Adapt and Overcome – by Anji Close

Anji is a club runner for Tyne Bridge Harriers who has very kindly agreed to share her injury story with us. What shines through is her determination, positive attitude and commitment to staying fit, which she did largely through aqua training. For more information on this, visit Anji's blog where she has details of training and videos of deep water running. Now it's over to Anji…

When I signed to my club Tyne Bridge Harriers in January this year, I had no idea how my first year in my black and white vest would pan out. I raced as a TBH only 4 times before being struck down with a serious injury, and at time of writing I haven’t run in almost 4 months. Here is my journey.

After recovering from a stress fracture (left cuboid) in early 2011, running became my life. I had been out for 10 weeks and during that time I swam twice every day, read nothing but training plans and came back knowing that I just couldn’t be without running in my life. I completed my first half marathon in September 2011 and became addicted to the buzz of racing, but often carried niggles particularly in my feet and ankles. I ran with the motto “Determination Is Everything” and never let myself feel beaten. At the end of 2011 I had set a new 10kpb by over 4 minutes as well as running my first 5mile race and my first multi-terrain 10k.

Signing to Tyne Bridge gave me more confidence and joy in my running than I had ever had before, and I’m first to admit this new vigour led me to massively increase my mileage to feed my addiction. I had entered masses of races and felt I really wanted to prove myself in the ladies team. New pain in my right foot leading into my first ever relay race in February 2012 led me to run awkwardly and during training in early March, I found myself with new severe pain in the left. I stopped running for a week or so and saw physio who diagnosed a ligament sprain in early April following an incredibly painful 10k and a niggly half marathon all in the same week. Looking back, I did everything wrong. At the end of that 10k I couldn’t walk at all and I knew something was seriously wrong. Again, I took a couple of weeks off running and returned with hope that I would make it back for my race of the year, the Manchester 10k which I was running with my coach pacing me for what would hopefully be my first sub-45.

My few runs in the interim were niggly and ended in loads of pain again, and my frustrations led my GP into recommending I had an MRI scan. The scan results came back on May 15th(the week of Manchester) and confirmed that I had two acute stress fractures in my left heel as well as evidence of a healing fracture in the fourth metatarsal on my right foot. I was devastated. I just had no idea how I was going to cope with a long period out again. The MRI images were sickening and I spent quite a long time over the following weeks just looking at them in disbelief.

I saw three orthopaedic specialists in that first week and all of them thankfully agreed that I wouldn’t need to wear a cast. Instead I was given crutches and a walking cast “moon boot” and ordered that I couldn’t weight bear or even cycle for the first month. Heel fractures are treated like an egg shell where one crack can lead to another and they told me this could go on for up to 12 weeks. The first weekend I was in the boot I travelled to Manchester as my accommodation was already paid for and I was determined to still be there for my coach who was now going to run it sub-45 just for me. I had an extremely emotional day but I managed to meet one of my running heroes Nell McAndrew who was wonderful and very supportive about my injuries.

Week 1

What happened next was a true cruel twist of fate that was to shape my rehab and recovery over the following few months. My coach and running buddy Rob came through the finish looking laboured and in pain, went missing for ages in the medical tent area and eventually came through in sheer agony. It is still hard to believe but the following day back at home, Rob was diagnosed with an acute stress fracture in the same foot as me. Now if you’re going to be injured with anyone, best be someone who already knows all of your moans and demands in training. Together we researched rehab options and following a few recommendations from people at the club, embarked on an aqua running programme. I had recently passed my Leadership in Running UKA qualification and decided to have a go myself at adapting an aqua running plan I had found online, as well as seeking advice from marathoner Aly Dixon who had previously been out for a long period with fractures in her foot and remained strong by using pool work. The plan was epic and included “long runs”, pace work, interval sessions, pyramid sessions and daily swimming or gym work focusing on upper body or core. The sessions were designed to mimic what you would do on the road as well as raising heart rate and keeping the legs strong. Deep water running using a floatation belt is often used by athletes when injured or for cross training, and at that stage it really was our only choice.

Week 6

I’d be happy to share the plan I created with anyone reading this, but there are several good ones online worth looking at if you are going to be out for a while. My plan comes with something of a health warning. An example week would look like this:

Sunday: Pace session of 2 sets of 7×1:30 hard with 30 sec recovery

Monday: Interval session of 2 sets of 6×2:30 hard with 30 sec recovery

Tuesday: Long Run of 60 mins steady aiming to do a mile

Wednesday: Pyramid session 1min up to 5mins hard and down to 1 again

Thursday: Rest (gym work only)

Friday: Block session of 6x 5mins hard

Saturday: Swim only.

NB: All sessions include at least 5min warm up and cool down of steady steps.

‘Hard’ is aiming to get to high cadence of 180steps per minute.

The plan was progressive and led into sessions of almost 70mins with 60 at high cadence.

Aqua running became our new addiction and the burn in the quads as well as weekly photographs of my legs (!) showed us that it was working. The high cadence of 180 was initially a challenge but once it clicks it becomes natural and we now regularly finish the sessions with a minute “race” in which my PB is 227 steps with Rob’s at an epic 241!

Now I’m not going to lie to you and say that it has been easy. Aqua running can be soul destroying. Its tiring, the constant cycle of getting in and out of the pool (some days twice) 6 days a week with a very uncomfortable belt on has led to several quite explosive arguments between Rob and I, I have cried in the pool and on two occasions I have got out, taken the belt off and said “I cannot do this today”. It’s hard to keep focused sometimes when you have no way of really knowing if what you are focusing all of your energy, time and often money into is actually even working. But we supported each other and as we are coming to the end of the 9 week programme, we agree we are glad we’ve done this together.When we finish the plan this week we will have done 48 aqua running sessions and only one of those was apart.

Now the big question. DOES IT WORK?

Following a few setbacks, I am still partly using crutches and not cleared to run. My heel still swells every day and can be painful to walk on. I can cycle and I’m beginning to use the cross trainer, and I know that I’m nearly at the end of this awful time. Rob however is a different story. His fracture is almost fully healed and he is running a few times a week now, and FAST. Rob tells me the high cadence his legs are used to in the pool has translated now to the road and this style along with how strong his legs are now has led to fast miles and in his first race back, a 2mile handicap race at our club he recorded a new PB of 12:16. He inspires me all the time and keeps me believing that I will come back stronger and faster.

Anji and Rob

 

It’s 16 weeks today since that 10k which I finished unable to walk and for almost 11 of those weeks I have been on crutches. It has been one of the worst periods of my life and at times I have thought frequently that I will have to give up on the only thing I have ever really loved. I have taken myself away from the running world a few times and I have shut people out who I felt wouldn’t understand. I absolutely can’t wait to run again. I have ended up missing Sunderland 10k, Manchester 10k, Potters Half Marathon, Bridges of the Tyne 5 mile road race and the Great North 10k, and I’m slowly making peace with the fact that I probably won’t be ready for my beloved Great North Run on September 16th. I have remained an active part of my club, working for our Twitter page @tynebrharriers as well as working on registration and results for our inaugural road race at the start of July. I also recently worked as a marshal for Great Run and the GN10k in Gateshead. It can be emotional knowing I was meant to run, but the rewards have been immense. Whilst injured I have met Nell, Aly Dixon, Steve Cram, Sally Gunnell, Gemma Steel and Scott Overall, all through being part of races I was meant to run in, and all of them have signed my unused numbers so that I wouldn’t be tempted to burn them in a fit of frustration.I would urge people with long-term serious injuries to remain involved in racing wherever they can.

I really believe in the phrase “Run the mile you’re in” and not to look back or forward. It just so happens that this particular mile has been long, painful and frustrating. But it won’t be long now, and I just can’t wait.

Determination Is Everything.

You can follow Anji on Twitter; @enigmagirl81. Tyne Bridge Harriers are based in the East End of Newcastle, if you fancy joining them, you can do here.

 

 

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Back pain and running – acute management advice

Today's blog is the start of a series on lower back pain (LBP). It's a complex area and so needs to be looked at over several blogs instead of one monster blog!

The first question with a back problem should be should I seek medical advice? The aim of this article is to help you answer this question.

Pain from the lower back can be severe and distressing but in most cases it is not due to serious disease or damage. The spine is a strong, stable structure that is unlikely to be harmed by normal everyday activities.

RunningPhysio always recommends seeking medical advice for injuries, and this is especially true with LBP. That said, approximately 80-90% of us will have back pain at some point and not everyone will choose to see the GP. Ultimately it's always your decision, but here is some guidance;

Likely to resolve with self management

• Pain is only in the lower back and doesn't spread into the buttocks, legs or feet
• Pain is mild to moderate in intensity (if rated out of 10 where 10 is the worst possible pain, you'd rate it 1-6)
• No pins and needles, numbness or unusual symptoms
• You can ease your pain in certain positions or using medications
• You're generally well in yourself

Action – general back pain management advice (below) consult with GP/ Health Professional if pain worsens or doesn't settle in 6-8 weeks. As ever if in doubt get it checked out.

Definitely see GP/ Health Professional if…

• Pain is more severe (you'd rate it 5-10 out of 10)
• Symptoms spread into buttocks, legs or feet
• You experience pins and needles or numbness in one or both legs or feet
• Leg/s feels weak or heavy.
• Pain is constant or harder to settle
• Your pain started following a mild/ moderate trauma – heavy lifting, turning in bed
• You have any previous history of cancer, TB or rheumatological conditions or your general health has deteriorated since your back pain started (especially if you have weight loss, night sweats, nausea or vomiting)

Action – see your GP or a health professional. Back pain with leg pain is a sign of inflammation around a nerve, especially if accompanied with pins and needles or numbness or weakness in the leg.

Attend A&E if along with back pain you experience…

• Urine retention – feeling the need to pass urine but being unable to go
• Faecal incontinence – losing control of bowel movements
• Saddle paraesthesia – pins and needles or numbness in the groin and between your legs, may also include erectile or sexual dysfunction.
• Gait disturbance – legs feel wobbly or unsteady and it's affecting your walking.
• Your pain started after serious trauma – RTA, fall from height, heavy collision during sport etc.

Action – head to Accident and Emergency (A&E) immediately. The above symptoms suggest more serious injury that needs immediate medical attention. There are a group of nerves in the lower back called 'cauda equina' these nerves supply the parts of the bladder and bowel involved in passing urine and faeces. If there is compression to these nerves and it's not addressed quickly it can have long term implications on bladder, bowel and sexual function. Thankfully this is rare, a study in 2007 estimated that it affects just 3.4 people per 1.5 million of the population. In my 10 year career I've only had to send 1 patient to A&E with suspected cauda equina compression.

General Back Pain Management Advice

Stay active – try and stay active where possible, this might include walking, cycling, gentle gym work or swimming you can do this by pacing yourself…

Pace yourself – often the key to managing pain is doing the right amount of activity, too much and you can get sore, too little and you can get stiff and weak. Pacing means doing as much activity as you can manage, usually this means 'little and often' rather than lots at a time. Gritting your teeth and pushing on through pain will often make pain worse. If you can run without pain (during or after) then you can continue to do so but don't over do it – stick with gentle comfortable runs. Ideally you should be within the first category mentioned above ('Likely to resolve with self management') if not then consult your GP or health professional before returning to running.

Stay positive – the majority of low back pain settles in 6-8 weeks and can still be treated well beyond this stage. Keep a positive attitude and bare in mind severe pain doesn't mean severe damage. The back is a sensitive area with multiple nerves which mean you can get severe pain there, even in the absence of significant damage.

Continue working – taking prolonged periods of time off work doesn't always help back pain. When off work we tend to be less active and spend more time sat and the back stiffens and gets worse as a result. People that continue working usually tend to do better than those that stop. That said, jobs that involve very heavy lifting may prove very difficult – in which case request a period of time on light duties rather than stopping work altogether.

Avoid bed rest and prolonged periods of inactivity – the old advice of taking to your bed or sleeping on cupboard door has been shown to cause more problems than it solves! Long periods of sitting, standing or lying in bed tend to make pain worse. Most people do a lot better by staying active.

Use appropriate pain relief – many people are reluctant to take pain relief incase it 'masks damage to the back' (I.e. they worry they will damage their back if they use analgesia to reduce pain), this is not the case. Pain relief allows people to stay mobile which prevents the back becoming weak and tight. Movement is good for the back (as long as you don't over do it) pace yourself and do what you can.

Try to settle symptoms – use heat/ ice, gently massage the area, try a few gentle back movements, have a swim, sauna or jacuzzi – see what works for you to settle your symptoms.

More information available here including some gentle exercises to try.

Final thoughts; back pain is very common and in the vast majority of cases does not involve serious disease or damage. The back is a strong stable structure, supported by strong ligaments and muscles and is capable of managing day to day activities. Most acute back pain will settle in 6-8 weeks, stay active, pace yourself and keep positive to help with a speedy recovery.

Part 2 coming soon – causes and solutions for back pain in runners.

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Getting more than you bargained for…

I woke up this morning to my phone's usual angry buzzing, hit the snooze button as many times as I could get away with and then reluctantly rolled out of bed. There on my phone was a little white 1 in a red circle, resting quite happily on top of the little bird from my Twitter App. What might that be I wondered? A message from that Cat that tells jokes? A retweet from Jon the Pigeon?

I slurped a little tea and had a look. It wasn't cat or pigeon but @runblogger;

 

I read his blog and is it a little sad to admit that I was delighted?! Runblogger.com is one of the largest running blogs around and Runblogger – AKA Pete Larson – is an exercise physiologist who's even had an excellent book about running published. After taking a little bit of criticism for my blog this weekend it was great to see him complimenting the piece.

Pete is part of the reason this site has taken off, he gave me a foot up in the early days when for a long time a link on his blog was my largest referrer. Even today we've had well over double the normal traffic just from his article! So if you're aren't following him on Twitter, now is the time to do so and check out his book which is available to download on kindle or buy as an actual book!

And Pete if you are reading this, thank you, your blog and it's nice comments made my day!

 

Yesterday's run was one of my favourite of the year so far. There wasn't a cloud in the sky and I ran a hot 13.5 miles in 1:48:35. The scenery was so stunning I had to stop for photos and got a little more than I bargained for…I just wanted a photo of the light shimmering off the sea…imagine my surprise when I checked the photo after my run….

Click to enlarge

Oops. Won't be framing that one!

This one on the other hand…

What's nice too is my 'rehab days' are starting to pay off. Since Brighton Marathon I've had some issues with my left knee. It's part ITB tightness, part patellofemoral pain. I've been spending at least one evening each week working quads (with single knee dips) and glutes (with sidelying abduction) then foam rollering ITB, hip flexors and calf muscles. It seems to have really paid off. Minimal discomfort on the run and no problems today.

Strength and conditioning has its benefits, and if you're running 4 or more times a week it's worth considering replacing a run each week with a rehab day or just adding it in if you have time. I'll close today's blog with another photo… Nothing rude in this one, I promise!

 

 

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Taping for the knee

You may have seen elsewhere on the blog the use of a modified McConnell taping for knee pain;

It's very useful for ITB issues and patellofemoral pain (often described as runners knee) – follow the links for more info on both.

Today I'm adding a more general tape for knee problems. It's designed to offload the knee a little and will help with most knee problems;

When you watch this second one, do bare in mind that a) FMG filmed it – somewhat reluctantly – and b) I was suffering from a Belgian beer hangover – for which I blame @Captain_Critic! Still the technique is there and easy to follow.

For both techniques I use Kinesiology Tape. Round the corners first with scissors to stop them catching on anything and peeling off. Make sure the skin is dry – use a towel to remove sweat or moisturiser (do women moisturise their knees? I have a male patient that does for some reason!) When applying the tape you first create an “anchor” of an inch or two under no tension, this helps it stick. Provide a gentle stretch to the tape as you apply, apart from the last inch or two which has minimal tension and is used as a second anchor. I know serious KT advocates use very different techniques with no tension, that's fine too you can find lots of those on YouTube, personally I find this method more supportive to the area you are trying to offload.

Tape can be left on for as much as 7 days! It will survive a shower, even a swim if it's good tape. It's not usually good after a long bath though. If you find it uncomfortable or have any redness, itching or reaction to the tape remove it.

Tape is good to use as a support/ offload strategy. Apply it at least 20 minutes prior to sport to allow it to stick properly, leave an hour if possible. You may just use it when running, or for longer periods if you have a very painful, irritable knee to help it settle.

Happy taping!

 

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Oops I opened a can of worms!

Yesterday's blog on research in sports got an interesting response, from nodding agreement to being told it was “utter crap!”

The critics said I was talking up the “personal anecdote” and that without research we can't know about “causal inference” i.e. what really has created the change we observe. Two good points, to be fair.

I've given it some thought and I stand by what I said, research is part of the reasoning process and not all of it.

In an ideal world we'd have conclusive research that had reached consensus on what treatments are most effective. We'd draw on that research and have truly evidence based practice. In reality there are few areas where such consensus exists. You've seen with my recent post on glucosamine and chondroitin, there are studies for and against and you take them all in to your reasoning process.

In time maybe a consensus will be reached on more topics. Only fairly recently have we reached agreement on the things we're actually treating. We've discovered that there may not be inflammation involve in tendonopathy, that ITB friction syndrome may not even involve any friction and that we can't diagnose around 85% of low back pain! How can we approach consensus on treating these areas when we aren't really sure about the underlying problem?

I had an interesting discussion with @NeilOConnell about this on Twitter. Some areas we have a consensus, an agreement on best practice, such as early management of low back pain – we know it's best to stay active and avoid prolonged bed rest. The same may be true for tendonopathy – a graded eccentric loading programme is generally considered a sensible approach. In some areas though we appear to be a long way from agreement. Look at these two papers on resistance training; The American College of Sports Medicine (ACSM) have produced recommendations based on over 200 research papers, despite this their findings were heavily ciriticised. Even if we use the ACSM's guidance, it's based mainly on healthy individuals, can we use that for those with injuries? So what do we do then? This was part of my point yesterday, in many areas the guidance from the research is unclear and we have to use it with clinical reasoning and experience.

Another issue here is biology isn't everything. In recent years we've realised that biological changes aren't always consistent with symptoms. Around 50% of people have a disc bulge on MRI without symptoms. X-ray changes with arthritis in the knee match very poorly with pain. We've developed a biopsychosocial model to help us see that the way a patient thinks, feels and behaves affects their symptoms and that work, lifestyle, relationships etc all play a huge part. Some research is based in this field, but a lot of research is based more in a simplistic medical model – diagnosis + treatment = outcome. There are some amazing studies on Psychoneuroimmunology – how stress, mood and how we think actually directly affects healing. We know that beliefs play a big part too, especially in pain. It's not easy to assess these factors and include them in research but we know they can play a part. This all comes back to my points yesterday on assessing each individual and seeing how complex the decision making process is and using guidance from the literature where possible.

I'm glad to see I'm not alone in thinking this, fellow sports physio @AdamMeakins has written about it today. I must also give him a great deal of credit for sending me this article by Hanson et al. 2012 in the British Journal of Sports Medicine which neatly sums up what I'm trying to say.

They comment on the complexity of the situation and how people's “natural, physical and social environment” influence each other leading to poor translation from research to practice, taking a quote from Green (2001),

“Where did the field get the idea that evidence of an intervention's efficacy from carefully controlled trials could be generalised as best practice for widely varied populations and situations?”

They talk about the importance of expertise, acknowledging the role of experience,

“However, there is also a need for better translation of evidence from practice into research…perhaps the real barrier is not lack of understanding, but a failure to listen! Good communication, good translation and indeed good research are necessarily a dialogue, a multidirectional conversation in which everyone's contribution is valued. If we could find the humility to listen we might be surprised to discover that policy makers, practitioners and the sporting community have valuable expertise that can enhance our research by making it more relevant, more practical and more applicable in the real world”

According to my stats I've seen over 5000 patients in a career spanning 10 years and multiple Physio departments both in the uk and abroad. Should this stand for nothing in my decision making process?

Hanson et al. 2012 conclude with this,

“Injury prevention research that does not connect with the practical realities of implementation and adoption, and does not build the consensus needed to ensure effective implementation, will not prevent injury or improve health”

So here I am, squishing the lid back on my open can of worms…my final point comes back to my point yesterday, I am not saying we can ignore research. I acknowledge it has a vital role but it is part of the reasoning process not all of it.

From Hanson et al. 2012

When I get some time I will try and reference some articles talking about things like is there friction in ITB syndrome and diagnosis of LBP…just haven't had the time yet today!…

 

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Research isn’t everything…

BBC's Panorama this week exposed the paucity of evidence behind some of the products involved in sports. I have to say, overall, I wasn't impressed with the programme – they had an agenda and fought to find evidence to suggest these products didn't work. A more balanced view would have been more helpful but it does raise a broader question on sports and rehab, “is anything backed up by research evidence?”

Let's look at some thoughts from the research on common sports practices and treatments;

“Protection, Rest, Ice, Compression and Elevation (PRICE) has been central to acute soft tissue injury management for many years despite a paucity of high-quality, empirical evidence to support the various components or as a collective treatment package.” Bleakley, Glasgow and MacAuley 2012

“While studies of strength, biomechanics, stretching, warm-up, nutrition, shoes, and psychological factors all raise intriguing questions about both the etiology and the prevention of running injuries, strong evidence that modifying any of these will prevent running injury requires further research.” Fields et al 2010

“The prescription of PECH running shoes (shoes with elevated cushioned heels and pronation control features tailored to foot type) is considered best practice when prescribing shoes to distance runners. However, the findings of biomechanical and epidemiological studies continue to call into question the efficacy and safety of this approach…..This systematic review found that PECH running shoes have never been tested in controlled clinical trials. Their effect on running injury rates, enjoyment, performance, osteoarthritis risk, physical activity levels and overall athlete health and wellbeing remain unknown. The prescription of this shoe type to distance runners is not evidence based.” Richards, Magin and Callister 2008

“Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise or physical therapy.” Lederman 2008

“In conclusion, there was little quality evidence to support the use of KT (Kinesio Taping) over other types of elastic taping in the management or prevention of sports injuries” Williams et al. 2012

So we shouldn't use ice, stretching, warm-up, running shoes, core stability or kinesio tape? Should we just stop everything?

There's more, I could go on and on (like usual!) but I've made my point…there is a surprising lack of evidence behind much of what we do, is it fair of the BBC to pick on just those things recommended by big sports companies? Also worth pointing out that for every opinion, like those above, there will be another piece of research saying the something different.

Research is part of our reasoning process, not the entirety of it. Experience and individual circumstances make up much of our decision making process. So ice may not have great research but I've seen it work for hundreds of people so I will continue to recommend it. Warm-up may not have concrete evidence to show it reduces injury risk but I feel a whole lot more comfortable running if I've warmed up properly so I'll keep doing it. The literature on running shoes might be inconclusive but when a patient presents with plantar fasciitis and can't even walk barefoot I won't be telling them to run barefoot! The shoes vs barefoot running is a huge topic for discussion and one Panorama really failed to cover fairly.

Panorama told us that an isotonic drink is no better than a jam sandwich! One of my favourite tweets last night was this by @sportprofbrewer;

 

Research itself is a limited tool. You have to ask how does it repeatedly fail to show that treatments work when we see them doing so again and again with our patients? Literature also fails to simulate the way physiotherapy works. We assess, form a diagnosis and identify key problem areas (like weakness, stiffness, poor control etc.). Our treatment is based on this and the individuals circumstances – level of pain, other medical conditions, work situation etc etc. Research, by comparison, often uses an intervention to treat a specific diagnosis. For example are quads strengthening exercises effective for patellofemoral pain? They probably will be for those with weak quads, probably not for those with weak glutes or a tight ITB or any of the other potential causes. What happens is a “washing out” effect whereby some of the patients get better but not enough to reach a “statistical significance” and they conclude “quads strengthening may improve patellofemoral pain but more research is required…”

There is of course, no doubt that research has it's role in our decision making process and there is some fantastic work being done but we need to acknowledge its limitations. Your experience and what works for you is as important, if not more so.

The BBC raised some useful points and it's important to question a manufacturers claims, which, to be fair to them was the aim of their programme. But when it comes to sports practices, products and treatments there is a much bigger decision making process than just using research. So you can retrieve your expensive trainers from the bin. Stop pouring your performance drinks down the sink and put your ice pack back in the freezer before it defrosts – it's not all as useless as the literature might have you believe!

 

 

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Should I take Glucosamine and Chondroitin?

No.

Phew, that was a short blog. Time for a cuppa and a biccie I think…

Alas, if only it was that simple…

… I get asked a lot about Glucosamine and Chondroitin (G&C) supplements in my clinic. They are, in theory, the building blocks to cartilage and have been widely recommended to reduce the progression of arthritis and cartilage problems. They are also part of a multimillion pound industry and one that funds much of its own research.

In 2010 the British Medical Journal (one of the most reputable of all scientific publications) published this article by Wandel et al. which reached fairly damning conclusions about the use of G&C. They performed a 'Network Meta-Analysis' of the available evidence (up to June 2009) and reviewed the data from the 10 trials that met their inclusion criteria (i.e. that they found were of suitable quality). These trials included a total of 3803 patients with arthritis of the knee or hip.

Their review examined the effect of G&C supplements (including Glucoasmine, Chondroitin and a combination of the two) on pain and joint space narrowing versus placebo. Pain was measured on a 10 point Visual Analog Scale (VAS – this means they were asked to rate their pain from 0 no pain to 10 worst possible pain and note it on a 10cm scale). Joint space narrowing can be seen on X-ray and occurs as a consequence of arthritic change.

They found that the overal difference in pain intensity compared with placebo (on the 10cm VAS) was -0.4 for Glucosamine, -0.3 for Chondroitin and -0.5 for the combination of both. All except 3 trials were funded by the manufacturers of the supplements. For those that were independent the treatment effect was 'minute to zero and by no means clinically relevant.' The changes in minimal joint space width were also all described as minute leading them to conclude,

“Compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space. Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.”

Reproduced from Wandel et al. 2010

So is it fair to conclude that it's not worth taking G&C supplements?

Well, sort of.

That's the definitive answer you were after! With any aspect of health care the decision is always that of the individual. I won't say, “take this” or, “don't take that”, instead I present the evidence to people to let them make an informed decision. I have seen patients describe dramatic reductions in pain after taking G&C. If the supplement helps your symptoms it may be worth continuing it, especially if stopping taking it causes an increase in pain. I've also seen many report no change and complain about the ongoing cost. 1 or 2 have reported occasional side effects, although these supplements are generally considered fairly safe to take.

Other studies have shown more promising results, with Bruyere et al. (2008) concluding G&C may reduce the need for total joint replacement. It's worth noting however, that in terms of quality of evidence, a systematic review of multiple research papers is usually considered better evidence than an isolated study. A recent meta-analysis of over 1500 cases by Lee et al 2010 did show that G&C may slow progression of osteoarthritis (as measured by X-ray change) although it required taking it daily over 2-3 years.

Sawitzke et al. 2010 found “no clinically important difference in pain or function” when compared to placebo. The Cochrane Review (2009) – Glucosamine Therapy for Treating Osteoarthritis had somewhat mixed results but concluded it may reduce pain and improve function.

The National Institute of Clinical Excellence (NICE) guidelines are seen by many as a reliable opinion on medical matters. Their guidelines on the management of osteoarthritis stated that,

“The use of glucosamine products is not recommended for the treatment of osteoarthritis.”

Prices of G&C vary a great deal, currently Boots Pharmacy has a 2 month supply at £30, meaning a 2-3 year course would be £360-540. If you chose to use just Glucosamine (without chondroitin) a 6 month supply is £30 meaning £120-180. So the question you need to ask yourself is, am I willing to spend that much on a treatment that might help or may make no difference to my pain or the progression of arthritis?

Words of caution: If you are planning to take supplements to treat arthritis or other conditions discuss this with your GP or Pharmacist.

 

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Resistance training and running

Resistance Training (RT) means the use of some form of resistance against muscular actions of the body. Commonly this can involve free weights, such as dumbells or kettlebells or weights machines such as leg press, leg extension or hamstring curl.

RT and distance running haven't always had an easy relationship. Many people believe that RT isn't helpful for distance runners and can even have a negative impact on performance. Some go as far as saying “performing weights using a machine should NEVER be done by any runner.”

The arguments against RT usually centre around a few points suggesting it isn't functional, can negatively affect performance and may reduce activity of stability muscles. These arguments may be valid but I've never seen them presented with any research evidence to support them.

Regular readers might remember we had a similar issue with the use of sidelying exercises for glutes. A number of people are adamant they shouldn't be used for rehab despite extensive research showing they have a role. This appears to be the case with RT, and once again I would urge people to remember that nothing is set in stone with physiotherapy or exercise science. As soon as you declare something to be an absolute certainty someone will find evidence to the contrary. I think it's important to be relaxed in your opinions and open to the ideas of others. To that end, I would recommend you read the article that the quote above comes from. That way you can see both sides of the debate and make an informed decision.

The National Strength and Conditioning Association (NSCA) recommends RT for endurance athletes;

“Intelligent use of the weight room, just like intelligent implementation of a running program, can have a dramatic influence on the success of the competitor. This success can be defined as faster running times, but can also be extended to include reduced injury risk, and an overall heightened enjoyment of the sport, a goal that many athletes surely have.” Erikson 2005

More evidence for the use of RT comes from excellent articles by Jung (2003) and Jones and Bampouras (2007 summary only). Their reviews of the literature will form the basis for our conclusions here.

We'll look at the effect of RT on a few key factors in running VO2 Max, lactate threshold, running economy, injury prevention and injury rehab.

VO2 Max

VO2 Max is the maximal capacity of an individual's body to uptake, transport and use oxygen during exercise. It is often used as a measure of physical fitness, more details available here.

Research has concluded that RT is unlikely to increase VO2 Max in trained individuals but also has been shown not to decrease it. I.e. while it might not help, it doesn't hinder.

Lactate Threshold

Lactate threshold isn't easy to describe. This very useful article defines it as “the fastest pace you can run without generating more lactic acid than your body can utilize and reconvert back into energy”

There wasn't a great deal of research into RT and lactate threshold. 1 study showed an increase in untrained individuals but no change has been shown in distance runners. Once again RT was shown not to have a negative impact.

Considering the nature of RT we wouldn't expect it to improve VO2 Max or lactate threshold in trained individuals. RT is not usually an activity that involves prolonged periods of exercise with high demands on the cardiovascular system. Instead it usually requires bursts of activity placing muscles under load. We wouldn't expect it to improve cardiovascular fitness and the research appears to have confirmed this.

Running Economy

Running Economy is how efficiently a person uses oxygen while running at a certain pace. It is a measure of running efficiency, a little like how much fuel a car would use at a certain speed. Imagine I asked you to run with a fridge on your back, it would drastically reduce your running economy but your VO2 max wouldn't change. You'd still be as fit physically, but you'd run a lot slower due to very poor running economy. On the upside, you could stop occasionally and snack on something from the fridge!

RT has been shown to improve running economy and Jones and Bampouras (2007) point out that there is a strong association between running economy and distance running performance.

The exact mechanism by which RT improves running economy hasn't been defined but there are several theories on how it works. A short version is this – resistance training improves muscle strength, neurological characteristic and 'stiffness' resulting in more efficient use of energy with every footfall. For the more technical amongst you it is thought to affect the Stretch Shortening Cycle improving efficiency of translation of ground reaction force into forward propulsion.

Thinking about it from a more common sense point of view, imagine if your legs were so weak you could barely get up from a chair, you wouldn't be able to run very well at all. Now imagine they are so strong and muscular that you look like Arnie in the 80's and your thighs are visible on GoogleEarth, you'd struggle to run then too! Somewhere there is a middle ground, an optimal amount of strength for the running you do.

Injury Prevention

Perhaps somewhat surprisingly there is a lack of research on the use of RT in injury prevention in runners. Fields et al. 2010 commented that, “there are no prospective, primary prevention studies in runners” in their review of the research underlying the prevention of running injuries. They went on to conclude,

“In spite of numerous studies, strong evidence for prevention of running injury exists only for controlling training errors primarily by limiting total running mileage…While studies of strength, biomechanics, stretching, warm-up, nutrition, shoes, and psychological factors all raise intriguing questions about both the etiology and the prevention of running injuries, strong evidence that modifying any of these will prevent running injury requires further research.”

It makes sense that improving strength should reduce injury risk but we just don't have the research to back that theory up yet. Maybe it's because training error, particularly doing too much, is such a common cause of injury that adding in more exercise (in the form of RT) doesn't always help the situation. Fitting RT within a busy training schedule without impacting upon the quality of other workouts can be a challenge, we'll touch on how to manage this shortly.

Injury rehab

I feel RT has perhaps its biggest role here. Away from research for a moment, experience tells me that resistance training can be hugely beneficial when used as part of a comprehensive rehab programme. I've run lower limb rehab groups for over a decade and seen countless patients improve with progressive resistance training including free weights and machines.

We combine weight machines such as leg press, leg extension, hamstring curl and hip abduction/ adduction with squats, single leg dip, calf raises and lunges. We add balance and control exercises on rocker boards, wobble boards, BOSU's, trampette and balance cushions. We use agility and sport specific drills with ladders, cones and hurdles and add in plyometrics and multidirectional stability work. We make cardiovascular fitness part of the programme and get people running, cycling, rowing or cross training. RT isn't all of the rehab programme but certainly can be an important part of it.

We've talked before about the big three strength, balance and flexibility and how important they are in limb function and running. There is a wealth of research showing how RT can be used to develop the first of the big three, strength. Indeed tweaking of your resistance training allows you to target specific goals within the broader category of strength, including power, endurance and hypertrophy (increasing muscle size).

What your goals are post injury and how you use RT to achieve them will depend on the injury itself and what deficits you have. Identifying these weaknesses usually requires some help from a Physio or sports therapist. I would recommend having some guidance before embarking on a resistance programme to rehab an injury as it is easy to aggravate a problem and it's more effective when used to target specific problem areas. Resistance Training should be pain free, and I would recommend a gradual increase in resistance if rehabbing and injury.

Practicalities – how should I use RT?

As mentioned above RT is most likely to be effective if used to strengthen areas of weakness, rather than a scattergun approach of a bit of everything. That said, common weak areas include calf, quads, hamstrings and glutes and all of these can be targeted with RT. In the coming weeks we will be adding videos to the blog on how to 'blitz' some of these muscles with 3-5 minutes of intense exercise.

When introducing a RT programme it is best to do it slowly, with gradual increase in load and frequency. Ideally RT should be done at least twice per week although you will see changes with a once weekly session. Allow at least 8 hours between running and then doing resistance training, ideally have a 24-48 hour gap. The research is less clear on doing resistance training and then running, I would suggest a similar 24-48 hour gap if possible. Running on legs that are recovering from RT is challenging and can risk injury. So a weeks schedule could be;

Monday rest Tuesday run Wednesday RT Thursday run Friday RT Saturday rest Sunday long run.

The long run is 'bracketed' by rest days and you have 24 hours between running and RT. Juggling running 5 or more times per week with RT is a real challenge. You may need to be doing both in the same day, if so consider doing one morning and one in the evening to allow at least 8 hours and choosing that day to do a recovery run rather than interval or hill work. Erikson (2005) and Paul and Bampouras (2007) both include upper limb strengthening in their RT programme, this could be done more easily on days when running and RT are combined.

Realistically for many runners, especially those of us with jobs, families, partners etc a once weekly RT session is more realistic. Hopefully the 'blitz' videos will provide a way of doing strength work in a short period of time to make it more feasible.

What about repetitions (reps), sets and loads?

This is a vital, and often neglected part of RT. Like choosing which muscle group to work on, selecting reps, sets and loads should ideally be based on specific deficits. There are 4 main categories strength, power, hypertrophy and endurance. The American College of Sports Medicine (ACSM) produced these guidelines which form the basis of the recommendations below;

Strength is about production of force, plain and simple. Building strength is increasing the force a muscle group can produce. To build strength do 8-12 reps using a moderate to heavy load (so the final 2 reps are challenging and you probably wouldn't manage an extra rep) do 3 sets each separated by a rest period of 2-3 minutes. Increase the load by 2-10% when you can manage 1-2 reps above your target e.g. If you're aiming for 12 reps with a certain load but can do 14. Strength work often forms the basis of power, endurance and hypertrophy training. Although distance running is an endurance event it may be that building strength with RT will be more appropriate for some runners, as mentioned before it will depend on the individual.

Power is closely related to strength but time becomes a factor. Power is essentially strength divided by time. A good example of power is Olympic Weightlifting – a huge weight is lifted at high speed. You'll need adequate strength before attempting power work so it's often best to work on strength first. When building power start with low to moderate weight and gradually build to heavy loads. Do 3-6 reps with an 'explosive tempo' I.e. quickly! 1-3 sets with a rest period of 2-3 minutes between each.

Hypertrophy means increasing muscle bulk. This is particularly useful if you have had an injury that resulted in muscle atrophy (reduction in muscle size). Again a basic level of strength is needed before doing hypertrophy work. There is some cross-over between the two and strength work is likely to result in some increase in muscle bulk. Initial loads and reps are similar to strength – 8-12 reps with moderate to heavy load, 1-3 sets separated by 1-2 minute rest period. This may progressed to heavier loads 1-12 reps (depending on load) 3-6 sets with a 2-3 minute rest period.

Endurance is how well a muscle produces the same amount of force when asked to continue to do so for a prolonged period of time. Use light to moderate loads, 15-25 reps, multiple sets (start at 2-3 and build up) with a 1-2 minute rest period between sets. I aim to fatigue a muscle group with endurance work, so the load you use should be sufficient to do that within 15-25 reps.

Reps and sets are somewhat redundant unless load is considered. Reps and load come together in something called Repetition Maximum or Rep Max (RM). 1RM is the maximum load you can lift once with good technique. 10RM is the maximal load you can lift 10 times with good technique. The load for 10RM will obviously be lower than 1RM. To work out 10RM pick an exercise and gradually increase the load until you find the amount you can lift 10 times (but couldn't manage 11). Just to confuse you, the loads recommended by research are often presented as a percentage of 1 rep max. I have included these and the details above in a table below for those that want that level of detail. For the rest of us, it's usually about lifting the heaviest load you can manage for the amount of reps you're doing, while maintaining a good, pain free technique.

The exact percentage of Rep Max and reps and sets recommended for strength, power, hypertrophy and endurance are subject to much debate. The guidelines from the ACSM looked at over 250 studies to produce their recommendations, despite this even their conclusions have been questioned. I'm very open to suggestions on reps, sets etc please feel free to put them in the comments section. What I have presented is a rough guide based on recommendations in research. Erikson's paper includes a sample RT programme including sets and reps as does Jones and Bampouras (if you can access it).

The ACSM make a host of other recommendations including that a mixture of free weights and machines are used and that concentric, eccentric and isometric work is included. For further details see their paper, linked above.

Study Limitations

There are limitations to the findings from the literature, as ever. Jung (2003) points out a sparcity of evidence showing improved race time as a result of RT. The methods used vary considerably, with some studies incorporating plyometrics as well as resistance training. A key point too is the population they have studied, again they varied from untrained individuals to elite athletes, although most were done in trained individuals (as measured by VO2 Max). One group that appears to be missing is injured runners, most of this work is done on 'healthy' subjects. The research done on injured individuals is often a) not specific to runners or b) involves a mixture of treatment approaches which may include RT. Even then research is seldom totally conclusive and there is a limitation in research itself – it's designed to allow you to apply a treatment approach or physical test to a certain population and yet, even within that population, people are incredibly different.

Even with a fairly specific population you'd have difficulties. If you studied runners, with patellofemoral pain syndrome between 20 and 40 years old, with no signs of arthritis on X-ray and you treated with resistance training you might only expect 30-40% to improve. Why? Because some will have it from over training, some from control issues, some with biomechanical problems, some with tissue flexibility issues etc etc. It's unlikely that research done is this manner will make definite conclusions.

Luckily though, we don't make decisions solely on research, we can use experience and learning too. It's often said as people we are each an experiment of 1 – see what works for you that's the key.

Final thoughts: Resistance Training has the potential to improve running economy and performance. It has long had a role in injury rehab and is likely to have one in injury prevention. The research reviewed here did not find that RT had a negative impact on VO2 Max, lactate threshold or running ability.

RunningPhysio recommends that you see a health professional prior to starting a resistance training programme to help you identify specific deficits. This can make RT more effective and reduce risk of injury.

 

 

 

 

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Mental Health and Running – anxiety, and inner peas.

Following Liz's inspiring story I thought I'd share a little of my own experience in managing my mental health. I developed anxiety in my mid-twenties, I'd always been a 'worrier' as a child but it took on a new level and gradually became a weight on my shoulders. There's a lyric in a Florence and the Machine song that goes,

“It's hard to dance with the devil on your back, so shake him off”

Anxiety was the devil on my back, and try as I might I couldn't shake the bugger off! At it's worst I felt a constant tension and tightness across my chest, I simply couldn't relax and my mind was churning all the time. For me to unwind I needed total immersion in something, a computer game, good film or book but as soon as I stopped doing this my worry would kick in again.

My understanding, at the time, was that anxiety was due to chemical changes in the brain. That view, it turned out, was a little simplistic. My way of managing had 2 parts 1) to try and improve this chemical balance by running to boost the amount of happy chemicals (endorphins etc) and 2) to avoid alcohol, which can be a depressant and caffiene which is thought to be anxiogenic (anxiety provoking). On top of this I ate blueberries. Yep, she'd loads of them! I read somewhere that they were good for mood. At times this approach worked very well but by around 2010 I realised I was actually getting worse.

The low point was a panic attack at work. I hid in the toilets and just cried as quietly as I could so no one would hear. Even then my mind was working incredibly fast, examining my feelings and thinking about them. The thing about a low like this though is that it can be good – it prompted me to ask for help rather than just battling along eating blueberries! I saw a counsellor through work and with his guidance started to piece myself together again.

Through this I developed a new and very useful understanding of how my mind worked. It wasn't just a case of chemical changes but 3 broad areas that are hugely interlinked. Biology, Psychology and Social factors. What you may have heard of as a biopsychosocial model. I can see you thinking, oh no he's going all technical on us again! Bare with me…

Bio – means the biological changes associated with mental health and there are many. There is an established link between body and mind biologically – when people say it's all in your head it's wildly inaccurate. A body under stress heals slower, feels more pain and has higher levels of muscular tension. The brain shows different levels of activation in the areas that process emotion and the 'fight or flight' response. Typically anxiety is accompanied with bodily sensations, churning stomach, excessive sweating, dry mouth or constant need to use the toilet. Much of this comes from an activation of the fight or flight mechanism which prepares the body to escape from immediate danger and involves the release of adrenaline and other hormones.

Psycho – to me this means how we think, how we feel and how we behave. Closely linked with the biology, as, if your body is in the middle of a fight or flight response it's more likely you'll think and feel negatively and act to avoid what's causing the fear. This can lead to a pattern of fear and avoidance and thinking negatively can almost become a habit. Part of this is something called ANTs – Automatic Negative Thoughts. Our brains produce thousands of thoughts per day, it's likely a percentage of these will be negative. They are automatic, we dont choose them or have responsibility for them. Sometimes these come with an emotional response too so we might feel sad, guilty, angry or worried about the thought. It's easy to get wrapped up in these negative thoughts and sadly ANTs often hunt in packs. When you're busy dealing with one thought a host of others can come along and overwhelm you. I have a theory that they are a product of the fight or flight response. Let's say you're a caveman, you spot a tiger a few feet away, your fight or flight response is triggered. With it comes a host of negative thoughts, “that tiger will eat me!” “I will die!” “I'll never get the chance to finish that cave painting” “there is no way I could fight it off!” “the only solution is to run away” this happens automatically – you don't choose to think like this and it motivates you to evade and run away. I think a crucial part is the feeling that you cannot cope with the threat you must run. In the modern world we rarely have tigers roaming the street, but situations in life can lead you to conclude “I cannot cope with this, I must run and avoid this situation in future” the problem is though, we are regularly faced with situations that are stressful and can't be avoided, especially if our social situation is a difficult one..

Social factors – this is another complex area, feeling anxious and depressed often leads us to withdraw socially. It then becomes more challenging to return to socialising again and you feel more withdrawn. More than this though, this area involves work, family, relationships, leisure activities and friendships. It's about our support network and how well we utilise that support. It's about our roles – I like to be the helper and hate being the one asking for help. It's about how we communicate too and who, if anyone, we are emotionally close to.

As I started to piece all this together I was able to make sense of things and see why running on it's own wasn't the solution for me. While it undoubtedly helped with mood and probably helped my body release endorphins and improve the 'bio' part it didn't change how I thought, how I felt or how close I was to people. So what did?…

The first step was recognising I was in a severely stressed and anxious state and that that was having a huge influence on how I thought, felt and behaved. I then needed strategies to relax my body and mind.

Now by relax I don't mean a glass of wine or a long hot bath I mean a formal relaxation technique. This is when I discovered the Mental Health Foundation website and their wonderful free podcasts. They have 10 or so all together and I went through and tried each of them until I found a couple that helped. Everyday I came in from work, the kettle went on and I relaxed for 15-20 minutes. At first I found my mind wandering off and negative thoughts popping up, “this is pointless” “this isn't working” etc etc. In fact in the early days I sometimes felt more stressed after relaxation than before, but I stuck with it. It taught me something hugely valuable – to let thoughts come and go and gently draw my focus back to the relaxation. After a few weeks I really looked forward to my relaxation sessions. Some of them were even quite funny – my counsellor had a very strong Nigerian accent and he would say, “imagine you are filling with inner peace” and I would hear “imagine you are filling with inner peas” all I could picture was my body gradually filling with thousands of little green peas!

The thing with relaxation is that you aren't trying to empty your mind or stop thinking, that's nearly impossible, instead you're trying to focus on something else and see when you become distracted by thoughts and gently, kindly bring yourself back to that focus. It's challenging initially but if you keep practicing it starts to pay off. There are lots of different types, like mental imagery and progressive muscle relaxation.

After a few weeks of relaxing every day the sensation of fear started to lessen, sometimes for a few hours, sometimes a few days. It wasn't far away and could quickly come back but I could see I was improving. I could also see how differently I thought and felt when not in an anxious state. I could be objective and rational, things no longer had that panic associated with them.

The next step was the Cognitive Behavioural Therapy (CBT) approach. Its basis is how you think affects how you feel and how you behave. Therefore if you challenge negative thinking you feel better and behave differently. I had tried this when in an anxious state and it had actually made things a lot worse. I got so wrapped up in my thoughts and challenging them that I was constantly ruminating, thinking things over and over in an exhausting battle in my head. This, I feel, is the downside of CBT – there is a danger of ruminating and over thinking and by challenging your thoughts it can feel like you are constantly challenging yourself. My counsellor helped me see that for CBT to work I needed to work on 1 thought at a time and to notice if I was getting sucked in to a pattern of over thinking. There is a free online CBT programme called Living Life to the Full it includes online assessment of your mood using a questionnaire, then makes recommendations based on this. For CBT based counselling or any other mental health concerns consult your GP.

Once I'd relaxed a bit my thinking was less negative and less extreme and I was able to challenge some thoughts and see where I'd been very negative. I developed a few techniques that seemed to work for me. One I call the 100% rule. It asks you to be objective.

Out of 100% how true is this thought?

Is it true 100% of the time? Can you think of an example when it wasn't true?

Can you change it?

If you can't change it, can you accept it, could you cope with it?

I also found it helps to deal with the first negative thought not the ones that result from it. So let's look at an example from just before my marathon.

Negative thought 2 days before my marathon;

My GPS watch might break and stop working during my marathon

Secondary to that

I might not be able to pace myself and get a rubbish time

Maybe I'll go out too fast and not finish

What happens to the charity money if I don't finish?

It'll be really embarrassing if I have to pay everyone back….

And so on!

So the first thought, out of 100% how true is it that the GPS won't work?

0.5% maybe, if less. It works fine at the mo.

It's not true 100% of the time in fact it's never failed to record a run, I'm just worried because it took a while to boot up the other day.

Can I change it? Yes I can update the software and make sure it's fully charged.

Can I cope with it if it doesn't work? Yes, just stick close to a pacer.

If I don't get involved in the secondary thoughts, just deal with the primary it's easier. The final trick I found was “move on and wait”. Sometimes you don't feel immediately relieved with this method. Part of you still worries, it's then tempting to think about it more and more. For me I found it's best to draw a line under it and move on. Usually, given half an hour or so, you feel better and can see the situation for what it really is. By the way, the GPS worked just fine.

The problem I found though is that some negative thoughts carry such an emotional charge that you can't help but be drawn into them. Before you know it, with the help of a few other negative thoughts thrown in, you're feeling stressed and anxious. CBT was a big help for me, but I needed something else…that something came in the form of Mindfulness.

Mindfulness is an amazing concept. It's fair to say it changed my life. It's quite hard to describe it, without it sounding a bit new age (which it probably is). Mindfulness is present moment awareness. It's being in each moment, observing non-judgementally. For me the key thing is the awareness. This is an area of us that sort of sits above thought and feeling and is usually kinder and wiser. To use the example above with the GPS, the awareness would help me observe how I was thinking, to see I was thinking negatively and then do nothing about it. Yep, nothing. Zilch. Zip. Nada. Nil. Mindfulness helps you see thoughts as just thoughts. To observe your mind like a river with you observing from the riverbank. Occasionally a negative thought floats by, you can jump into the river and get caught up in it or just observe it and let it float by.

Mindfulness, like relaxation, is something you learn and cultivate. You do this through mindfulness meditation, which is a little different from relaxation although there is a lot of crossover. In mindfulness you are observing something, usually you start with your breathing. You focus on how the breath sounds, how it feels as the air moves in and out of your mouth and how your stomach rises and falls. All the while thoughts pop up and you observe them but keep bringing your attention back to this focus. It doesn't have to be breath, it can be a part or the whole of your body. It could be sounds you hear, tastes you experience, things you see. One of my favourite meditations was going to the beach and sitting on the pebbles. I'd listen to the sea and the crunch of people's feet on the stones as they wandered by. I'd feel the warmth of the wind stroking one side of my face and smell the BBQ's and occasional waft of cider breath from a nearby tramp! For more on Mindfulness the Mental Health Foundation has an online course but I don't think it's free. I can recommend the work of Jon Kabat-Zinn, especially Mindfulness for Beginners (available as a book or Audiobook). Below Jon Kabat-Zinn talks about the Mindfulness Based Stress Reduction programme (MBSR).

 

With time the meditation really, really helped. I had cultivated an awareness of how I was thinking. I could spot a negative thought and just not get drawn into it and I started to see how much these negative thoughts affected how I behaved. A breakthrough session came when I turned this mindfulness in on myself and started to really look at how I felt when I was anxious. I had this ball of tension in my chest and I decided to put it under a microscope and observe it – it looked a bit like this;

Seeing how you think and patterns in how you feel helps you to see when you're thinking and feeling anxiously. Because of that it often halts anxiety in it's tracks and worries no longer spiral out of control. A big help was spotting the 'urgency' the need to think about this now. When I was really anxious I'd use any spare minute to think something over in an attempt to find an answer. Now if I spot that sudden desire to engage and worry about something I see the signs of anxiety and move on to something else.

There is a whole lot more to Mindfulness than this. Research has shown that it changes the way the brain works. In one study subjects used Mindfulness meditation for 8 weeks and showed a change in activity in the area of the brain that processed emotion and the fight or flight response. In a older study by Jon Kabat Zinn they demonstrated up to a 50% reduction in pain in patients with chronic symptoms with an 8-10 week meditation programme. It's been shown to improve healing of skin conditions (psoriasis) and to improve relationship satisfaction. And it's even possible to run mindfully. Mindful running isn't easy and you'd probably need to practice other types of meditations first but if you're even just a bit more mindful when running it can enhance the experience. Mindful running means you hear every footfall, every birdsong, you smell the flowers you whizz by and see the sun glinting off the sea. It also means you're less likely to be drawn in to running along, focussing on how heavy your legs are, how tight your chest feels or worrying about something rather than enjoying the experience.

So how does this story end? With running to keep on top of the bio, mindfulness and CBT to take on the psycho and my growing confidence and better communication helping with the social part of this I gradually got better and better. In fact by April 2011 as I watched the Brighton Marathon I felt fine, even to the extent that now I rarely meditate or use relaxation techniques – I just don't feel the need to. But I do feel I'm more mindful, not just in 15 minute periods of meditation, but every day. I feel more human, more compassionate and infinitely more relaxed. The story didn't end there though, it took on a new chapter. Inspired by the marathon runners in 2011 I did Brighton Marathon in 2012 to raise money for the Mental Health Foundation as a thank you for helping me put myself back together. I've raised over £800 but the just giving page is still open (hint, hint!)… My slogan during the marathon was “26.2 miles is nothing compared with how far you've come….”

Well, it was until mile 21, then it became “oh my god, I'm totally broken! 26.2 miles is a ridiculously long way, what was I thinking!” Still, I finished it in a respectable 3:12:28.

My closing thoughts are this; I'm not a counsellor, nor am I trained in psychology. I'm not suggesting solutions here, just sharing my experience. What works for me may not be the answer for other people. What I've discovered is that running is a hugely valuable part of improving my mental health but for me I needed to look at how I felt and thought as well. Now I'm filled with inner peas and I did shake that devil off my back….

The worst part of this costume was the red body paint that I couldn't seem to shift even after a load of showers. 3 days later, on the morning I was due back to work I sent a friend a text which simply read, “oh my god. It won't come off!”

 

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Mental Health and Running – Liz’s story

This post is the first in a series of articles on RunningPhysio looking into mental health and running. It's a huge topic in the running community and many people run to help their mental well being, so we are very lucky to have Liz to share her story with us. Liz is a blogger in her own right and has a fantastic blog which I have to admit is one of my favourites, you can also follow her on Twitter – @4races4cities. It's a very personal story but one I'm very glad she felt she could share with us…

Twelve years ago, my Mum took her own life.

Initially, I wrote ‘my Mum killed herself’ at the end of that sentence, but I deleted it. ‘Took her own life’ sounds warmer somehow, doesn’t it? It’s less harsh, and those black words seem less stark against the white background of this blog post.

I’ve spent a lot of time writing about my Mum, mental illness, and the charity fundraising I do for Mind. You can read more about it all here.

I have spent less time, however, writing about my own personal struggle with mental illness. When Tom asked me to guest blog for him, I wasn’t sure what to write about. My own running blog is quite light-hearted and a bit silly, so when Tom suggested I write about the affects of exercise on depression and anxiety, I realised that it would be a good opportunity to share my experiences, in the hope that it might strike a chord with someone out there.

Anxiety has been part of my life for a very long time. The grief surrounding my Mum’s death was channelled, not through crying and pining, but through severe anxiety, culminating in terrifying panic attacks and OCD. I saw different types of therapists and was prescribed strong anti-anxiety medication, at one point I was very nearly sectioned under the Mental Health Act.

Nothing worked.

Years passed by, and I just learnt to live with my mental health problems, I became a shadow of the person I was and lived half a life – anxiety and OCD clung to me tightly, suffocating my every move, and I couldn’t shake them off.

You’re probably wondering why I’m sharing this on a physiotherapist’s blog, right?

Perhaps you came here to read a post about IT band pain, or curing your plantar fascitis, or find specific exercises to strengthen your leg muscles.

You’re probably a runner.

Well so am I.

I haven’t always been a runner. Running kind of crept up on me two years ago, in the midst of the heartbreaking end to my eight-year relationship. My anxiety levels at the time were sky-high and I was struggling to cope. I don’t know what provoked me to put on my trainers and go for a run.

I guess I didn’t really know what else to do.

So I just ran.

I didn’t go far, only up to the end of the street and back, but it was enough, enough to quell the panic that rose in my chest and quieten the racing thoughts that darted back and forth in my mind. My heart rate soared, and yet instead of culminating in a panic attack, the way it always did, I felt euphoric and alive.

The next day, I laced up my trainers and went out for another run, this time venturing a little further. I had taken part in a 5 and 10K race in the past, and knew that my legs were capable of covering a longer distance, so I just kept going. I think I ran about 5K in total, but it could well have been 26.2 miles. I felt strong, capable and empowered. Again, I returned home exhausted but elated. My anxiety levels seemed to lower and I felt like my head was clear for the first time in years. Running seemed to distract me from the cycle of worries that fed the anxiety – something really resonated deep within me, and unlike my past forays with running, this time it stuck.

I noticed a local half marathon advertised on a lamppost, which I saw when, yes you guessed it, I was out running. I impulsively signed up for it, knowing that I would have to train hard. I scoured the Internet for half-marathon training plans, and bought myself a pair of proper running trainers, clothes and a Garmin GPS watch. My days were arranged around my running schedule, and I constantly read books and magazine articles to garner tips and advice on becoming a better runner. Weeks went by and I started to feel so much better, I lost weight and began to pay better attention to the way I fuelled my body so that I could run faster and for longer. Most importantly, I slowly felt the powerful grip of anxiety releasing its hold on me.

My attitude towards the way I viewed myself also started to change. I had always thought that I wasn’t capable of doing things; I’d spent so many years hiding in the shadows, too afraid to step up and challenge myself, and yet here I was, training for a half marathon on a whim and pushing my body and mind to places I’d never been before.

There were days when I wanted to give up.

I’ve lost count of the amount of times that I would sit under a tree in the local park, part of my running route, head in hands, crying with frustration. Running challenged me in ways that I’d never experienced – it pushed and prodded and hurt and dared me to run further, faster, and harder. It would have been so easy to just bail, let myself be beaten, but I didn’t. I wouldn’t allow it.

I don’t quite know how running relieved me of the years of suffering with my personal demons; there’s been a lot of research over the last few years, and scientists aren’t quite sure either. All I know is that it worked for me. These days, I am free from anxiety and the panic attacks, and I can honestly say that I am the happiest I have ever been. My life is filled with enriching experiences, energy and laughter. And running.

It’s all about the running.

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