A few weeks ago, I published an article on how the mitochondria require exercise in order to remain functional and optimize energy production. Today, I would like talk about what that might look like if someone has been chronically ill. Remember, I am not an exercise physiologists, a physician, or anything of the sort, but someone who studies mitochondria and happens to have a lifetime of experience with exercise and healing from illness. What I have written below is based upon research and experience. It represents how I would approach the rehabilitation of mitochondria after long periods of deconditioning from bedrest. These are techniques that I have used in some form or another at various points in my life. This is not medical advice.
Exercise and ATP
There are a lot of misunderstandings surrounding the notion of exercise relative to certain conditions involving fatigue. Top amongst them, is that we can rest our way out of the fatigue. Anyone who has had chronic fatigue knows full well that rest does not resolve the fatigue. That is because the fatigue is metabolic, or rather, mitochondrial in nature. The mitochondria are simply not producing enough energy, efficiently to maintain survival functions let alone the stress of exercise. Two of the drivers in this sort of fatigue are inadequate mitochondrial nutrients – the mitochondria require vitamins and minerals to derive energy from food and produce ATP or energy – and inadequate muscular demand. With chronic fatigue, the two reinforce each other to create a seemingly continuous downward spiral in health . This means we must tackle both in order to regain health. Per the article Exercise is Mitochondrial Medicine:
…exercise exerts a medicinal effect to improve mitochondrial health and whole muscle function.
Certainly, there may be underlying genetic mechanisms or other environmental constraints that damage the mitochondria, but we know from research that even genetic defects can be managed with nutrient support. Indeed, some research suggests that nutrient support may compensate for the genetic dysregulation while rescuing and restoring capacity in the face of genetically-induced pathology. Most recently, this has been discovered with Huntington’s disease, but there is a long history of this with variety of genetic defects (reviewed here, here).
While the nutrient repletion and support portion of this equation is difficult, the exercise component is particularly tricky, especially if one has been ill for a long time. Too many patients are told to just ‘get up and get going’, without any real appreciation of what drives mitochondrial capacity. One cannot exercise without at least semi-functioning mitochondria. It just does not work. So nutrients must be on board. Unfortunately though, without some exercise, one cannot fully heal the mitochondria. We need tackle both in order to heal but how we exercise for mitochondrial rehabilitation is entirely different than how we exercise for general fitness. Eventually, the two will meet, but in the beginning, mitochondrial exercise is so far afield from what most people consider exercise, that it seems odd to call it exercise at all.
Step One: Mitochondrial Nutrients
I cannot stress this step enough. One must tackle mitochondrial nutrients first and continuously, if one has any hope of successfully implementing a mitochondrial exercise program. We have dozens articles on the topic of mitochondrial nutrients and even wrote a book on one particular nutrient, thiamine. Please read and address before beginning this or any other program.
Briefly though, mitochondria are responsible for synthesizing ATP – the energy cells need to function. When mitochondria are ailing, when they have inadequate of micronutrients in either absolute (frank deficiency) and relative terms (increased need/functional deficiency), they cannot not produce enough ATP to meet the demands of living and fatigue sets in.
The research on chronic fatigue supports this. Those with ME/CFS have problems with the first step in mitochondrial energy production, with an enzyme that effectively opens the door to the entire process. When this is door blocked (by inadequate nutrition or toxicant exposure), energy metabolism is derailed. Instead of being able to produce 30-38 units ATP per glucose when processed in the mitochondria, now the cell becomes responsible for ATP production and here it can only derive ~2 units of ATP per molecule. That is an enormous decline in energy and this is at root of fatigue. Imagine operating on a fraction of the required energy.
The fatty acids and amino acids pathways may also be derailed by poor micronutrient status. This means foods with these derivatives will not follow the appropriate paths to become energy (fatty acids may produce up to 100 units of ATP per molecule) or form the building blocks of other important molecules. Instead their metabolites will be diverted to highly inflammatory molecules. So step one in the process of ‘exercising’ with fatigue, is to get the nutrients on board so that the body can convert food into energy, cleanly and efficiently.
Step Two: Increase Demand
There is a whole bunch of chemistry behind the need for exercise, much of it covered in the last article, but the gist: mitochondria will produce energy relative to demand from the musculature. When there is a lot of demand and provided the mitochondria have sufficient nutrient support, the mitochondria will maximize energy production by streamlining all sorts of processes to increase efficiency and ensure optimal output. When there is limited muscular demand, however, not only is energy output diminished, but so too are the efficiencies that make increased energy output possible. Capacity declines, and with that the individual’s ability to exercise or even perform the most basic movements of everyday living, deteriorate. That means that while nutrients are required and should be the first step in healing, to fully maximize mitochondrial capacity, one must move the muscles. These two signals are critically important for building energetic capacity.
The question: how does one begin to exercise after or while being ill, immobile, or largely bedridden for an extended period? Short answer: very slowly and carefully. Long answer: we begin with most basic of functions – increase oxygen intake and contract the muscles. In other words, deep breathing and muscle contraction. Simple right? It seems so, but in reality, because it is so simple and incredibly tedious, it is not something many us of want to do, let alone do with the regularity required to improve mitochondrial capacity. It is especially difficult if one was an athlete before becoming ill, but it most be done.
The only goal of these movements is to increase blood flood flow, which will bring more oxygen and more nutrients to the mitochondria in the muscles and elsewhere. Traditional exercise does this automatically, but when one has been ill, we have to begin with the most basic functions. You can do all of this from bed or seated. I like laying down best because it allows me to feel the blood flow to different parts of my body more easily but as you progress, you may want to add some seated or even standing exercises.
Breathing, breath control, and diaphragmatic flexibility are among the most important functions of being healthy. Below are few breathing exercises to begin. This is not an exhaustive list, but simply a beginning point.
- General deep breathing. Lay flat, relax everything. Begin by breathing in through the nose and out through mouth slowly. Try to exhale more slowly than you inhale. Make a long shsh noise as you exhale. Breathe down your spine and into your pelvis. Bring the belly button towards your spine with each exhalation. You should feel the body begin to realign itself as everything begins to relax. Take 10-20 deep breaths with each session. If you can, repeat multiple times a day. When you feel comfortable, lay on the floor with your legs resting on a chair so that the bend in your legs is at a 90 degree angle. This is called supine 90/90.
- Diaphragm wake-up breathing. Breathe deeply into your diaphragm and imagine it diaphragm expanding outward towards your ribs and contracting inward towards your spine with each breath. Repeat until you can feel the diaphragm moving. I like to put my hands on my ribcage to breathe against and then compress as I exhale. The breathing here is more forceful than the technique above. It has to be to move the diaphragm. If this is too much, repeat only a few times at first, then and increase to 5-10 ‘reps’ as you build capacity. The goal here is wake up the diaphragm. Again, this can be done multiple times per day, a few reps at a time.
- Muscle breathing. This is a deep breathing exercise where you will ‘breathe’ deeply into different muscles. This exercise can become more intense the longer one does it. I like to do it at night before bed or if I happen to wake up in the middle of the night and cannot get back to sleep sometimes I will use this exercise to relax everything and fall back asleep. Begin by breathing deeply into the belly. Use long slow breaths, either in and out through the nose or in through nose, out through the mouth. Expand your belly with each breath. Hold for a few seconds between inhalation and exhalation. Then begin breathing into different muscles. Again, hold a few seconds, then release. Allow the muscles to unwind. Where ever you hold tension will begin to release and contract. It will feel like waves through the musculature. You may cramp a bit, but if you relax and breathe into the cramp, eventually it will release. The cramps can be painful though. If it is too much, stop and shake it off before beginning anew. The goal with this exercise is to wake the muscles, unwind the tension of immobility, and to reacquaint yourself with the muscles in your body. As you progress and get deep into the musculature, the changes can be profound and exhausting, so start and progress slowly. Begin with only a few minutes (5-10) at a time, one or two days per week. Increase with a few more minutes each time. For me, a good session takes ~45 minutes. I do this once only every few weeks because that is the pattern that works well for me. You may find you need to do this more frequently.
- Bracing. The ability to create and hold intra-abdominal pressure (IAP) is a more advanced movement and I would not recommend it until one has mastered, and can easily tolerate, the other exercises. Once you are ready, take a big breath into the belly, expand the belly out forcefully in all directions and hold for a few seconds and then release. Rest and repeat. It is a simple, but taxing exercise. This type of breath control is used when lifting heavy weights but I believe it can be useful as a standalone or with some of the contraction exercises below to increase mitochondrial conditioning.
Getting to the point where you can manage deep breathing may take some time if you have been chronically deconditioned. Give your body the time it needs build tolerance. The best way to do that is to create and maintain a schedule and perform a set length of time and number of reps/breaths for each exercise. If you plan this in advance, you are more likely to perform the exercises. Track your responses, especially in the beginning. You may need to adjust the rep scheme downward if you began to aggressively. That is okay. We begin where we are now and not necessarily where we want to be or think we should be.
When you feel comfortable at a certain level, increase the reps in each session and/or the number of sessions. Then hold at this new level until you feel comfortable again. Rinse and repeat. Importantly, you can and should do these exercises regularly even after you are back to more traditional exercise. They will help maintain proper breathing and recovery.
The other component of mitochondrial exercise is muscle contraction. Recall from the last article that contraction of the soleus muscle in the calf over an extended period of time improved systemic oxidative phosphorylation – the process by which energy/ATP is made in the mitochondria. This means that simply contracting muscles improved mitochondrial energetic capacity. That is remarkable and we can use that finding to retrain our mitochondria to make energy more efficiently. All we need to do is contract muscles, regularly and repeatedly.
You can do these exercises laying or sitting and begin with whatever rep scheme is comfortable. If you have been bedridden, begin these exercises while laying bed, with a goal of progressing to doing these in the seated or even standing position. As with the breathing exercises, make a plan and stick to it. Designate at what times during the day you will do the contractions, how many contractions, which muscles and with how much rest between. Evaluate your progress after a few days and adjust accordingly.
Begin with what you can handle easily and without stress. If it is only 10 reps, do only 10 but repeat across the day – 10 reps every hour or every two or three hours, whatever makes sense for your body. Just begin and be consistent and then gradually increase over time.
I would begin with calf contractions as the research above suggested, either a set number of reps for each calf, together or independently, or for a set amount of time. For example, you may do 10-15 contractions to begin with and increase that number over time and/or you may do as many contractions as you can for a set amount of time – say 15 seconds and then increase the interval over time. If you are seriously deconditioned, I would recommend doing rep sets first and for a while before switching to intervals or AMRAPs (as many reps as possible).
While the research involved the contraction of the soleus muscle, I would think that contracting other muscles would be beneficial as well. So over time, perhaps add a few thigh contractions or glute contractions, perhaps move up to the abs, the pecs, the various muscles in the back and/or the biceps and triceps. Start with what you can handle without stress and without crashing and just hold there for a while to build up capacity. Then increase, hold, and repeat.
In many regards, it doesn’t matter where or how you begin, just that you begin contracting some muscles. The mitochondria need these signals to make more energy. The goal of these exercises is to progress to hundreds of reps across the day, first laying, then seated and then standing. This may take months, so be patient.
More Advanced Movements
When you progress to seated contractions, do heal raises with the calf contractions, extend your legs with the quad contractions, mimic a curl with the bicep contractions or extend your arm with a triceps extension. Similarly, as you progress, you may decide to activate the abs more aggressively. While laying on your back, place your feet heel to heel/toe to toe in a butterfly position. Interlace your fingers behind your head and slightly lift your head and hold for a few seconds. You should feel the abs contract all the way down to your pelvic. A more advanced glute and hamstring exercise, hip thrusts, requires that you simply raise your hips from the ground and hold. If it is comfortable, roll over on to your belly and curl your hamstrings or extend all fours and raise up into a superman position. At each step though, increase the reps and exercises slowly. Hold at a particular exercise/rep scheme until your body adapts before expanding the number of exercises or reps.
Initially, I would begin performing the muscle contractions separately from the breathing exercises, but as you progress with the breathing exercises and the muscle contractions, you might find it useful to combine an inhale with a contraction, hold, and exhale for a small portion of the reps each day. You might also begin to consider adding bracing exercises where you breathe into the belly and hold while performing the contraction(s), only to exhale when finished. Doing this will prepare your body to hold weight more effectively.
Once again though, take everything slowly and be thoughtful about your efforts and progress. Give your body rest and grace when it needs it. It makes no sense to go into this too hard and too fast only to crash. Reconditioning takes time. Conversely, give it a push when you think you can handle it. Over time, there will be improvements, and eventually, you will be able to do more with less effort. When this happens, extend the exercise into everyday tasks, add bands to the program and maybe even light weights.
Is This Really Exercise?
Some of you might be thinking that these exercises are too simple and too easy to be considered exercises at all, especially if you were active or an athlete before becoming ill. Admittedly, they are simple and performing them at a pace that will allow your body to adapt and heal will be tedious and may be excessively slow, but these movements are the backbone of any exercise. Breathing and contraction are the two most fundamental aspects of exercise. This is at the root of mitochondrial function – oxygen and nutrient flow. That is what we are going for. If we can get those two things operating favorably, we can build additional capacity over time.
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