28 March 2014

Déjame Vivir – A new epic and amazing film from Kilian Jornet’s Summits of My Life project

Truly epic and absolutely amazing. I think of birds living their lives completely free and flying over the mountains when I see Kilian, Emelie, Bruno and the others in this film pass over the summits. I really liked the first Summits of My Life film A fine Line, but this is something else entirely, a wonderful collection of love to not only the mountains and running, but to life. Further words from me unnecessary, just get the film from the Summits of My Life webstore and judge for yourself. If you anyway want to read a comprehensive review Megan Hick just posted one at the Irunfar webpage.

26 March 2014

Acute kidney injury (AKI) following endurance running – Is ultramarathon running really healthy?

It is now a time in passing, in between the winter and spring, with cold clear weather and hard dry roads and trails. I am still tired since my trip to Canada last week and have difficulties finding the right geist so even running feels automatic and as a too long wait for something else.

Passing of a hill on my way to work

I tried to motivate myself by reading some interesting articles in the past days and they have led me to ask whether ultramarathon running is really healthy. The short answer is that we do not know. There are still no good prospective long-term studies of ultramarathon runners looking at morbidity and mortality. A large study called the Ultrarunners Longitudinal TRAcking (ULTRA) study has recently started with Dr Marty Hoffman at VA Northern California Health Care System and Univiversity California Davis and Dr Eswar Krishnan  at Stanford as the principal investigators.  The first baseline findings from this study has just been published, for instance in Hoffman &  Krishnan “Health and exercise-related medical issues among 1,212 ultramarathon runners: baseline findings from the ultrarunners longitudinal TRAcking (ULTRA) study”. PLoS ONE 2014; 9(1): e83867. In the long term this study has the potential to answer some of the more general health related questions.

The articles I have read have on the contrary argued that ultramarathon running is not healthy. These studies have looked at biochemical markers in the blood and urine of disease and organ pathologies and found highly abnormal values in ultramarathon runners following a race. That strenuous endurance physical activities like ultramarathon running lead to abnormal laboratory values has been known for quite some time, for instance reviewed by  Sanchis-Gomar and Lippi in the article “Physical activity - an important preanalytical variable” Biochemia Medica 2014; 24:68–79. What is new is the extent of the abnormality of the markers and that they involve markers normally used to diagnose for instance severe cardiac and kidney disorders. Lippi and co-workers looked at the emerging markers of severe cardiac disease and cardiovascular stress serum Copeptin and Midregion Proadrenomedullin (MR-proADM) after a 60 km ultramarathon in 16 healthy runners (Lippi et al “Serum copeptin and Midregion Proadrenomedullin (MR-proADM) after an ultramarathon” J Clin Lab Anal 2014 Epub ahead of print. They found that the serum concentrations of both copeptin and MR-proADM remarkably increased after the 60 km run, by 6.4 times (interquartile range (IQR), 2.710.4) and 2.3 times (IQR, 1.8-2.6), respectively. The percentage of subjects exhibiting values above the upper limit of the reference range in male was 0% for both copeptin and MR-proADM before the ultramarathon, but increased to respectively 81 and 63% postexercise. They authors ask based on these findings whether exhaustive exercise such as ultramarathon running might be considered globally beneficial or even safe, especially in unfit or/and untrained population. I agree fully with this question, but again, we do not know as an abnormal laboratory value by itself is not a disease. I will in a later blog post further look at what is known about the effects of running on the heart and here instead look at the real life-threatening disease acute renal failure which evidently is occurring in a small subset of runners following an ultramarathon.

I have in a recent blog post described the high risk of developing acute mountain sickness (AMS) and the less frequent, but much more severe, complications of high altitude during ultramarathon running in the mountains high altitude cerebral edema (HACE) and high altitude pulmonary edema (HAPE). A more frequent severe medical complication of ultramarathons and other endurance races is acute kidney injury (AKI) and acute renal failure (ARF). I will in this blog post look at the frequency of kidney complications of ultramarathons and how it could be prevented and treated. The related complication exercise-associated hyponatremia (EAH), which is more frequent among runners having acute kidney injury, but were treatment is contradictory, will be discussed in a separate post.

How common is acute kidney injury (AKI) in ultramarathons?

That both ultrarunning and marathon running might lead to laboratory changes indicating kidney damage has been know long, see for instance the article by Irving and colleagues entitled “Plasma volume and renal function during and after ultramarathon running” published already in 1990 in Med Sci Sports Exerc. 1990; 22: 581-7. There have been a number of articles published since then, for instance the recently published article by Lipman and colleagues entitled “A prospective cohort study of acute kidney injury in multi-stage ultramarathon runners: The biochemistry in endurance runner study (BIERS)” published in Res Sports Med. 2014; 22: 185-192. This was a prospective observational study during the Gobi 2008; Sahara 2008; and Namibia 2009 RacingThePlanet 7-day, 6-stage, 150-mile foot ultramarathons in 30 participants (76% male with a mean age of 40 ± 11 years). Kidney functional laboratory parameters Creatinine (Cr) and glomerular filtration rate (GFR) were calculated and incidence of AKI were calculated and defined by the so called RIFLE criteria. Quite surprisingly, the majority of the participants (55-80%) developed AKI and significant renal impairment after each ultramarathon with significant declines in GFR after each stage compared with the pre-race baseline (p < 0.001). Nevertheless, there was no apparent cumulative effect observed and the renal function returned to near baseline levels between stages.

The similar results were found in the study “Variation of serum and urinary neutrophil gelatinase associated lipocalin (NGAL) after strenuous physical exercise” by Lippi and colleagus in Clin Chem Lab Med. 2012; 50:1585-9. In this study creatinine and neutrophil gelatinase associated lipocalin (NGAL) in serum (sNGAL) and urine (uNGAL) was assessed in 16 trained male runners before and after a 60 km ultramarathon. Serum and urinary creatinine increased significantly by 38% and 78%, respectively. The eGFR contextually decreased by 31%. sNGAL, uNGAL and uNGAL/creatinine ratio increased by 1.6-fold, 7.7-fold and 2.9-fold. In six of 16 athletes (38%), the acute post-exercise increase of serum creatinine met the criteria of AKI.

The prevalence figures of AKI of 55-80% and 38% following an ultramarathon could be compared with the similar prevalence of grade I AKI of 40% (McCullough et al “Changes in renal markers and acute kidney injury after marathon running” Nephrology. 2011; 16:194-199), 48% (Mohseni  et al “Prevalence of hyponatremia, renal dysfunction, and other electrolyte abnormalities among runners before and after completing a marathon or half marathon” Sports Health. 2011; 3: 145-51) and 30% (Kratz et al “Effect of marathon running on hematologic and biochemical laboratory parameters, including cardiac markers” Am J Clin Pathol 2002; 118: 856-863) found after a normal road marathon. No runner in these studies developed severe AKI. The study by McCullough and colleagues is interesting as they also performed cardiac MRI measurements in the 25 participants and the lack of changes in respect to inferior vena cava volume, ejection fraction, or atrial and ventricular volumes argue against volume depletion, fluid shift, or pre-renal azotemia as a lone cause of AKI. Instead they hypothesize that it is cardiac exhaustion might lead to AKI and suggested further research about long-term consequences of endurance running for renal function. For ultramarathon running I think a more likely cause of AKI is exertional induced muscle damage, so called rhabdomyolysis, as the waste products from the degraded muscle, in particular myoglobin, damages the kidneys leading to acute tubular necrosis (ATN). A good recent review of acute kidney injury following rhabdomyolysis is Bosch et al “Rhabdomyolysis and acute kidney injury” N Engl J Med 2009; 361: 62-72.
Rhabdomyolysis and Acute Kidney Injury. Figure from Bosch et al in NEJM 2009; 361: 62-72 
Rhabdomyolysis and acute kidney injury in ultramarathon running

A number of studies have found highly elevated levels of creatine kinase (CK), a biochemical marker of rhabdomyolysis, in runners of the 100 mile (161 km) Western States Endurance Run (WSER) (Lang et al 1983; Lang 1984; Lind et al 1996; Hoffman 2010; Hoffman 2012). There are no good concomitant measurements of CK and creatinine so it is not possible to assess the risk among the runners with rhabdomyolysis to develop acute kidney injury (AKI) or  acute renal failure (defined in most studies as increase in creatinine of >0.5 mg/dL above a presumed normal baseline. However, a small retrospective study from the laboratory of Hew-Butler and Hoffman of the 2009 WSER identified some clear cases of acute renal failure following rhabdomyolysis (Bruso et al “Rhabdomyolysis and hyponatremia: a cluster of five cases at the 161-km 2009 Western States Endurance Run” Wilderness Env Med 2010; 21: 303-308). Five (5) of the 400 starters of the 2009 WSER were hospitalized with hyponatremia and rhabdomyolysis and of these five three progressed to develop acute renal failure. These three patients were characterized by higher initial blood urea nitrogen (BUN; 43–69 vs 18–23 mg/dL) and creatinine (2.8–4.9 vs 1.1–1.2 mg/dL) levels but were not distinguished by CK concentrations. All of these three patients finished the race and appeared to have used NSAIDs to a greater extent, had a tendency to be younger and were

more likely to have lost body weight during the race. Two of the patients presented with classical symptoms of rhabdomyolysis and EAE, i.e. emesis, dizziness, lightheadedness, cough and dark urine in the first case and dizziness, lightheadedness, and anuria in the second case, at the medical tent at the finish. They were treated with intravenous normal saline, but then presented to the hospital within 24 hours with thigh pain and dark urine (case 1) and weight gain and anuria (case 2). The third case of acute renal failure was presented to the hospital 1 day after finishing the race with continued nausea and flank pain. It is clear that rhabdomyolysis and hyponatremia could co-exist in ultramarathon runners following a strenuous race like WSER and that this could progress to life-threatening renal failure. There appears not to be any clear correlation between EAH with low blood sodium concentrations and blood CK levels (Hoffman et al 2012), but in addition to the report by Bruso and colleagues there are some other case reports reporting this (Ellis et al  “Case report: exercise-associated hyponatremia with rhabdomyolysis during endurance exercise” Phys Sportsmed 2009; 37: 126 –132).

 A recent laboratory study has looked at the effect of muscle damaging exercise followed by running in heat on AKI and found that a hot environment might be considered an additional risk factor for development of AKI (Junglee et al 2013 “Exercising in a hot environment with muscle damage: effects on acute kidney injury biomarkers and kidney function”  Am J Physiol Renal Physiol. 2013 30: F813-20).  

Diagnosis, treatment and prevention of AKI following an ultramarathon

From the above it is obvious that a large number of runners will have laboratory evidence of at least mild acute kidney injury (AKI) following an ultramarathon race, but very few will progress to acute renal failure (ARF). A very interesting recent study by Hoffman and colleagues looked whether it would be possible to by taking a urine dipstick of finishers at the 2011 100 mile (161 km) WSER ultramarathon to diagnose AKI (Hoffman et al “Urine dipstick analysis for identification of runners susceptible to acute kidney injury following an ultramarathon” J Sports Sci. 2013; 31: 20-31. Post-race urine dipstick testing was completed on 152 (49%) and post-race blood also was obtained from 150 of those runners. Based on "injury" and "risk" criteria for acute kidney injury of blood creatinine 2.0 and 1.5 times estimated baseline, respectively, 4% met the criteria for severe AKI and an additional 29-30% met the criteria for having mild AKI/risk of severe AKI. Interestingly, urine dipstick tests that read positive for at least 1+ protein, 3+ blood, and specific gravity ≥ 1.025 predicted those meeting the severe AKI criteria with sensitivity of 1.00 (95% confidence interval [CI] 0.54-1.00), specificity of 0.76 (95% CI 0.69-0.83), positive predictive value of 0.15 (95% CI 0.06-0.30), negative predictive value of 1.00 (95% CI 0.97-1.00), and likelihood ratio for a positive test of 4.2. It would thus be possible to quickly screen runners for the risk of development of severe AKI both during the race and immediately post-race by taking a urine dip-stick. Most runners of risk of severe AKI will not feel anything until quite late in the disease process and then mostly note that there will be less urine production, something which is common anyway after an ultramarathon. It is easier to diagnose rhabdomyolysis, which usually present with the classical triad of muscle aches, weakness and dark colored urine.

Treatment of both AKI and rhabdomyolysis is generally early, aggressive repletion of fluids. However, it is not that easy and treatment should be supervised and managed by a specialist. For instance, a major caveat and risk is that the runner has exercise associated hyponatremia (EAH) as well, where normal fluid resuscitation could be deleterious. Checking for signs of fluid overload and EAH such as weight gain during the race and ideally also blood sodium levels is really important before starting treatment.

There are neither no good studies how to best prevent AKI in association with an ultrarunning racing. Most races now include a medical check-up before the race and I would recommend including testing for an underlying kidney disease, which would obviously be a major risk factor for post-race AKI, by at least measurement of baselevel creatinine. To prevent rhabdomyolysis there are some indications that Vitamin C and Vitamin E substitution might be beneficial, but there exists no controlled studies whatsoever and no recommendations regarding this can therefore be given. Perhaps most importantly, there appears to be consensus in recommending avoidance of non-steroid anti-inflammatory drugs (NSAIDs) like Ibuprofen and Diklofenac before and during the race as it is known that they will stress the kidneys. I agree with this and think it better to follow this recommendation; despite the lack of good clinical studies here as well.

In summary, I do not know whether ultrarunning is healthy. Probably not at least during races, but long term data is lacking. With the right precautions and awareness of the objective, physical and medical dangers I think the unhealthy consequences, like the risk of development of acute kidney injury, can be managed.

20 March 2014

Hypothermia and cold-induced injuries when trail running in the mountains

I am on Frankfurt airport on my way back to Sweden having been a couple of days on a business trip to Ottawa in Canada. It has been a great trip not the least due to the good training. It was a while since I was on a business trip now and I was surprised how well the running on the treadmill worked – it is quite easy to run way too fast and I therefore mix speed with climbing on the maximum incline (15 degrees on most machines). I climbed 1000 meters (3280 feet) each morning and in combination with running some kilometers at high speed and strength training for in particular my legs I feel like I am back in form after the long slow winter training.

It was certainly winter in Ottawa, however, with temperatures below  -20 degrees Celsius (-4  degrees Fahrenheit), yesterday and lots of snow – a real contrast to Uppsala where the spring was in full bloom when I left. I have not been much outside during this trip, and did not bring training clothes for running outside, but feeling the cold icy wind in the face made me almost long for putting on running shoes and head out in the snow. Now I had to settle for some walks through the inner city.
The Centennial Flame at Parliament Hill in Ottawa
The Parliament in Ottawa surrounded by snow and cold
One of my long-term dreams is to run one of the long winter races in North America like Yukon Arctic Ultra, Iditarod Trail Invitational or the Extreme Winter Ultra Marathon. There is a growth in ultramarathon trail racing in the winter and in Scandinavia there are now a number of winter races like Rovaniemi 150, Ice Ultra and ArvikaActic Ultra. There is also a growth in the number of winter fastest known time (FKT) running attempts and I have for instance with great interest followed the very interesting detailed race report in many chapters from the Swedish runner Otto Elmgart whoran alone from Kiruna to  Narvik, adistance of roughly 180 kilometers (110 miles) in a Project he calls Goodfire. While I think the cold will be a major challenge in winter races I think you are expecting it and therefore come much more prepared for it than during races in the summertime.  Unexpectedly changing weather leading to cold conditions and risk of hypothermia (body core temperature below 36°C (97 °F)) of the runners in summer races could be much more dangerous than constant cold during a winter race. I have in a previous blog post described some of the dangers with running in the mountains andnotably most of the deaths of runners during mountain trail races have occurreddue to hypothermia in summer races.

Looking in the literature for studies of hypothermia during mountain running there is surprisingly few studies published. Most studies published appear to be of military operations and the influence of fatigue on the thermoregulatory control, for instance coming from the research by John W Castellani at US Army Research Institute of Environmental Medicine in Natick, MA, USA (see for instance “Thermoregulation during cold exposure after several days of exhaustive exercise” published in J Appl Physiol 2001; 90: 939–946 and “Prevention of cold injuries during exercise” published in Med & Sci in Sport & Exer 2006; DOI: 10.1249/01.mss.0000241641.75101.64). That there is not much literature on the area was noted already in 2003 in the excellent review “Physiology of accidental hypothermia in the mountains: a forgotten story” by Ainslie and Reilly in Br J Sports Med 2003; 37: 548–550. In this review, the authors outline the dangers of switching from an activity of high metabolic heat production, like running or walking in the mountains, to an activity of low heat production, for instance due to slow down due to fatigue or an accidental fall. It can be rather difficult to manage this during a long mountain ultramarathon like Tor des Géants (TDG) and towards the end of the race you have certainly become more proficient in rapidly putting on and removing clothes depending on the surrounding terrain, temperature/wind/moisture conditions, and your exertion level. One study has found that clothing with at least four times as much insulation is required to maintain body temperature at rest at an effective air temperature of 0°C as when running at 16 km/h at the same temperature (Noakes “Exercise and the cold” Ergonomics 2000; 43: 1461–79). Extra clothes and an insulation rescue blanket required in most mountain trail races could certainly be life-saving and are clearly motivated not only during racing but also when training in the mountains. There have recently been a controlled study of the beneficial effects of clothing published by Burtscher et al entitled “Effects of lightweight outdoor clothing on the prevention of hypothermia during low-intensity exercise in the cold” Clin J Sport Med 2012; 22: 505-507.
Predisposing factors for hypothermia. From Castelanni et al 2006 

Obviously, the risk of frostbite is much higher during winter when ambient temperatures are constantly lower during races. However, at high altitudes with low temperature and winds the windchill effect might certainly be notable. I really suffered on my third night at Tor des Géants running down from Col Lasoney to the life base in Gressoney St Jean – it was only around 0°C and light snowfall, but the wind coming from the north was incredibly strong blowing away some of the reflective race track signs. When I came to the Ober Loo aid station on my way to Gressoney St Jean it felt like I had begun develop some frostbite on my checks and I stayed some extra time to warm up with a cup of Tea Caldo with plenty of sugar. It has been shown that hypoglycemia impairs shivering and increases the risk for hypothermia so the sugar was probably extra beneficial in this situation.  Looking at the windchill chart in consensus article “International Olympic Committee consensus statement on thermoregulatory and altitude challenges for high-level athletes” by Bergeron et al published in Br J Sports Med (2012). doi: 10.1136/bjsports-2012-091296, however, it was probably not that as the risk of frostbite at 0°C should be very low. For PTL this August I will bring a wind meter and thermometer to better assess the winc chill temperature (WCT) during the race. 
Wind Chill Temperature (WCT) chart from Meterological Society of Canada

Something which will not require an instrument to measure is rain and moisture and that this has an effect on the thermoregulation when running was recently shown in a Japanese study by Ito et al entitled “Effects of rain on energy metabolism while running in a cold environment” Int J Sports Med. 2013; 34: 707-11. In this pilot study, 7 healthy men ran on a treadmill at 70% VO2max intensity for 30 min in a climatic chamber at an ambient temperature of 5°C in the presence (RAIN) or absence (CON) of 40 mm/h of precipitation. Esophageal temperature and mean skin temperature were significantly lower (P<0.05) in RAIN than in CON, while minute ventilation, oxygen consumption and levels of plasma lactate and norepinephrine were significantly higher (P<0.05) in RAIN than in CON. The light snowfall making in particular my hands and face wet during the third night at TDG was certainly a contributing factor to my suffering. Another factor was probably that this was the third night and that I had been racing for over 60 hours and thus had started to become rather sleep deprived. That sleep deprivation can affect thermoregulation has also been studied, for instance in the study by Castellani et al entitled “Eighty-four hours of sustained operations alter thermoregulation during cold exposure” published in Med & Sci Sports & Exercise. 2003; 35: 175 – 181.

In summary, I think hypothermia is perhaps the most important objective danger during mountain ultramarathon races also during the summer months and proper preparations both to prevent and to take care of this should it occur during races is paramount.

14 March 2014

Acute High-Altitude Illness / Acute Mountain Sickness (AMS) and mountain ultramarathon running

While I think it works perfectly fine to simulate the steep technical ascents and descents encountered in Alpine terrain on some of the trails on the local hills here in Uppsala it is of course impossible to simulate the high altitudes in the “real” mountains. Disturbingly, when I was skiing with my family in Courmayeur some weeks ago I got an annoying headache and felt a little nauseated the second day of skiing. The altitude was moderate around 2500 meters, but I could clearly identify the similar feeling as I had the second day of Tor des Géants (TDG) last year when I during the second stage started to have similar experience when going over an altitude of around the same altitude of 2500 meters. The second stage of TDG passes some of the highest passes, among them Col Loson at 3299 meters (10823 feet), and I really struggled over those without being able to get enough energy due to the nausea. I felt much better already on the descent to the second life-base to Cogne and even though I was afraid for the rest of the race that the feeling would return at some of the high passes later in the race I did not experience the same thing and seemed to have been acclimatized to the height. The same thing was repeated when skiing in Courmayeur as I did not feel anything on the third day and onwards.

Col Loson at 3299 meters (10823 feet)

Looking into the rather extensive literature on Acute High-Altitude Illness / Acute Mountain Sickness (AMS) it is clear that my symptoms of headache plus nausea and fatigue clearly could be attributed to this. Some of the good recent reviews on the subject is “Acute high-altitude illnesses” by Bärtsch and Swenson in New England Journal of Medicine (NEJM) 2013; 368: 2294-2302, “Wilderness medical society consensus guidelines for the prevention and treatment of acute altitude illness” by Luks et al in Wilderness & Environmental Medicine 2010; 21: 146-155 and “Altitude illness: update on prevention and treatment” by Eide and Asplund in Current Sports Medicine Reports 2012; 11: 124-130 and "Acute Altitude Illness" by Imre et al in BMJ 2011; 343: d4943 . The figure below is from Bärtsch and Swenson’s article in NEJM and outlines the symptoms and signs of AMS and those of the more severe disorders High-Altitude Cerebral Edema (HACE) and High-Altitude Pulmonary Edema (HAPE).  There is a risk of progression of AMS into the more rare life-threatening HACE and HAPE, even though the correlation is not perfect.

Figure from Bärtsch & Swenson NEJM 2013; 368: 2294

Acute Mountain Illness (AMS) is surprisingly common with an incidence of about 25% of persons rapidly ascending to moderate altitudes of > 2500 meters. HACE and HAPE are much less common and typically only observed at higher altitudes. A good figure on the effects of various altitudes is from the Imray et al article 2011:

Figure from Imray et al 2011; 343: d4943

There was just a really interesting study published in Medicine Science Sports Exercise 2013; 45: 792–800 by  Beidleman and colleagues entitled “Predictive models of acute mountain sickness after rapid ascent to various altitudes”. In this study they have looked at previously published data and created a risk model for predicting the probability and severity of AMS after rapid ascent to altitudes of 2000 to 4500 meters. In the first figure below from their article the lowest group of lines start at 2000 meters and and increases by 500 m until reaching 4500 m for the top group of lines. Panels A and B demonstrate the effect of activity on probability of AMS in high active versus low active men and high active versus low active women. Panels C and D demonstrate the effect of sex on probability of AMS in high active men versus high active women and low active men versus low active women. The next figure demonstrates the probability of mild, moderate, and severe AMS going from 2000 to 4500 m in high active men, low active men, high active women, and low active women. One of the most pronounced risk factors is if you previously have experienced AMS.
From Beidleman et al Med Sci Sport Exerc 2013; 45: 792
From Beidleman et al Med Sci Sport Exerc 2013; 45: 792

I have tried to find incidence figures of AMS for mountain ultramarathons, like UTMB, Hardrock 100 or TDG, at high altitudes without finding any studies. As the ascent to at least moderately high altitudes in these races indeed is very rapid, and many runner’s start without long acclimatization as is the standard for alpine climbing expeditions, I expect there are many runners like myself who have experienced AMS. Reading race reports from races you also get the picture that at least in some instances AMS can lead to early drop-outs. I think what many runners refer to as “nutritional problems” or similar might actually be AMS.

What could you then do to avoid AMS when running a mountain ultramarathon at high altitudes? There are some evidence-based recommendations with regards to pharmacological interventions that could be taken to prevent AMS. To prevent AMS and HACE Acetazolamide or Dexomethasone are recommended. However, I would be cautious of both drugs as they are really not ideal for ultramarathons – for instance Acetazolamide can increase the risk of hyponatremia, another major risk when running ultramarathons. To prevent HAPE Nifedipine is recommended, but as HAPE is much less common and so severe I think you should not run mountain a ultramarathon at high altitudes if you are at risk and have experienced this before, at least not before consulting the medical director of the race. So what could you then do to prevent AMS? Slow ascent of 300–500 m/day above 2500–3000 m as recommended for mountain climbing is clearly out of the question. What is left is acclimatization at altitudes above 2500 meters before the race and this is what I will opt for when running PTL this August. Looking at my personal onset of symptoms of AMS after around 12-24 hours I think a short acclimatization of one or two days when I go on day hikes at above 3000-3500 meters will be enough.

If you develop AMS usually non-steroid anti-inflammatory drugs (NSAIDs), such as diclofenac or ibuprofen, are recommended for the headache and anti-emetics for the nausea. However, NSAIDs are clearly not recommended for mountain ultramarathon running as there are other risks with those and I think it also too risky to try to suppress the symptoms of AMS during a race as it would be very important to early in the process detect possible progression to HACE, which would require immediate descent and interruption of the race.

In summary, I think I really could have saved time during TDG if I had been better acclimatized to the altitude and avoided, or at least had less severe, AMS during the second day. Looking at my speed and position during the race I lost a lot of time during the second day when my legs still were really fresh and I had not yet become sleep deprived as later in the race.

Analysis of my peformance at TDG 2013

13 March 2014

Is it possible to run in the mountains with a torn lateral meniscus in the knee?

It has the past few weeks been incredibly warm in Uppsala and the spring is almost exactly two months ahead of last year when the snow lingered into the beginning of May. There is certainly no snow now and you can find plenty of coltsfoot, snowdrops and crocus already in bloom in the parks. The conditions are perfect for running and I have started to add hill repeats and longer weekend runs to my daily commuting runs to and from work. In particular the hill repeats have been though as my aerobic capacity has decreased during the winter with slow-distance volume training and my legs have lost much of their speed and quickness. However, this morning I had a great run in the local hill, where Uppsala Castle is situated, within a stone’s throw from my home.

Spring run up the hill to Uppsala Castle
Compared to last year, when I had some persistent early season pain in my calves and Achilles tendons, my body feel much better and stronger. The only worrisome thing is of course my right knee after the accident in the beginning of January when I was hit by a snowboarder from behind when I was skiing. I still can feel pain and stiffness in the knee when rising after having been sitting too long in a meeting. I have also felt some pain when riding my bike - running actually works much better than biking which is strange. I have however not really tested the knee when running in high speed and, more importantly, not when running in non-level terrain. It was therefore really great that I did not feel much when really testing the knee in this morning’s training run.

I am actually quite surprised that it feels so good. I finally got my diagnosis of my knee injury last week after having waited, as you regretfully have to do for most medical procedures in Sweden, for many weeks on an MRI. I was quite depressed when I got the verdict “Lateral Meniscus Tear”. The MRI showed specifically according to the radiologist’s statement: “Collateral and cruciate ligaments are intact. Medical meniscus is intact. In the lateral meniscus there is a central dorsolateral  rupture which probably extend to the upper meniscus surface. Moderately increased amount of fluid in the suprapatellar bursa”. 
MR images of my right knee showing the torn lateral meniscus
Really bad according to this and the season could be over before it begun. Worse, it could mean an end to running in the mountains forever as the menisci really play an important role in load transmission and shock absorption, joint stability, joint nutrition and lubrication and proprioception (reviewed in Fox et al The basic science of human knee menisci: structure, composition, and function” Sports Health 2012; 4: 340-351). The orthopedic surgeon I consulted recommended an arthroscopic operation to further assess the extent of damage and to treat the injury through partial meniscectomy.

However, as I am already now a short period after the accident having only minor problems with my knee when running I opt for leaving the meniscus in situ and continue with conservative treatment with increased strength training and physiotherapy. I am also afraid of the increased risk of osteoarthritis after meniscectomy (see for instance Katz et al Surgery versus physical therapy for a meniscal tear and osteoarthritis in N Engl J Med 2013; 368: 1675-84) and would like to try to avoid surgery by all means if possible. Having performed arthroscopic knee operations myself I know how traumatic these could be for the structures in the knee and it is only natural that this cause problems both in a short and in a longer perspective. It is also interesting that if I had not got the results of the MRI I would most likely just have continued my training as before. Now I will have to push myself harder with regards to strength training for my quadriceps and other knee supporting muscles and also run more tougher hill and trail runs. It is still 165 days to PTL so I am not worried and based on the run this morning I need not be. So, yes, I think it possible to run in the mountains with a torn lateral meniscus.  

10 March 2014

Are 200 mile races the next thing?

From a European perspective it is quite strange that it is not until something has happened in the US that it appears to count in most media. That the 350-mile race IditarodTrail Invitational has been there for several years, the 205-mile (330 km) trail race Tor des Géants (TDG) will be organized for the fifth time in 2014, that the 200 mile long Petite Trotte à Léon (PTL) at UTMB is a long standing event and that there are several other European races, for instance Swiss Iron Trail, BeskidyUltra Trail, Volta Ceranya Ultrafons and GAX TransScania, with distances over 125 miles appears to fade in the wake of the interest the new 200-mile race in the US Tahoe 200 generates. That even Badwater is considerable longer than 100-miles (it is 135 miles) appears to be forgotten and there is no mentioning of 48-hour time events which for quite some time grown in popularity. However, there have since the announcement that Tahoe 200 will be held for the first time in September been several articles and blog posts published asking whether 200 mile races are the next thing. For instance Jill Homer asks this question in her excellent blog Half Past Done and there was now just an article in Outside Magazine entitled “Ultrarunning Gets Serious” by Heidi Mills portraying this as a new trend. I do not think it is a new trend – I think longer trail races is just one niche of the general rapid growth of ultrarunning, just like fastest known time (FKT) attempts on fixed trails and distances is another.
Picture from the article in Outside Magazine
I have previously written several blog posts claiming that from a running and muscle physiological perspective, shorter distances like 100 kilometers might be tougher than longer races. In longer continuous races there are other challenges, not only general fatigue and sleep deprivation, but also the influence of the environment will be greater and for this reason I think they can give another kind of experience. I recently read two different race reports about PTL 2013 illustrating two different ways of coping with the extreme alpine environment during this long race. The “Flipper’s Gang” from the UK managed to complete thewhole race as a team without a GPS, while the description of how the international team “Too Cute to Quit” deteriorated in the extreme environment is one of the best and most educating race reports I have ever read (the latter report is divided into several sections). How to optimally perform in extreme environments is clearly an area in need of more research. The fascinating article “A neuroscience approach to optimizing brain resources for human performance in extreme environments” by Paulus and colleagues in Neuroscience & Biobehavioral Reviews 2009; 33: 1080–1088 is a good review and comes up with the hypothesis that “individuals who are optimal performers have developed a well contextualized internal body state that is associated with an appropriate level to act. In contrast, sub-optimal performers either receive interoceptive information that is too strong or too weak to adequately plan or execute appropriate actions.” Longer ultramarathon races is clearly a better test of the interaction between the environment and the body and mind as they in contrast to shorter races clearly require more strategic decisions. I guess that will make them both more challenging and attractive as it is another dimension of the race. Certainly not a “better”, more “trendy” or “the next” dimension, but different.

05 March 2014

Downhill trail and mountain running technique

For almost all long and steep ascents during a long mountain ultramarathons such as Tor des Géants (TDG) or Petite Trotte à Léon (PTL) most competitors walk rather than run. It is of course important to train how to walk/hike rapidly uphill and to in general improve the aerobic capacity in order to sustain the strain of these ascents at high altitudes.

Not fun to run on - Picture from Beat Jegerlehner's blog post about TDG

However, I clearly learned during last year’s TDG that what you really need to train in order to gain time is downhill running. Not having trained that properly before the race I was really slow in most descents, except perhaps for the very last one during the race as described in my race reports. It was really frustrating to be passed during most downhill descents, in particular the more technical one’s, despite feeling good in my legs and feet. It was therefore with interest I read today’s post “Your Ultra-TrainingBag Of Tricks: Don’t Let Downhills Be Your Downfall” at irunfar.com by IanTorrence. It is a great post with plenty of good advice I will try to follow in my practice. However, I will of course never even be near the best trail runners in downhill running technique and proficiency, just look at the inspiring videos below of some of the best downhill runners – indeed inspiring. I really have to work on my cadence, something which also appears to be supported by the recent study "Preferred step frequency during downhill running may be determined by muscle activity” by  Sheehan and Gottschall  published in J Electromyogr Kinesiol 2013; 23: 826-30. In summary I will quote the conclusion from the article "Energy cost of walking and running at extreme uphill and downhill slopes" by Minetti and colleagues published in J Appl Physiol 2002; 93: 1039-1046: "If athletes wish to improve their performances in competitions alternating ascent and descent phases, they should pay greatest attention to the training of movement coordination during downhill running."
Kilian Jornet showing his superior downhill running skills in a Kilian’s Quest movie

Kilian's downhill technique at really technical terrain during his FKT record run up and down Matterhorn
Anton Krupicka running downhill

Cameron Clayton giving a downhill running lesson

Sage Canaday running downhill

Emelie Forsberg showing great downhill cadence