Is it good to train in the heat?

So, I guess it's hot out.  And as a result, training has been tough.  In addition, my AC isn't working, so I'm a little extra discombobulated.  I've heard that there is a strong correlation between high temperatures and violent crimes; is this true?  If not, it should be!

But one positive thing may come out of all of this agony: the heat may be making me faster.

It's a question that I've thought about many times.  Training in the heat should help one perform better in the heat.  Even from a mental standpoint, getting used to having the sun beating down on you while you push your limits intuitively seems important.

However, does training in the heat help overall performance?  I have (wrongfully) assumed it was better to train in more comfortable temperatures to allow for a higher level of exertion without having to worry about hydration, overheating, or the sheer mental strain.

However, there is some research out there showing that it may actually be a good idea to train in the heat- even if you are planning on competing in the cold.

Study #1

Take, for instance, this 2010 study.  In the study, a group of cyclists underwent a 10-day heat acclimation process.  Basically, they rode pretty easy (50% of their max) in a hot environment (40 degrees C).

Their change in V02max (maximum ability to consume oxygen), time trial results, cardiac output (how much blood the heart can pump per unit of time), and lactate threshold (the effort level when you start producing lactic acid) were measured.

To no surprise, they athletes showed an improvement in all parameters when re-tested in a hot environment.

However, when re-tested in a cool environment, the athletes amazingly showed significant improvements in all categories: V02max (5% improvement), time trial results (6% improvement), cardiac output (9.1% improvement+/- 3.4%), and lactate threshold (5% improvement).

So, simply put, these athletes had more efficient circulatory systems, and went faster because they rode in the heat.  The best part is they didn't even have to push hard in the heat- all they did was follow a protocol that kept them at 50% of their max effort.

Study #2

It's not as though the above research is the only body of evidence showing this type of positive change.  Take for instance, this study.  Long story short, the subjects consisted of 8 high-end rowers.  They were given no fluids and did a series of rowing activities over the course of 5 days in a hot environment (once again, going pretty easy).  This was then followed by a 2K time trial.

By the 5th day, the rowers showed a 4s improvement in their TT.  Interestingly, they ended up losing more weight in that last day's effort (3%) then their first day of testing (2.1%).  However, the fluid content of the blood (plasma) actually increased form day to day.

Once again, by going easy in the heat and allowing for some dehydration, the athletes saw an acute improvement in performance.

Why does it work?

So why is there this spike in performance?  Researchers believe the answer comes down to that increase in plasma volume shown in the second study. This review article does a great job of summarizing the topic.

An increase in plasma in our blood is not related with an increase in red blood cells, so why does the oxygen transporting capacity, and more importantly our performance, improve with a plasma increase?

When we become dehydrated, our bodies quickly learn to adapt to the stress they are being put through.  As a result, we retrain excess fluid in our blood (more than we otherwise would), a state which is logically named hypervolemia.

The authors explain, "Hypervolaemia serves to minimize cardiovascular stress by preventing significant reductions in mean arterial pressure, central venous pressure, and cardiac filling, thereby maintaining or improving stroke volume."

In short, the added fluid volume in our blood vessels helps us to pump more blood through our circulatory system.  It also helps to maintain a healthy blood pressure as we hammer away.

Practical Application 

The bottom line of this research is consistent with what is common sense for most of us- we train hard and beat ourselves down as much as we can (provided we can recover and avoid injury), and our bodies will adapt and perform better as a result.  However, just like mileage and intensity, there are limits to training in the heat (which you can very easily figure out, as I wrote about here).

It's hard to train in the heat,  there's no doubting that.  That being said, this research shows you really should not avoid it.  Just like the exertion of a tough interval session, this added discomfort of suffering through a sweltering workout will pay dividends whether you are racing in the heat or on a cooler day.

Intro to scoliosis

For my June article in the New Hamburg Independent, I wrote about the often misunderstood condition known as scoliosis.  As per usual with these articles, it is more of an introduction into the topic.  If you have additional questions, do not hesitate to contact me!

The truth about treating scoliosis

Scoliosis is a medical condition where the spine curves from side to side rather than sticking to its normal, centralized position.   It impacts about 1.5-3% of our population, so is a relatively common condition.  Despite how common the condition is, there still seems to be an abundance of confusion and miss information on what causes it, and more importantly, how to manage it.

So what exactly does make a spine to curve from side to side?  There are three major reasons; (1) it’s congenital (you were born with it), (2) it is secondary to other diseases or conditions (such as cerebral palsy or trauma), or (3) idiopathic (in other words, we do not know).  Surprisingly, the majority of cases are idiopathic.  More often than not, the curves develop for no apparent reason.

 It is important to note that all three of these examples are different from the tilt we sometimes get in response to an acute back injury.  In these instances, muscles can be asymmetrically tight, nerves may be pinched, or the soft discs that separate our vertebrae may be damaged.  These types of injuries may result in discomfort when trying to stand upright, and therefore we tend to lean to the side that feels the best.  This is not a sign of a true scoliosis, and as soon as the cause for that back pain is fixed, the lateral bending in the spine will disappear.  

The best way to diagnose scoliosis is with a detailed physical exam, history and radiographs to measure the extent of the curvature.  The type and extent of the curvature will have a strong impact on how the condition is treated.

When deciding how to treat the condition, it is important to note if the patient is skeletally mature.  This is important because if the spine has stopped growing, the risk of the curve progressing is very low.  However, if the spine still has potential to grow, then there is also a much higher likelihood of the curve getting worse.

Other important risk factors include if the patient is female and if the curve is located in the mid-back.  These are two additional factors that are associated with a higher risk of curve progression.

In terms of treatment, there are three major approaches; (1) physical therapy, (2) bracing and (3) surgery.

The goal of any scoliosis physical therapy plan is to correct the biomechanical issues that arise from the curve.  There is conflicting evidence in the literature of if an exercise plan can reverse a curve, or even slow its progression.  However, what exercise can do is maintain function along with range of motion, and have an extremely positive impact on quality of life.  These exercise protocols should be prescribed by a properly trained manual therapist, and can be complimented with soft tissue work and other treatment modalities.  Physical therapy is the absolute most important approach in mild to moderate cases of scoliosis.

Bracing, by contrast, is typically used only in more advanced instances of scoliosis in patients who are not yet skeletally mature.  There are a few different types, but the basic mechanism of each is to apply external support to slow the progression of the curve.  These external braces are not associated with a high degree of success typically as a result of how hard they are to use.  They must be worn 22-23 hours per day, and are so tight that they restrict breathing and the ability to move normally.  It should be no surprise that compliance with these braces is often low.

Finally, the last resort treatment for those suffering from scoliosis is surgery.  Again, this option is typically reserved for those who are not yet skeletally mature and/or have advanced forms of scoliosis.  There are a few surgical options, but the most common is to attach steel rods to the spine, and fuse the vertebrae together.   This provides mechanical support to prevent the curve from progressing, but should only be used in high-risk and more advanced cases.

Finally, it is important to keep in mind that in a vast majority of cases, scoliosis does not have any long term health implications.  One recent large-scale study showed that after a 50 year follow up, scoliosis patients had the same cardiac health, mental health, lung function and neurological function as those without scoliosis.  

With whatever type and degree of scoliosis that you have, it is never a mistake to seek opinions from multiple health care practitioners.  While scoliosis typically is not a serious condition, it should not be ignored.  If you or somebody you know suffers from it, it is important to have a properly trained medical progression examine it sooner rather than later.

It's not fair: The impact of perceived injustice on healing

We all get injured.  Muscle strains.  Headaches. Broken bones. Tendinitis. Whiplash.  Experiencing and getting through these aches and pains is part of life.  For the most part, we all want to get through them as quickly as possible.

Yet, doesn't it seem that certain people recover faster from injury than others?  Even if two people have exactly the same injury, and do exactly the same things to manage it, the healing time can still be drastically different.

So what separates us?  There is no doubting that physical characteristics, such as age and level of fitness, can impact recovery time.  However, if all things physical are held equal, healing times for the same injury can STILL differ drastically.  

Why is this? One possible explanation: the influence of the mind.

Researchers now clearly understand that injuries and recovery time are highly dependent on what is going on with a person's psychology.  We now know that pain is 100% of the time experienced in the brain.  This pain is processed in the emotional center of our mind, and depending on the state of the center, the pain we perceive can drastically change (a topic I blogged about here).

Studies (such as what is discussed here) even show that chronic back pain is more easily predicted by psycho-social factors (like depression), rather than stuff we can see with MRIs.

Or even take the classic example of chronic tendon pain (which I blogged about here).  In short, the nervous system is more of a player than the damaged tendon itself in terms of the symptoms we feel.

So it's clear that it's not just the extent of the tissue damage that dictates recovery time.  The mind and nervous system are important.  And while there are many psychological traits that impact recovery, one that has a huge influence starts with simple thought: "this isn't fair."

Perceived Injustice

Researchers now understand that perceived injustice plays a very crucial role in recovery time with any injury.  Injustice, in essence, is the sense that someone has wronged you and retribution is warranted.  In other words: you think your injury is somebody else's fault, and you want to get even.  

So does wanting to "get even" impact recovery?  This study not only explores the issue, but also looks at how a simple survey can predict the magnitude of influence that perceived injustice has.

In one part of the study, a group of patients injured either at work or a motor-vehicle accident were examined.  The patients were asked to complete the Injustice Experience Questionnaire (IEQ), rating each question (below) on a scale of 0-4 (0- never, 4- all the time).

Here are the questions in the IEQ:

• I am suffering because of someone else’s negligence
• It all seems so unfair 
• Nothing will ever make up for what I have gone through
• I feel as if I have been robbed of something very precious
• I am troubled by fears that I may never achieve my dreams 
• I can’t believe this has happened to me 
• Most people don’t understand how severe my condition is 
• My life will never be the same 
• No one should have to live this way 
• I just want my life back 
• I feel that this has affected me in a permanent way
• I worry that my condition is not being taken seriously

Then, the researchers took the results of this IEQ, and looked to see if there was any correlation with factors such as; depression, disability, return to work and pain levels.  They found that the subjects with higher IEQ scores were strongly correlated with the following:

• An increase in catastrophic thinking (i.e. ruminating, exaggerating, thinking of worst-case scenarios)
• Fear of movement and re-injury 
• Higher levels of depression
• Higher pain severity
• The IEQ could even predict how quickly the subjects returned to work.  

If you're injured, take a look at the above questions in the IEQ- are you applying a score of 3 or 4 to many or most of them?  If you are, there's no doubting that you are angry, and feel as though what has happened is unfair. Unfortunately, this also means that you are more likely to be depressed, to feel more pain, and to have a slower return to work (compared to somebody with the same injury and a lower IEQ score). 

At the end of the day, if you are injured as a result of somebody else's negligence, it is completely normal to relate to some of the questions in the IEQ.  However, when too much focus is on being angry and getting even, the research is clear: we stay angry and we do not heal.  

How do we get better as quickly as possible?  There is no doubt that more than the body matters when recovering from injury.  Our attitudes, emotions, and even perceptions of pain also must be addressed to maximize recovery time.  

So to get better as quickly as possible, my advice is simple: focus on moving on, focus on healing, believe you will get better, and work toward living a life that makes you happy.

Sugary mouthwash might make you faster

It is no secret that the key to success in endurance sports, from a nutritional standpoint, is carbs.  I have blogged about them in the past, and it is clear that you can really make or break your race with how many carbs you have taken in.

Now, a new line if research is showing it is not only important to ingest enough carbs, but that it can also be beneficial to trick your brain into THINKING carbs are being ingested.  

How do we do this?  We rinse with a sugary solution. 

Quick background

For any short duration activity (like a golf swing, or quick sprints), carbohydrates are not the primary source of fuel.  However, once you get to an activity duration of around 5 minutes at a decent intensity, you start to tap into glycogen- the chains of sugar stored in your muscles.

So whether you are running a few miles or running a marathon, glycogen is important.  We can top these glycogen stores up by making sure we consume sufficient amounts of carbohydrates in the days leading up an event- there is no mystery here.  

Unfortunately, these glycogen stores are not always enough.  Scientists have consistently shown that if the activity is long enough, that glycogen source will become depleted and performance will plummet   

So what do we do?  Eat carbs during an event.  

Interestingly, it is not the size of the person that dictates how much to consume.  Instead, we are limited by how quickly carbs can be absorbed in the intestines.  So whether you are 5'2 or 6'2, this number (for glucose) is about 1g per minute.  So really, the max glucose you are going to be able to take in during an event is 60g/hour (there are ways to ingest more, but that is for another day).  

However, for shorter events, 60g/hour is excessive, especially for events under an hour in duration.  If your body is constantly fed carbs in close proximity to the start of an event, insulin will spike.  This will result in a decreased ability to access the glycogen and fat already stored in your body, and once again, performance will suffer.

That does not mean there is nothing you can to do enhance your performance with carbs during events under an hour.  The answer: a sugary mouth wash.

Study

This 2010 summary article does a great job of breaking down a new(er) line of carb research: the benefits of rinsing your mouth with sugar and spitting it out.

The basic idea is this: your brain controls your performance partially in anticipation of what is GOING to happen to the body.  For instance, studies like this one show that when the temperature goes up, we slow down BEFORE our body temperature goes up - in other words, our mind FIRST slows us down to try to prevent overheating, not in response to it.

The same concept applies to the sugary mouth wash.  The thought is that when sugar is sensed in the mouth, the reward system in the brain is activated; the brain thinks food is coming, and as a result our body gets the green light to hammer away.  We are able to go faster not because we are actually fed, but because we are anticipating we WILL be fed.  

And whether we fully understand the mechanism or not, the fact is, a sugary mouthwash seems to work.  Check out these results  from the study.  The first one shows a 2.9% improvement in a cycling time trial.  The third study shows a 1.7% increase in distance traveled during a 30 minute run...you get the idea.  These results are pretty impressive because there is no actual impact on the body's physical ability to perform; just the mind is giving the body a message to push harder.

Some practical notes

The most important note about this line of research is that this strategy only works for activities at a particular duration.  The range for this is usually quoted to be for activities that are about 30-75 minutes in duration.  Once you get over this 75 minute mark (or even for events over 1 hour), carbs definitely need to be ingested to maximize performance.  Once your glycogen is low, you can rinse all you want with sugar, but without fuel you will be unable to continue!

So, if you are trying to break that 50 minute mark for the 10K for the first time, it may be a good idea to try this mouth-rinsing strategy.  The science suggests you will get the energy boost of carbs without actually having to swallow them and risk getting an upset stomach!  However, when running that half or full marathon, you're better off to actually swallow 30-60g of carbs/hour.

Cervicogenic Headaches

Here is my article from this month's health section of the New Hamburg Independent. It takes a brief look at the best treatments for headaches that originate from the neck. As per usual with the limited space, this is more of a introduction to the topic rather than an all-inclusive explanation. Feel free to message me with your questions or comments!

New research points to exercise and spinal manipulation for certain headaches

Headaches are an extremely common and often debilitating disorder that people in our society suffer from. In fact, some research has shown that only 10% of our population is lucky enough to go headache-free over the course of one year.

So how do you get rid of these annoyances? First it is important to understand what is causing your discomfort. Common examples of headache types include migraines, tension headaches and cluster headaches. In this article, we will be talking about how to treat a specific type of headache that accounts for 15-20% of all cases: cervicogenic.

Cervicogenic headaches occur when there is damaged tissue in the neck that refers pain to the head. With a headache that is purely cervicogenic in origin, there is no actual pain being generated in the head itself; it is exclusively injured tissue in the neck that causes pain to travel into the head, and as a result, a headache is perceived. Most commonly, the tissues that can refer pain into the head include muscles, joints, ligaments and nerves.

Since cervicogenic headaches originate at the neck, it should be no surprise that the research shows treatment to the neck works best.

For instance, a 2010 study published in the Journal of Rehabilitation Medicine looked at the role of exercise in the management of these headaches. Subjects were either put into a neck strength exercise group, an endurance exercise group, or a control group where no specific exercise was completed.

At the 1 year mark, the strength group had shown a 69% overall improvement, the endurance group showed a 58% improvement, and the control group had only improved by 37%. Neck exercises clearly helped these individuals with their headaches.

Another treatment for cervicogenic headaches is manual therapy, including spinal manipulation (SMT). A separate 2010 study published in the Spine Journal took a look at how effective SMT is in the treatment of these types of headaches. The participants were separated into two groups; one received SMT, the other received a non-therapeutic “light massage.”

By the end of the 24-week study, participants who received SMT experienced 2.6 fewer cervicogenic headaches per week on average when compared to the “light massage” group. Therefore, if your headaches are originating from your neck, then SMT seems to be a viable treatment option.

While these studies are promising, it is important to keep in mind that there are many causes for headaches. In addition, just because you have one type, that does not mean you are immune from the other classifications of headaches. In fact, it is quite common to suffer from mixed-type headaches, where individuals may experience multiple types of headaches all at once.

Finally, it is also important to note that not all headaches are primary in origin. Sometimes they are secondary symptoms to a more sinister underlying condition. That is why it is important to make sure you seek a proper diagnosis from a duly trained health professional before piecing together a plan of action for your headaches.

Psychology of pain

Last week, I had the opportunity to talk to the Retired Business and Professional Men's Club about low back pain.  Over 100 members showed up, and they all asked a number of great questions.  In the end, much of what we discussed revolved around how to address chronic pain.  With this article, I am going to take a quick look at some of what we discussed.

Chronic pain is not just in the tissues, it's in the brain

What is the difference between acute and chronic pain?

With acute injuries, it is usually pretty clear why pain exists.  An injury takes place, tissues are damaged, inflammation pools into these areas, and things start to hurt.  With chronic cases, the reason why people feel pain is much more complex.  Often tissues are healed after 6 months, yet pain still persists for some reason.  A common example of that is the chronically painful Achilles tendon, which I blogged about here.

Recently, I wrote an article for the New Hamburg Independent discussing factors associated with back pain. Interestingly, psychosocial and lifestyle factors  (i.e. depression, obesity, anxiety, job dissatisfaction) were more strongly correlated to back pain than test results, such as findings on radiographs.

So why is this?  The answer, at least in part, comes down to the fact that pain is something that exists only if there is a brain there to perceive it.  If you tear a muscle, you could remove that muscle from the body, pass a current through it, and its contraction strength would be decreased compared to the healthy version of the same muscle.

However, as soon as you disconnect that muscle from the body, that muscle is no longer painful.  Pain is not an intrinsic characteristic of tissues like force of contraction is.  Pain is something that only exists if there is a brain to process the signal.

Psychology of pain

While a painful experience requires a brain, that is not to say chronic pain is all in your head.  However, it does explain why two people with very similar levels of tissue damage can have vastly different pain experiences depending on an array of factors impacting their psychology.

A great 2005 article summarized a number of different factors that contribute to how we perceive pain.  First, they explain that pain is actually processed in the limbic system, the emotional part of our brain.  When cancer patients underwent a frontal lobotomy (part of their brain was removed), these patients were still aware of the pain, but they no longer cared or considered it painful.  The same pain signal was reaching the brain, the brain  just was no longer equipped to tell the person that they are in pain.  Thus, pain no longer existed.

On a more practical note, they do a beautiful job of summarizing modifiable factors that have been shown to have an impact on the pain we perceive   Examples include how focused you are on the pain, how you learn to react to pain, the context you feel the pain in, how anxious or scared you are, and how you expect to react to the pain.  All of these are examples of things you can change to alter how much pain you feel without changing how much tissue damage is present.

An interesting example of this is how distracting patients may be an effective means to control pain.  For instance, burn patients experience excruciating levels of pain during their treatments and physical therapy.  Even with the use of opioid painkillers, the process can be unbearable.  Yet, when these same individuals are distracted using a virtual reality game, the pain they feel is significantly reduced.  There is no change in the tissue, no change in the pain signal reaching the brain; it only changes to how the brain processes that signal.

Another example discussed within the article takes a look at learned pain.  Two groups of people had their pain threshold tested.  One group observed models who were trained to react calmly and to have a stoic demeanor in response to the stimulus.  The other group of subjects observed models exhibiting poor tolerance to pain.  With no other difference between the subjects other than what they observed, those who watched the models with good pain tolerance required almost 3.5 times the stimulus until they reached their pain threshold.

What is the practical application?

At the end of the day, chronic pain is an extremely complicated issue.  It is of course important to address the specific tissues that are causing your pain, but it is also very important to look at these broad factors as pieces to the puzzle to solving your chronic pain.  Chronic pain is, by no means, all in your head.  However, altering what is going on in your head will undoubtedly have a positive impact on the pain you feel, and as a result, your quality of life.

Here is a cool video explaining chronic pain.

Improving Running Economy: Hands on Head

Recently I wrote an article for Canadian Running Magazine looking at a system of drills developed by Pete Grinbergs to help improve the efficiency of your running stride.  It is definitely a teaser to what the system is all about.    To see what it actually looks like in action, check out Pete's video here.

In my opinion, hands on head (HOH) is a novel and intriguing solution to something that is often neglected, and sometimes unnecessarily complicated.  Does it work?  And if so, to what degree?  That is yet to be determined.  Regardless, it's free, it's safe, it's easy, so why not try it to find out?

Here is the article:

Lab Rat- Hands on Your Heads

Want to run more efficiently? Peter Grinbergs, head coach of Wilfrid Laurier University’s cross-country team, has a suggestion: Put your hands on your head. Grinbergs’s Hands on Head (HOH) system, developed after 30 years of coaching, involves a series of drills that focuses on diagnosing and correcting stride inefficiencies. His athletes will follow up hard workouts with light strides, walking high knees and barefoot drills - all with their hands firmly placed on their heads....
Click here to read the full article.

The complex nature of back pain

This post is from this month's health section of the New Hamburg Independent.  It takes a brief look at the complex nature of back pain.  Research is continuing to show that people experience pain for reasons far beyond what can be explained with x-ray and MRI machines- keep reading to find out why!

   

Researchers show back pain is more than just muscle and joint damage

 Low back pain is an extremely common condition, and is something approximately 80% of us will experience at some point in our lives. When we suffer a flare up, it is often assumed that we have done something wrong.

“I slept wrong and sprained a joint,” or “I lifted wrong and strained a muscle,” are common explanations I hear in practice.

However, there likely is more to the story, especially with chronic low back pain.

A group of prominent researchers have recently reviewed and summarized all of the best studies on this common type of low back pain.  Surprisingly, these researchers showed that many lifestyle, social and psychological factors are more strongly linked to back pain than are many anatomical causes.

For instance, a common anatomical change we often attribute back pain to involves degenerative changes throughout the spine. In short, this involves a decrease in fluid content in the spongy discs that separate your vertebrae, and a wearing down of the cartilage of the joints at the back of your spine.

While it is logical to suspect that these anatomical changes are associated with low back pain, these researchers have shown that they are not nearly as concerning as we once thought.

Instead, lifestyle factors such as smoking, being overweight, and perceiving yourself as generally unhealthy is more strongly connected to back pain. In addition, psychological and social issues such as depression, anxiety, low job satisfaction, monotonous work, and poor social support are all linked to an increased risk of back pain.

Thus, while strained muscles and associated joint issues play a role in low back pain, this review clearly shows that any pain you may be feeling, especially if it is chronic, is likely a result of a collection of factors involved in your life.

Since the cause of the chronically painful low back is a result of a multitude of factors, logically the solution should also include a number of approaches.

That being said, it is important to note that we are only referring to the most common type of back pain, which is called ‘mechanical low back pain’.

There are less common, but quite serious, conditions that must be ruled out if you are suffering from back pain. Some of these include tumors, infections, and traumas. Also, if there are neurological symptoms such as shooting or electrical pain down your leg, or numbness and tingling, then something beyond mechanical low back pain is affecting you that must be diagnosed and treated.

If you do fall into the category of suffering from mechanical low back pain, the solution comes down to identifying and addressing all of the contributing factors of your pain. For some, that may mean quitting smoking, losing weight, and finding a more enjoyable job. For others, that may mean learning to cope with stress more effectively, developing a better social network, and putting into place a plan to treat their depression.

Regardless of the person, mechanical low back pain should always be treated with some form of physical activity. Specific exercises for the back that help to strengthen and stabilize the entire core should be implemented. General cardiovascular and strength training should also be added to the plan of management for the best results.

So is back pain related to problems with our anatomy? Absolutely. Tearing a muscle, spraining a joint, and developing osteoarthritis undoubtedly hurts, and these factors should not be ignored. However, this line of researcher shows that you should not just stop there, and that improving your psychological, social and lifestyle health will go a long way.

Why doping should not be allowed in sport

In a recent post I looked at the Lance Armstrong saga (which is kind of old news now), and doping in the sport of cycling as a whole. In response to that post, I received a number of e-mails and messages, which was great to see. 

Interestingly, most of the comments were not about a solution to doping in cycling, but rather were focused on this article written by J. Savulescu, B. Foddy and M. Clayton. The general consensus was that doping in sports is wrong, but that the  authors make a pretty convincing case to the contrary. 

Rather than actually exploring a solution to doping in cycling as promised, this blog will take a quick look at why performance enhancing drugs (PEDs) in sport should not be allowed in direct response to the arguments presented by Savulescu, Foddy and Clayton. To get a full appreciation for their arguments, take a read through the article first.

Argument #1

(1) In the article, the authors state that the pros of doping outweigh the cons for athletes given today’s risk/reward infrastructure for athletic success versus getting caught. The financial gain of being the best seems to outweigh the relatively small risk of being caught, and then the diminutive punishment handed out if caught is not enough of a deterrent.

While this argument clearly shows why some athletes do opt to dope, it by no means presents a reason why PEDs should be allowed. Instead, this argument actually helps in identifying an area that we can work on to further discourage the use of PEDS. In addition, it has recently become apparent that agencies, such as USADA, are taking steps in the right direction in correcting this supposed imbalance with the risk/reward to doping.

Take the Lance Armstrong scenario and how USADA has now set a strong precedent with this case. Armstrong was banned for life and stripped of all of his major accomplishments, despite never testing positive (room for debate here). He was not simply banned for 2 years, nor was he stripped of only a couple of victories. Instead, almost his entire career was erased. Granted, this type of punishment was justified based not only on his personal use of PEDs, but also his involvement with trafficking and covering up the cheating. Regardless, this sanction should undoubtedly act as a deterrent to any rider who wants to become the best. It shows that whether you test positive or not, you will eventually get caught, and unless you confess, everything you’ve ever worked for will be taken away. So are the penalties too forgiving? Maybe in some cases, but the punishments are headed in the right direction.

The second part of the authors' argument assumes that the relatively low likelihood of getting caught makes it impossible to discourage athletes from doping. The article references the fact that only 10-15% of athletes at a major competition are tested. Of that 10-15%, a majority will not test positive simply because the type or dose of the PED is not detectable.  However, does this mean that only 10-15% of athletes need to be worried, and the others can relax? No. The testing is random, and therefore the entire collection of athletes must consider being tested as a real possibility. While this does not have the same impact of testing every single athlete, it undoubtedly will impact the decision to dope beyond just 10-15% of athletes. In addition to this, as mentioned above, athletes can still be sanctioned without positive tests, adding an additional deterrent.

The authors state that cleaning up the sport is unattainable, and see this as reason to allow drug use. Instead, this seems to represent where we have room for improvement, rather than a reason to allow PEDs. The good news is that these improvements are already being put into place.

Argument #2

(2) The article’s second argument discusses the assumption that the use of PEDs violates the spirit of sport. They argue that if everybody had equal access and equal opportunity, the use of PEDs would level the playing field and ensure that race winners are not those who have won the genetic lottery. As with the implementation of training, tactics, and nutrition, the use of PEDs would provide an additional parameter that an athlete can manipulate, and thus add more uncertainty and variability to who wins. As a result, the authors believe that it is a misunderstanding to think that using PEDs violates the spirit of sport.

The issue with this argument is that it completely ignores what the spirit of sport entails, despite listing its tenants in the article itself. They are as follows:

· ethics, fair play and honesty

· health

· excellence in performance

· character and education

· fun and joy

· teamwork

· dedication and commitment

· respect for rules and laws

· respect for self and other participants

· courage

· community and solidarity

How does sticking a needle into your arm show courage (I guess if you have a phobia of needles, then you might be able to convince me)? How does rubbing a cream into your skin display dedication and commitment? How does popping potentially harmful pills display a concern for health? Even after reading the argument, I fail to understand how the use of PEDs does not violate these tenants.

If one trains to his or her maximum ability and competes with integrity and courage, yet fails to win, this is undoubtedly an unsettling feeling. However, this effort satisfies all of the components to the spirit of sport, and I think most athletes can agree that there is a sense of pride for going down swinging with this type of defeat.

Now, take this same athlete, conduct the same training, and win because a needle was injected at the right time. At this point, the dignity the athlete had for losing despite an honest effort is taken away. Even if the athlete wins, he or she knows that that their victory had not been earned. This reminds me of Rocky 4 . Rocky ran up mountains and threw logs around; Drago trained with drugs and fancy 1980’s technology. Even if Rocky lost that fight, we all would still love his courage and will to fight for victory in an honest way. Rocky exemplified the spirit of sport in its truest form. Now picture that same movie, except Rocky has the needle injected into him. All of a sudden, that honesty and integrity is lost, and the spirit of sport he represented disappears with it.

The spirit of sport is not to drug away genetic differences, but to compete in spite of them. After all, a true underdog victory is one of the greatest things to watch in any sport!

Argument #3

(3) The third argument the authors present takes a closer look at how allowing PEDs would facilitate leveling the playing field in terms of the genetic lottery. As we have already touched upon, some people are born with physical attributes that leave them better equipped to compete in certain sports. For instance, those who have a genetic pre-disposition to a higher hematocrit, or red blood cell density, will have an increased ability to transport oxygen to their muscles and thus perform better in endurance oriented sports. Then, with the use of drugs like EPO, this genetic advantage can be taken away, which the authors believe is fair.

Here, the authors falsely assume that the genetic lottery is the only type of “lottery” that results in unfair advantages in sport. What about the individual who is born into a rich family and thus has access to the best equipment? What about the athlete who is fortunate enough to be surrounded by intelligent and encouraging mentors earlier in their life? What about the athlete who is born in a part of the world where higher education in fields such as human physiology, athletic training, and other topics advantageous to performance are easily attainable? What about the athlete who is born where proper nutrition itself is accessible?

Genetics is not the only reason why some athletes are born lucky.

If you haven’t done so already, check out the book ‘Outliers’ by Malcolm Gladwell. It discusses how hockey players with birthdays in the first 3 months of the year are the most likely to make it to the NHL. Why? Because they were bigger as kids. This size advantage got the athletes more attention and better coaching early in life.  They made the AAA teams, and this all carried through into adulthood.

Some have the advantage of the genetic lottery, some have other advantages. Just because some are born with lucky genes, that does not translate into definite success. It is only a single piece to the puzzle.

I would have to say it is fairly safe (and by fairly I mean extremely) to argue that Lance Armstrong has much better genes than me. There is no way I will ever be able to develop the V02 max he possesses when in peak form. However, with training, my 1^st marathon ever was faster than his 1^st marathon ever. Genetics does not equate to winning.

If this issue is looked at a little more closely, the leveling of the playing field that the authors discuss may not actually be taking place at all.  Imagine how legalizing PEDs would impact the poor, neglected athlete who has no training experience and a serious lack of proper equipment, yet still manages to excel because of his or her genetic aptitudes. Who are we to decide that these types of individuals should no longer excel? 

Allowing PEDs would not level the playing field; it would simply skew in favour of the genetically disadvantaged and otherwise advantaged subset of the population.

Argument #4:

 The next argument presented by the authors is essentially a counter argument to the notion that PEDs would just be for the rich. It references the cost to train, race, purchase high altitude tents ($7000 US) among other expenses, and how they compare to the relatively “inexpensive” EPO ($122/month).

This argument fails to acknowledge that (1) $122/month actually IS expensive and (2) even if the PEDs are affordable, it is not a reason to use them.

$122/month equates to just under $1500/year. Is this cheaper than some expenses that high end athletes accrue? Yes. But this is an expense that most athletes cannot incorporate into the baseline cost of doing business. Consider, for example, the 2011 Boston marathon. The prize structure is set up so that the 15^th place runner received $1500. Just enough to cover the cost of EPO for the year. In 2011, that 15^th place runner finished in 2:16:54. A blazing time at one of the highest profile races in the world gave him just enough money to use EPO for the year. The 16^th place runner finished in 2:17:35, still an amazing time and a great finishing position. This runner is elite, and yet received no prize money. So would the use of PEDs be affordable to all high end athletes? I think it is pretty clear that the answer is no.

While it is true that PEDs are not affordable to many athletes, arguing this is irrelevant. Does being able to buy drugs provide reason to use them? The core reasons why PEDs should not be allowed has nothing to do with unequal distribution. Even if each and every athlete had the same access to the drugs (which they do not), it still violates spirit of sport and competition.  

Argument #5:

The next argument this article presents looks into how allowing and subsequently regulating the use of PEDs would result in an increased level of safety. They argue that the use of EPO, for example, is only dangerous when you start to increase your hematocrit over 0.5. So, athletes should be allowed to dope up to that level, and then be monitored to ensure that they stay there.

This is a complicated issue because it must be looked at on a case-by-case basis. First of all, the authors do admit that any drug that induces potential danger to the athletes should be banned (such as anabolic steroids).

“We should permit drugs that are safe, and continue to ban and monitor drugs that are unsafe,” they state.

That's a step in the right direction.

One of the main  "safe drugs" that is discussed in this argument is EPO. Once you start increasing your hematocrit above 0.5, the viscosity of your blood starts to get to the point where it is a challenge for your heart to push the blood through your blood vessels. This can result in death, simply due to an inability to adequately transport oxygen throughout your body.

So yes, keeping the hematocrit at 0.5 would decrease the risks associated with the drug. But those are not the only risks. A recent study did a great job of summarizing some of the key adverse reactions to the use of EPO:

"Adverse effects of recombinant human erythropoietin

•  Flu-like symptoms: Commonest side effect which subsides within 24 hours
•  Allergic and anaphylactic reactions
• Seizures and hyperkalemia: Rare
• Hyperviscosity
• Thrombosis: A meta-analysis involving nearly 10,000 cancer patients indicates that treatment with rhEPO increases the risk of thrombosis
• Hypertension
• Possibility of cancer progression: There is somewhat less convincing evidence that rhEPO enhances tumor progression
•  Pure red cell aplasia (mainly reported in patients with CKD): Autoantibodies in the serum can neutralize both rhEPO and endogenous EPO. This was mainly observed in CKD patients, especially after SC injection. Its incidence after 2000 has reduced, especially with the IV formulations”

Do these issues only arise when the drug is used in excess? Or would the chronic use of EPO to maintain a hematocrit level of 0.5 throughout a 15-20 year career also lead to these adverse reactions? At the end of the day, I would not want to take the risk, and I know I would not be alone. This drug may be safer to use if hematocrit levels are monitored, but the legalization of EPO would also encourage people to use a drug that could potentially lead to a number of other adverse reactions.

The only fool-proof way to ensure that nobody suffers adverse reactions to EPO is fairly simple; don't use it. It is extremely difficult to die at the hands of a drug that never enters your system. This is where the money should be spent; discouraging athletes from using EPO rather than monitoring and regulating its use.

Conclusion:

There is no doubt that J. Savulescu, B. Foddy and M. Clayton present some arguments that warrant debate and thought.  But when this debate and thought is applied to what they present, the flaws in their logic quickly shine through.  Our testing protocols may not be perfect, but they are headed in the right direction.  Taking away the genetic lottery would not level the playing field, but only skew it in favour of a select group.  The use of PEDs is not a cost that most athletes can or should attempt to afford, and the side effects will still be a worry even if the drugs are regulated.   Finally, and most importantly, the use of PEDs quite clearly violate the spirit of sport.  When logic is applied to what  J. Savulescu, B. Foddy and M. Clayton present, our thoughts quickly match up with what the intuition of most have been saying all along: the use of PEDs in sport should not be allowed. 

Frozen Shoulder

Here is my article from this month's addition of the New Hamburg Independent health section.  It is a basic summary of a common and poorly understood shoulder condition: adhesive capsulitis.

As always, feel free to comment or e-mail if you have any questions!


The truth about frozen shoulder

Shoulder pain is a very common problem affecting Canadians. There are a diverse range of tissues that can become injured and lead to shoulder pain including; muscles, ligaments, nerves and even cartilage within the joint.

However, there is another relatively common source of shoulder pain that seems to be poorly understood and is often misdiagnosed. This condition is referred to as ‘frozen shoulder’ or ‘adhesive capsulitis’.

Adhesive capsulitis affects 2-5% of the general population, but affects anywhere between 10- 34% of people who suffer from diabetes or thyroid conditions.

Common symptoms of this disorder include pain and/or reductions in range of motion that get progressively worse, sharp pain with certain movements, and an abnormally hard or abrupt end feel when moving the shoulder.

This collection of symptoms, while concerning, does not mean you suffer from adhesive
capsulitis by necessity. Rotator cuff tears, fractures and even arthritis can present in a similar fashion. However, the key issue with adhesive capsulitis is the length of time it requires
to heal. In fact, research has shown that adhesive capsulitis can take anywhere between 18-24 months to completely resolve.

Throughout this time frame, the condition is typically divided into three phases. Stage one, otherwise referred to as the ‘freezing’ stage, is characterized by a progressive loss of range of motion of the shoulder and increased pain. Stage two, the ‘frozen’ stage, describes a period of time where the shoulder pain and range of motion reaches and remains at a plateau. Finally, the third ‘thawing’ stage is marked by range of motion that slowly improves, accompanied by gradually decreasing pain.

So, why does adhesive capsulitis take so long to improve? The honest answer is that scientists and doctors are not completely sure. Some studies have shown it is related to blood flow, and how your arm connects to the shoulder blade.

Surrounding the joint where the humerus connects to the shoulder blade, there is a bag
of connective tissue that contains a joint fluid to help facilitate smooth and frictionless
motion. Studies have shown that with adhesive capsulitis, there is a significant amount of inflammation and adhesions that build up between that joint capsule and the joint itself.

In order to be symptom free, the joint capsule must be detached from the underlying bones and heal fully. There is poor blood supply to these structures, and that partially explains why it takes so long for the capsule to return to normal, and for full motion to be restored.

Nobody wants to suffer for 18-24 months. So what can you do to help improve your recovery time? The first line approach should include conservative measures to help maintain and improve your range of motion. Shoulder mobilizations, soft tissue therapy and a strong commitment to a rehabilitation plan may help control symptoms and maintain function.

In more persistent cases, surgery may be worth considering. For example, surgeons may opt to enter the shoulder joint arthroscopically, and cut the adhesions between the capsule and underlying bones.

With whatever you chose to do, it is important to keep in mind there is no evidence showing one treatment to be better than the other. What may work for one person may have no impact on another.

Also, with this condition, it is very important to not get discouraged. While it is a long wait, one should keep in mind that most cases of adhesive capsulitis will get better on their own within 24
months.