play with. The simple act of being still, concentrating deep breaths on mindless numbers - or whatever you choose - might be a good opening to any breathing exercise.
But at the end of the day, it's all in the way you use your diaphragm. And singing is probably one of the best ways to improve.
Food for thought!