31 May 2013

My best shoes ever?

This week I got my new Salomon Sense Ultra shoes. It was like Christmas Day to open the box and so far it is the best running shoe I have ever experienced despite my extremely high expectations.


I am not alone in this notion and there have been a number of other really comprehensive reviews published in various blogs and magazines, for instance Irunfar, Runblogger, Swedentrails, Runningshoeguru, Sagetosummit, Trailrunnermag, Running trails. The only drawback is that the shoes feels a little bit stiff on pavement and hard flat surfaces. They have also made me run too fast, I have repeatedly had to slow down when I looked at the watch and saw that I was running under 4 min/km when I thought I was doing around 5 min/km. I am considering to use my Salomon Sense Ultras as the main shoe for TDG – perhaps a daring move considering the distance. However, I have always preferred light shoes and in my teens I used to compete in cross country races like Lidingöloppet (30 km) in my track and field shoes with spikes. Growing older I started to use more protective shoes until last year when I for instance ran La Boucle at Trail Verbier St-Bernard (TVSB) in Salomon Fellcross. They were great, however quite unforgiving for my toe nails (lost two of them post-race) and the excellent fit of Sense Ultra make me less concerned about this. Before making my final decision I will test the shoes in more mountainous terrain and on technical step trails like the ones in the Aosta Valley. And, for running to and from work on mostly hard flat surface I will use other shoes and spare my Sense Ultras for the real challenges.
On another note - it is now less than 100 days left to Tor des Géants I realized this morning.

27 May 2013

Running use disorder - is ultramarathon running an addiction?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published earlier in May at the American Psychiatric Association (APA) meeting in San Francisco. The criteria in DSM is widely used for diagnosis of mental disorders in both the US and other countries and recognized both by health authorities, insurance companies and industry. Obviously, there is a large debate about the criteria, in particular as there tends to be a lot of varying opinions regarding these disorders. This debate tends of course to be louder just when the criteria are updated.

One of the new diagnoses in DSM-5 is “substance use disorder”, replacing former “substance dependence” in the previous DSM-IVTR classification. I entertained myself this morning with trying to diagnose myself whether I had a “running use disorder” according to the new criteria. DSM-5 specifies the severity of the diagnosis “use disorder” depending on how many of 11 symptoms that are fulfilled; 2-3 symptoms mean a mild disorder, 4-5 a moderate and over 6 a severe disorder. I fulfilled 9/11 criteria for having a “running use disorder”. I cannot reveal the criteria here due to copyright issues, but I can definitively say that I have cravings for running, experience withdrawal when not running and have developed a tolerance for running. I also spend a great deal of time running, I sometimes run in physically hazardous situations and I continue to run despite having physical pain and I am always on the borderline to develop use injuries due to my running.

It was running despite the risk to develop injuries that made me think about the analogue between running and substance abuse. Last season I suffered periodically of Achilles tendinopathy of in particular my right ankle. The symptoms did not prevent me from racing as planned and to gather my points for the UTMB, but they made it necessary to adjust my training periodically and avoid very long training runs. Yesterday I was out for a 14 mile (23 km) run with the last 7 miles on a relatively flat and hard surface and last night I felt pain in my Achilles tendon again. It went fine running to work this morning, but I will now have to be more vigilant on my symptoms and not to run to fast in particular during these longer runs.

There was recently a study published by Nielsen and colleagues discussing the classification of running-related injuries based on volume or pace errors (Nielsen et al. Int J Sports Phys Ther 2013; 8:172-9).

From Nielsen et al. 2013 based on Taunton et al. Br J Sports Med 2002; 36:95-101.
 The authors review the evidence that a change in running pace may be associated with the development of achilles tendinopathy. From my personal experience I think it is much truth in this, however, there are certainly other risk factors involved for myself despite a too high pace; for instance sex (male), age (early 40’s), shoes (yesterday I used light trail shoes without much stability) etc. A recent review about the risk factors can be found in Munteanu & Barton J Foot Ankle Res 2011; 4: 15. Both the incidence and prevalence of Achilles tendinopathy among ultramarathon runners appears to be around 10% in several studies so I am certainly not the only one struggling with this. And I am certainly not the only one being classified with a “running use disorder”.

23 May 2013

To use or not to use trekking poles during ultramarathon running?

There is an ongoing debate about whether to use trekking poles during ultramarathon running or not. The proponents of using poles argue for instance that poles are beneficial as they:

1) offer relief of knees and quads in particular when going downhill;
2) improve posture and help propel the motion going uphill;
3) help eliminate hand swelling in long races;
4) increase balance and stability on technical trails (in particular if you have a tendency for vertigo);
5) help disburse weight when running with a backpack;
6) aid in water crossings; and
7) establish and maintain a natural rhythm/cadence for forward motion.

The opponents of using poles argue on the other hand for instance that poles:

1) increase use of mental energy as they require focus to not drop and where to put and place;
2) is a safety risk when you fall;
3) lead to abrasion of hand grips and require you to wear gloves;
4) is a hassle as your hands are not free;
5) adds to the weight you need to carry during the race;
6) increase total energy expenditure during the race as you have to carry more weight and use your arms and upper body more during running; and
7) is for old people and wimps.

Looking into the scientific literature about poles there is again no clear good studies to convincingly show benefits for a race such as TDG or UTMB. Nevertheless, there is clearly no studies showing that using them would be harmful and there are a number of studies indicating possible benefits.

In an interesting study by Howatson and colleagues 37 volunteers made the ascent and descent of Mount Snowdon with a day pack having either poles or no poles. The group having poles had significantly less rating of perceived exertion (RPE) during the ascent, showed attenuation of reductions in maximal voluntary contraction immediately after and 24 and 48 h after the trek, delayed onset muscle soreness (DOMS) was significantly lower at 24 and 48 h after the trek, and creatinine kinase (CK) was also lower at 24 h after the trek (Howatson et al. Sci Sports Exerc 2011; 43: 140-5).

Another study by Bohne and Abendroth-Smith of 15 experienced hikers carrying varying loads going downhill showed a reduction of the sagittal plane moment at the ankle, knee and hip joints in the lower extremity with pole use. Reductions were also observed in the peak power absorption for the ankle and knee. These results held true across pack load conditions (Bohne & Abendroth-Smith Med Sci Sports Exerc 2007; 39:177-83). The reductions in the joint forces is supported also in studies by Schwameder and colleagues in downhill (25% decline) movement (J Sports Sci 1999; 17:969-78) and Willson and colleages, where also the use of poles enabled subjects to walk at a faster speed with reduced vertical ground reaction forces, vertical knee joint reaction forces, and reduction in the knee extensor angular impulse and support moment (Willson et al. Med Sci Sports Exerc. 2001; 33:142-7).

 A study by Saunders and colleagues showed increased energy production (V02 and heart rate [HR])  in 14 hikers when wearing poles during a hilly course without any increase in RPE (Saunders et al. J Strength Cond Res. 2008; 22: 1468-74). Opposite results were found by Foissac and colleagues when 11 subjects were walking at a fast pace uphill on a treadmill inclined at 20% degrees. In this study no increase in VO2 max with poles weighing 360 grams could be observed. In this study there was however a marked redistribution of muscle recruitment as poles significantly reduced lower limb muscle aEMG values by about 15% and increased upper limb muscle aEMG values by about 95%, mainly due to more activity in the biceps brachii and anterior deltoid (Foissac et al. Med Sci Sports Exerc. 2008; 40:1117-25). Another uphill treadmill study showed a small increase in heart rate with poles, but alleviated some stress from the lower extremities leading to lower stride lengths and lower RPE (Knight and Caldwell Med Sci Sports Exerc. 2000; 32:2093-2101). Yet other studies showed neither no increase in HR nor energy expenditure with poles, but a lower RPE (Jacobson & Wright Percept Motor Skills 1998; 87: 435-438; Jacobson et al. Int J Sports Med 2000; 21: 356-359). A relatively recent study comparing energy expenditure during walking with poles either uphill, level or downhill at a treadmill in 12 volunteers found that the use of hiking poles appeared to increase energy cost (EC) , V02 and ventilator response (VE) only during downhill walking (Perrey & Fabre J Sport Sci Med 2008; 7: 32-38). This study found no effect of poles on HR.

In summary these results indicate that using poles might be beneficial both during the race and afterwards in particular for uphill terrain, but that the energy expenditure might be increased during downhill running with poles. Not surprisingly, however, a study of 15 volunteers showed an increase in balance when using two hiking sticks compared to one and that using one stick was superior to using none (Jacobson et al. Percept Mot Skills 1997; 85:347-50) and this might be important when running downhill in technical terrain. More studies are clearly needed in this area.

I have been using poles for some of my runs, and for me they are indispensable for longer technical runs like TDG. I use them more for uphill terrain than downhill, even though I appreciate the support during technical downhill when I cannot run that fast. I am currently using Black Diamonds Ultra Distance Carbon Poles as they are both light (265 grams for a pair of 110 cm long poles) and sturdy (being made in Carbon). There are lighter poles available from Raidlight (Trail Poles 240 grams for a pair of 110 cm long poles) and Mountain King (Trail Blaze 230 grams for 110 cm long poles), but they are or at least appear less stable as they are made in alloy. Leki Traveller Carbon poles has the advantage of having a continuously variable length between 90-130 cm and they are also sturdy, but the heavier weight (338 gram per pair) made me choose the Ultra Distance Poles.  The drawback with the Ultra Distance poles is that you need to settle for a fixed length and I have chosen quite short ones as I use them mainly for uphill running, but they are very light and quickly foldable if not used. So, my personal answer to the question to use poles or not is certainly yes for a race like TDG.

I am continously searching for new studies on the use of trekking poles for running and I will update the blog continously with new posts linked here:

21 May 2013

Lower body compression garments

Another excellent running week. Finally it has been, at least in terms of Swedish standards, summer temperatures in the high 60’s (20°C). In order to get more miles in my legs I have started to run to and from work, a distance of around 4.5 miles (7.5 kilometers) in one direction – that gives a good basic foundation of around 45 miles (75 kilometers) per week to add to some long distance runs in the weekends and some technical hill runs in late evenings during the weekdays.
I have started to prepare for Tor des Géants also in terms of thinking about equipment, clothing and shoes. I am, as noted before, very happy to have been able to initiate my first collaborations with different companies having products I would like to try and believe in. The first company I approached was 2XU regarding compression clothing. I started to use their compression garments, in particular socks and calf guard sleeves, last season and have found them very helpful. In other words, I clearly believe they will help me both in the preparations and during the actual race. In particular for an extremely long race such as TDG I think lower body compression will be important. Regretfully, there are no good studies of the effect of compression garments on very long endurance activities. For shorter runs, up to one hour, there are more and more studies indicating positive effects such as for instance:
1)      Prevention of swelling and increase in leg volume (Bovenschen et al. J Athl Train 2013; 48: 226-232)
2)      Maintenance of lower limb muscle power measured as post-run counter movement jump (CMJ)/vertical jump performance (Rugg & Sternlicht J Strength Cond Res 2013; 27: 1067-1073; Ali et al. J Strenght Cond Res 2011; 25: 1385-1392; Jakeman et al Eur J Appl Physiol 2010; 109: 1137-1144; Davies et al. J Strength Cond Res 2009; 23: 1786-1794 [muscle damage in studies by Jakeman and Davies induced not by running but by plyometric drop jumps])
3)      Reduction in delayed-onset muscle soreness (DOMS) 24 hours after a 10-km road run (Ali et al. J Sport Sci 2007; 25: 413-419)
4)      Lowering of blood lactate concentration after exercise (Lovell et al. J Strength Cond Res 2011; 25: 3264-3268)
5)      Increase in calf tissue oxygen saturation (StO2) (Ménétrier et al. Int J Sports Med 2011; 32: 864-868)
6)      Lowering of heart rate during high-intensity running (Varela-Sanz et al. J Strength Cond Res 2011; 25: 2902-2910; Dascombe et al. Int J. Sports Physiol Perform 2011; 6: 160-173)
7)      Lowering of rate of perceived exertion (RPE) in submaximal running in heat at 32°C (Goh et al. Eur J Appl Physiol 2011; 111: 819-826) or at 400 meter running tests (Faulkner et al. J Strength Cond Res 2013; 27: 669-676)
8)      Lower energy expenditure measured as VO2 slow component difference at a submaximal running pace of 80% of maximal VO2 for 15 minutes (Bringard et al. Int J Sports Med 2006; 27: 373-378)
9)      Improvement in running performance/velocity (kmxh) measured at both the anaerobic and aerobic thresholds  (Kemmler et al. J Strength Cond Res 2009; 23: 101-105)
On the other hand there are several studies indicating limited effects of compression garments worn during running, in particular with regards to overall running performance (see for instance Barwood et al. Int J Sports Physiol Perform 2013; In press; Dascombe et al. Int J Sports Physiol Perform 2011; 6: 160-173; Sperlich et al. Phlebology 2011; 26: 102-106; Sperlich et al. J Sports Sci 2010; 28: 609-614; Ali et al. Eur J Appl Physiol 2010; 109: 1017-1025). It is important to bear in mind that, compared to studies designed to investigate the efficacy and safety of new drugs and interventions in health care, none of the studies in this area is of a particular high quality and should best be denoted as pilot studies opening up for more scientific research in the area. There is neither no standardization in measurements between studies and the data is therefore even more heterogeneous and fragmented.  And, as mentioned, there is a complete lack of studies to my knowledge regarding effects of wearing compression garments during mountain races like TDG or UTMB. Good recent reviews of the effects of compression garments is Born, Sperlich & Holmberg Int J Sports Physiol Perform 2013; 8: 4-18 and MacRae, Cotter & Laing Sports Med 2011; 41: 815-843.
Importantly, however, there have to my knowledge been no studies showing major negative effects of wearing lower body compression garments during running. Intuitively, looking at my swollen legs after an ultramarathon, I think in particular calf compression might be very helpful in reducing this swelling and reduce muscle damage through reducing oscillations. And, even more importantly, once used to wearing compression garments they are really more comfortable. I have tried various brands and the one most comfortable for me is 2XU. This notion is shared by for instance another ultrarunner blog where there is a good review of different brands of graduated compression garment

13 May 2013

A good week and weekend

This has been a very inspirational weekend for ultrarunners. I followed the Transvulcania race live over the net yesterday and it was nerve wrecking almost to the end in both the men’s and women’s competitions. In the men’s race excelled Kilian Jornet and won despite just having started the running season. In the women’s race the new Swedish superstar Emelie Forsberg won her first ultra competition in the skyrunning series, also without many miles in her legs so far this season.  I also followed the 10th IAU 24 Hour World and 19th European Championships in Steenbergen over the net. If it was hot in La Palma during Transvulcania it was cold and rainy in Steenbergen and it might have affected the distances covered. There were several Swedes that made good results, among them Andreas Falk and Sandra Lundqvist.

It has been a reasonably good week for me as well with regards to running. I have started to focus on technical up and downhill running. To cover more distance, while fitting it into a hectic schedule of work and family life, I have started to run to and from work. I have also established my first collaborations with sponsors before Tor des Géants. I am very happy to be able to collaborate with 2XU regarding compression clothing, Enervit regarding nutrition and Salomon regarding shoes. I will describe the individual products in more detail further on in the blog.

04 May 2013

Sightseeing trough running

Washington D.C. is a really lovely city for running – I am staying next to Capitol Hill and have been able to run down to and across Potomac River two afternoons/evenings in a row. Going quite slowly it is a run of one hour along the National Mall and Constitution Gardens and in that time you pass all major sights like the US Capitol, Washington Monument, the White House, the WWII and Vietnam Veterans Memorial, Lincoln Memorial and Arlington Memorial Bridge.

U.S. Capitol

The White House
The only negative thing is that it is quite flat. However, I did manage to run uphill again for an hour this morning on the treadmill before sunrise and my meeting started with breakfast. Surprisingly, my legs feel despite three good exercises the past day very fine tonight.

02 May 2013

Jet-lag, sleep deprivation and ultramarathon endurance running

I am writing this on the airplane back to the US for my next business meeting after a few days of vacation in Paris. I can definitively say that my normal sleep-wakefulness cycle have been disrupted due to the long-haul flights over multiple meridians the past few days - even though I fear my jet lag will be even worse when I return to Sweden this weekend.

A great review paper describing the influence of sleep on physical performance was written a couple of years ago by Reilly and Edwards (Physiology & Behavior 2007; 90: 274–284). The most extreme experiments have been performed with total sleep deprivation for several days. Consistently in many studies, continuous physical activity for around 100 hours leads to marked impairment in particular in mental performance such as reaction time and short time memory already after one night followed by progressive deterioration. Over time, bizarre behavioral episodes, illusions (visual, auditory and olfactory) or hallucinations are often noted. Interestingly, the decline in mental performance is more pronounced than the one in physical parameters and a meta-analysis of sleep deprivation done by  Pilcher and Huffcutt (Sleep 1996; 19: 318–26) showed that showed that mood measures were more sensitive than cognitive tasks, which were, in turn, more sensitive than motor tasks during sleep loss. The same observations have been seen with for instance military battle combat units and long-distance sailors experiencing chronic/partial sleep loss over several days where only minimal amount of sleep each night is allowed. It appears limited loss in VO2 is seen at work rates up to 80% VO2 max, but that the effect on mood states, increasing depression, tension, confusion, fatigue and anger, and decreasing vigour were seen The data collectively can be interpreted as supporting Horne's brain restitution theory of sleep, suggesting that the primary need for sleep is located in nerve cells rather than in other biological tissues (Why we sleep. Oxford: Oxford University Press; 1988).

Reading these articles, and some of the blogs and accounts of previous TDG finishers, I know what to expect in September – however everyone is different and it is going to be interesting to see how I personally react to this amount of sleep loss. I will try to experience at least one long training run for several days with limited amount of sleep before TDG to see how I react and how I can use power naps in order to manage. The only consistent factors showing benefit in studies of prolonged sleep deprivation is napping and caffeine.

In less extreme cases of sleep deprivation, such as nocturnal shift work and traveling across time zones, I on the other hand have plenty of experience and know how I react both physically and mentally. When I started my residency in orthopaedic surgery many years ago I of course quickly noticed noticed that I had to be vigilant and be really perceptive in the ER and OR as my attention span decreased, my rate of errors increased, my performance in perceptual-motor tasks was decreased and, perhaps most notably, my mood regretfully changed quite markedly. I could, however, still go out for a run when I left my shift in the mornings and perform. Nevertheless, I quite quickly adapted and got used to working night shifts and actually enjoyed it quite much as I never experienced the constant light-headedness many of my colleagues did. I am neither too much affected by flying over the Atlantic as I do much now, however, I can certainly not say I like it. For short trips like this to the US East Coast I normally use training in order to stay as much as possible in my normal time zone as I go up very early in the morning and go the hotel gym. Sometimes it does not work, however, as I have dinners like today where I have to stay up late. I really do hope to have time for a short run on the treadmill before that.