31 January 2014

Is it more important to be physically or mentally tough to run a mountain ultramarathon? Mental strategies to overcome the heights and distance

I saw a blog post on the Adventure Blog discussing whether it was more important to be mentally or physically tough to climb Mount Everest. The blog post refer to another post by Alan Arnette asking the same question. It is a brilliant post by Arnette vividly describing the difficulties on each step up to the summit. However, I was a little disappointed as it really does not try to answer the question, instead Alan simply says you need both and to be in balance. Yes, that is of course true, but what is most important and can you overcome physical weakness with a superior mental strength and strategy or is it vice versa? He also only focuses on the way up to the top, while I think, and sadly enough statistics on mortality on the mountain prove me right, that the way down is even more challenging.

Mount Everest
Nevertheless, reading these posts led me to remember an article I read a couple of years ago by Burke and Orlick entitled “Mental strategies of elite high altitude climbers: Overcoming adversity on Mount Everest” published in J Hum Perform in Extreme Environments 2003; 7: 4. In this article they describe a study where they performed in-depth interviews of ten climbers who had reached the summit of Mount Everest at least once. In the interviews they identified various mental strategies to overcome the adversities of the extreme environment both during the ascent and the descent. During the ascent they revealed that the climbers relied on focus (10 out of 10 climbers), short-term goal setting (8/10), feeling support from other climbers (4/10), drawing on past experiences (4/10), belief in personal capacities (4/10), connecting with one’s body (6/10). During the descent the climbers highlighted focus (10/10) and short-term goal setting (5/10) as the most important mental strategies as they really are exhausted. A general comment from the climbers was that success on Mount Everest is 70% mental. Not surprisingly, the authors use the findings in this study as support for Orlick’s own theory about the Wheel of Excellence based on interviews with world-class elite athletes. The seven elements of excellence in this model include commitment, belief, positive imagery, mental readiness, full focus, distraction control, and on-going learning. His website about the Wheel of Excellence is really interesting as it contains plenty of inspiring and thoughtful interviews with high performing individuals published in the Journal of Excellence where he is the editor.

Asking the same question whether it is more important to be physically or mentally tough not when climbing Mount Everest but to run a mountain ultramarathon there are no studies to refer to. There are however plenty of studies of mental coping strategies during running in general. A good recent review is “Do 'mind over muscle' strategies work? Examining the effects of attentional association and dissociation on exertional, affective and physiological responses to exercise” by Lind and colleagues published in Sports Med 2009; 39: 743-764. As the title says, the article focuses on different dissociative (for instance listening to music while running) or associative (for instance focusing on the breathing or heartbeats while running) strategies. I will write more about this in a later blog post, but the current research tend to favor association as a better coping strategy to avoid to “hit the wall” during long endurance events, at least when racing, and this is also my personal strategy for the most part, even though I put on some music for instance some of the nights during TDG. A very interesting recent article I read was about the positive effects of “self-talk” on endurance performance by Blanchfield and colleagues in pre-print in Med & Sci in Sports & Exercise.

It is clear that we use mental strategies to control the physical strain and there are indications that this is more important during longer running than shorter (see for instance “How do humans control physiological strain during strenuous endurance exercise?” by Esteve-Lanao and colleagues in PLoS ONE 2008; 3: e2943). There is also a lively debate about the so called central governor model of regulation of fatigue proposed by primarly Timothy D Noakes (see for instance “The central governor model of exercise regulation applied to the Marathon” in Sports Med 2007; 37: 374-377). My personal view is that, albeit physical preparedness is essential to complete a mountain ultramarathon, mental toughness is more important both while training before and during the actual race.

27 January 2014

Fear of heights (Acrophobia) and mountain running

Is it possible to run a mountain trail race or skyrunning race when having acrophobia (fear of heights)? I discussed this with a colleague over lunch today and we had contrasting views. He thought it impossible, while I am quite convinced that it is possible to run a quite technical mountain trail, including exposed rope sections, while having moderate acrophobia. Acrophobia can differ in severity, but in most cases is manifesting with for instance inner agitation, a queasy-stomach feeling, subjective postural instability with to-and-fro vertigo and weakness in the knees. Fear of heights was described as early as in the Greek Corpus Hippocraticum in the 5th century BC with “a worsening of eyesight and a feeling of uneasiness when walking along the edge of a precipice or over a bridge”.

I would not say that I am severely afraid of heights, but I have noticed that my pulse is elevated on exposed mountain sections and that I have a queasy feeling and even somehow slow down my locomotion and restrict my visual exploration. This is different from when I grow up when one of my favorite pastimes was to climb quite high trees. I had a summer treehouse in a tall pine tree at a height of around 20 meters and never felt any fear of heights. Looking at the epidemiology of acrophobia I noticed that some kind of fear of heights is very common. A cross-sectional epidemiological study of 3,517 individuals representing the German population by Huppert and colleagues entitled “Down on heights? One in three has visual height intolerance?” published in J Neurol 2013; 260: 597-604 indicates a lifetime prevalence of 28% and a higher incidence of the initial attacks during the second decade. The severity of the visual height intolerance (VHI) can vary considerably, but in up to half of the cases it can restrict daily activities. Brandt and Hubbert has recently also published a good overview of acrophobia entitled “Fear of heights and visual height intolerance” in Curr Opin Neurol 2014; 27: 111-117.

Has my objective symptoms of acrophobia restricted my running in the mountains? No, I think on the contrary it has made me even more stimulated by it as it is a great feeling to get the adrenaline rush and overcome it. I might be a little bit slower over some sections and I can be a little bit more cautious, but in general I think it is more stimulating than restricting. One dream which would really give me an adrenaline rush would be to walk to the teahouse on the South Peak of Mount Hua Shan in the Shaanxi province of China on what is known as HuaShan Plank Path or Cliffside Path Walk. Just check the pictures at this blog or this Youtube video.

HuaShan Plank Path

Another thing I long to do is to visit the new attraction Pas dans le Vide or "Step into the Void" at Aiguille du Midi over Chamonix in the Mont Blanc Massif. Apparently it took 3 years to build this spectacular, albeit somewhat touristic, attraction. Check out these pictures or this Youtube video.

Pas dans le Vide

Most of all, however, I am looking forward to PTL in August and the technical passages at that race.

21 January 2014

Altitude effect on running compared to cycling

One of the really good sources for news and updates on ultrarunning is Ultrarunnerpodcast. Today they provided a link to an interesting post from Alex Hutchinson in Runner's World about how altitude affects running compared to cycling. There are planned efforts by Fabian Cancellara to set a new 1-hour distance record in cycling, beating Sosenka’s record of 49.7 kilometers from 2005. Quite surprisingly, it would according to the post be more beneficial to do this at such a high elevation as 3000 meters. In running, the classical paper by Péronnet  and colleagues entitled “A theoretical analysis of the effect of altitude onrunning performance” published in J Appl Physiol  1991; 70:399-404, clearly shows that  even for such a short distance as 800 meters an increase in altitude would be disadvantageous (see figure). It would be interesting to compare endurance long-distance cycling with ultrarunning with regards to the same theoretical perspective of altitude.

From Péronnet et al. J Appl Physiol 1991; 70: 399-404

20 January 2014

Objective dangers, death and serious injuries through accidents on the mountain trails – how dangerous is mountain running and skyrunning?

I have had a though start of 2014 from a runner’s perspective. While skiing in Åre, the largest Swedish ski resort, I was hit by a snowboarder from behind when I was skiing down a rather icy and steep piste/slope. I thought I was skiing fast, but apparently the snowboarder was either faster, or, more likely, had less control. Anyway I was hit on my right leg and I must have twisted my leg as the right ski binding released even though I did not fall.  I did not feel a lot of pain right at the moment, I guess due to the adrenaline rush, but when I had come halfway down the slope after putting on my ski again it started to feel bad in my right knee. Fearing a serious knee sprain I stopped skiing for the day and, as my knee was not very painful and not swollen the following morning I went up with the cabin to the mountain high zone to ski again. It then felt really bad, however, so there was no skiing that day either and the following day my knee was so swollen and painful that I barely could walk. I went to the local primary care physician/general practitioner office and as Åre is in a ski resort they have both clinical experience and a fairly modern x-ray facility. Luckily, there were no broken bones or torn bone fragments from a ligament rupture (see X-ray picture), and the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) and the medial part of the knee appeared to be intact and stable. However, I had so much pain in the posterolateral corner of the knee that it was difficult to examine. There appeared however luckily not to be a complete avulsion of the popliteus muscle tendon or the arcuate ligament (popliteofibular ligament, fabellofibular ligament, popliteomeniscal fascicles, capsular arm of short head of the biceps femoris and anterolateral ligament). The swelling and pain has since last week subsided considerably and I have now started to bike to work and work on rehabilitating the knee. I was on a follow up visit with an orthopedic surgeon specialist in the end of last week and in the worst case scenario there is a damage to the lateral meniscus and I am now waiting for an Magnetic resonance imaging (MRI) of the knee. Anyway, it felt so good this weekend so I could not refrain myself from putting on my running shoes and go for a slow run in the snow which has now finally come to Uppsala as well.

The plain X-ray looks good - now waiting for the MRI

Being through a comparatively benign accident like this I started to think about how lucky I have been to never have injured myself through an accident while running. I have rarely even experienced a sprained ankle. Also thought about my wife who was in a serious car accident being hit by a large truck the past weekend; she was thankfully unhurt but our car was completely demolished. Thinking back to Tor des Géants (TDG) last year where the Chinese trailer Yuang Yang died during the first night of the competition as he fell descending Col Crosatie and sustained a head injury I wondered how common serious adverse events like that are in mountain trail running and skyrunning. Not surprisingly, I could not find any good studies on incidence, prevalence or mortality from accidents in mountain running. That they do exist is evident from tragedies similar to the one happening at this year’s TDG. Notable examples in recent years are for instance the tragedy at the Grand Raid du Mercantour in France in 2009 when the three runners  Christine Gaussin, Hervé David and Philippe Burdin died of hypothermia after supposedly falling down a grassy slope at an altitude of 2,300 meters after being caught in a violent snowstorm; the similar death of hypothermia after a fall of Brian Belfield when he was competing in the Buttermere Sailbeck Fell Run in the UK in 2012; the strange disappearance and supposed death by a fall or similar accident of Michael LeMaitre in the 5 kilometer (3.1 miles) long Mount Marathon Race in Seward, Alaska in 2012; and the fatal fall of Thierry Delaprez over a cliff at a technical section of Le Grand Raid Réunion/ La Diagonale des Fous in 2012.
The best recent study of injury rates in ultramarathon runners is probably the study by Krabak and colleagues  entitled “Study of injury and illness rates in multiday ultramarathon runners” published in Med. Sci. Sports Exerc. 2011; 43: 2314-2320. In this study they prospectively followed 396 runners competing in the RacingThePlanet© 4 Desert Series of ultramarathon races from 2005 to 2006. A total of 1173 injuries/illnesses were observed with 1111 (94.7%) considered to be minor in nature. Of the 62 (5.3%) major injuries/illnesses, resulting in a runner discontinuing the race, most were due to medical illnesses (58%) and less likely to involve a musculoskeletal injury (22.6%) or skin disorder (19.4%). There were no deaths or serious accidents.
From Krabak et al. 2011

In another study by Fallon entitled “Musculoskeletal injuries in the ultramarathon: the 1990 Westfield Sydney to Melbourne run“ published in Br J Sports Med 1996; 30: 319-323 did not observe any serious injuries in the 32 runners followed, but a great number of non-serious issues due to the strenuous activity, in inflammation of the particular the extensor retinaculum at the anterior aspect of the ankle ("ultramarathoner's ankle"). Comparing the studies in ultramarathon running with studies in regular marathon shows, not surprisingly, a similar trend in serious illness and death due to medical issues and a study by Mathews entitled “Mortality among marathon runners in the United States, 2000-2009” published in Am J Sports Med. 2012; 40:1495-1500 identified 28 people (6 women and 22 men) who died during marathon races among 3,718,336 total participants over the 10-year study period. The overall male and female death rates for the 10-year period were 0.75 (95% confidence interval [CI], 0.38-1.13), 0.98 (95% CI, 0.48-1.36), and 0.41 (95% CI, 0.21-0.79) deaths per 100,000 finishers, respectively.
There are no studies of mountain and trail running and I would perhaps expect a lower mortality rate due to cardiovascular illnesses as I expect the participants to be more experienced, fit and physically prepared for the races. There will also be a lower risk compared to high altitude climbing and other activities in the mountains. However, there will always be a certain risk for serious injuries and deaths due to the objective dangers also in mountain running and I fear that this risk might increase as the races tend to be more popular and the trails more spectacular. After all, the mountain environment is something to really respect even at the moderate altitudes of 2000 to 3000 meters common to many mountain marathon races and also at even lower altitudes it might be a challenge to pass a cliff in bad weather or when you are tired. Despite the best safety precautions by the race organizers and it comes down to the personal judgement and decision by the runner and even luck. After TDG last year I personally have begun to look at the races like I would climbing a summit and try to live after Ed Viesturs words: "Reaching the summit is optional - Getting down is mandatory".