training

On: technology, tests and treatment.

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Listen to the patients history, they will tell you the diagnosis.

Possibly not entirely, as patients sometimes miss detail or forget timelines.

However, subsequent to a thorough history and examination, all other tests should be used to confirm or deny your hypothesis, including imaging and blood tests.

The problem comes when we, as practitioners or medical professionals, get distracted by new technology or training. This means we look at what we can do, not what we should do.

Ethically, one should do the least for the most benefit. So just because I can order a blood test doesn’t mean I should, if it won’t change my subsequent decision tree. And just because I’ve bought a shiny machine, the information it produces won’t necessarily fundamentally alter the treatment plan.

As for treatment itself, the gold standard therapeutic ladder must always be applied. Physical intervention, then medication, then surgical intervention.

Knowing how to apply this, when to step up and down, the precise tool and most importantly when to stop, is what we spend years training for and why the patient needs to select their practitioner with care and recommendation.

Only then will they find the person that understands and diagnoses their presentation, educates and treats it effectively and most importantly demonstrates how to prevent its recurrence.

Whoever you, as a patient, go to, don’t be taken in by the technology and treatment modalities, look behind the curtain, look at outcomes and be driven by the outcome.

If you think we can help, please do call, we have over 20 years of experience, in both NHS and private practice, to help you work with your presentation.

You evolved to run…

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It has been said many times before, especially here, that you evolved to run. The combination of an independent respiratory system (via diaphragmatic control), the ability to lose heat via sweat, the nuchal ligament in the neck, large gluteals and an achilles tendon all indicate that we run. There are also evolutionary theories that indicate our brains developed to allow us to predict the behaviours of animals we were hunting.

Running also has a fantastic effect on the skeleton, triggering hormones in the long bones that help control appetite (Lipocalin-2), driving osteogenesis (the continued creation of new bone) and preventing degeneration. It even helps neurogenesis, the creation of new brain cells and nerve pathways, by flushing fresh blood through at a much higher rate for longer, as well as suppressing excessive glucose storage by forcing muscles to use it as fuel.

Many people, including respected orthopaedic surgeons, believe that running is not healthy for the joints, and that it will leave to early degeneration. There is some validity to this concern, but with a certain number of caveats. If you have not run for a significant period of time, or are overweight, then you may experience joint pain when you start. Similarly, if you are not biomechanically efficient, then you find it harder work than you expect. Not only that, if you look at indigenous runners, they don’t do it in the same way we consider standard, rather running and walking, depending on the terrain.

However, a number of studies (https://doi.org/10.1002/art.24840, https://link.springer.com/article/10.1007/s00167-013-2686-6) as well as others, show that there is no detrimental impact on the joints, with some evidence that it actually helps strengthen the tissues.

What is the practical upshot of this? If you can, start running. Carefully, steadily and allowing a great deal of time. The upside far outweighs the downs. If you can’t, cycle or walk.

If you want to start running, do so slowly. Follow the NHS couch to 5k program. Given that any weight over your theoretical optimal (BMI of 23 – 27 depending on muscle mass) is increased load on the joints, limit your long runs to reduce the chance of injury while you work on the weight. And, as you approach a maintainable weight, you will experience the benefits far more than the lows.

If you can’t run, do something that mimics the cardiovascular and skeletal load. Lift weights, row, walk at a rate that leaves you sweaty, it all helps.

Beyond 3 basic skills

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Previously, the 3 basic movement skills were raised.

These were:

  1. Getting off the floor from lying on your front
  2. Getting off the floor from lying on your back
  3. Walking at least a mile carrying a load

These use the primal movement patterns and the vast majority of us have been able to do them since the age of 2.

We can therefore advance these and actually start to develop them as a physical practice to improve our health, with very little other equipment.

If you have not exercised for a while, or have pre-existing medical conditions, please do consult your GP or practice nurse for a health check before starting any program.

As a test day, start by going for a brisk walk, sufficient to get you slightly breathless after 10 minutes, then aim for a mile, or 20 minutes. Once in a safe place and once you are warm, get on the ground. First, from your front, get up. Then from your back.

If that was challenging, or you struggled to get up, your first month would be simply practicing until you can do 10 from both front and back.

Once you can do that, you can add some more load.

With nothing more than a couple of bin liners, a reel of strong tape, an old rucksack and a bag of builder’s ballast (sand / gravel mix), you can create all you need for a very effective workout.

Fill a bin liner with a few kilos of the ballast. Tape it into a strong, short sausage shape and place this in another bag for safety. Create a few of these, of differing weights.

Once you have the weights, put sufficient in your rucksack to equal 5-10 kilos then do a 30 minute walk at a brisk pace.

Once back, adjust the load in the rucksack to about 2-5kg and perform 10 front get ups with the bag on. The, taking a sausage across your shoulder, perform 5 with it on the right before doing 5 on the left. As you get stronger, increase both the load in the rucksack for the walk and the getup challenge.

You should find that that provides a decent workout and can act as a gateway to more training techniques.

One day. 

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One day you may need to run. Not in your trainers, Lycra and fitted top. Not after a good warm up, chatting with your friends and on a sunny day. 

It will be when you are least prepared. 

Maybe it’ll be raining. Or after a long day. When you’re wearing a smart suit or carrying a shopping bag. 

It might be for a bus, or to stop a child running into traffic, or to escape danger. It will be a sprint from the start, and unrelenting. 

Practice. 

Get a pair of boots, sweatshirt and pair of old trousers. 

Find a hill. Or a field. 

Take the luxury of a warm up. 

Then sprint. 

Try to hold a hard pace for a minute.

Walk back to the start to recover. 

Do it again. 5 – 10 times. 

It never gets easier. But you are more prepared. 

80:20 Revisted

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With the forthcoming release of Dr Kelly Starrett’s new book, I have been reconsidering the advice we tend to offer injured (or preferably non injured) athletes. Dr Starrett (a Phd physical therapist) offers practical and applicable advice on injury prevention and recovery, stating that if you cannot perform basic functions safely (squatting, stretching etc) then you need to sort them out before you try running.

These days, with web access virtually ubiquitous in the western world, there is a surfeit of information available at our fingertips. The difficulty is in discerning what works and what doesn’t. With the rise of athletic “biohackers”, who promote tips and tricks for small percentage improvements, finding the signal amongst the noise is even harder.

For most of us, performance improvement comes down to three simple things.

  • Optimise Nutriton / Diet
  • Train efficiently
  • Recovery / Sleep

Dr Starrett covers much of this in his excellent book Becoming A Supple Leopard and reviews indicate he will cover this in the running guide.

Breaking down the above bullet points, optimising diet means ensuring you eat cleanly and sensibly most of the time, getting a suitable balance of proteins, fats and carbohydrates, with plenty of micronutrients. Nothing clever or fancy but by not doing this, you are ensuring that your body is not going to operate effectively. This is the base upon which all the others stand, mentally and physically.

The part we all think about is the training aspect. We plan, prepare and put in the hours and miles to attempt to achieve our goals. But are we doing it in the most efficient manner? Could we save time by cutting out junk miles or hours in the gym, since more is not always better. Is there such a thing as a recovery run, or easy workout? Would that time be better spent with friends and family, which might help improve our mental state, or doing mobility work (as described by Dr Starrett)?

This ties in to point 3, recovery and sleep. Do you recover enough? Are you waking refreshed and ready to go each morning without needing an alarm or two? There is no set formula for this since the factors involved in recovery are complex, including external stressors, but by tracking basic biomarkers (resting heart rate, blood pressure, oxygen saturation (SpO2) etc) and personal reflection, we are able to observe how our bodies are responding to the load we place upon them. If your resting heart rate is elevated and your SpO2 depressed then you are simply not recovering from the load. Another simple test is to attempt to create a change in your heart rate during a training session. If during a run or ride, you cannot easily elevate your heart rate by increasing pace or effort, then there is a possibility that you are neurologically as well as physically tired and as such, backing off would be advised.

Some people are beginning to use heart rate variability (HRV) to track their stress and recovery. Like many tools, this gives a view into the workings of the body, in this case the autonomic nervous system, which can be used to explore the effect training or stress is having. Many researchers and doctors have shown that there is a link between low variability and mortality from a number of causes but these are measured using ECG over a long period of time (24 hours), especially after an acute myocardial infarction. Some work is being carried out with regards to the use of HRV to track physiological changes due to stress and training and although this appears to be useful over long term measurements, such that trends can be visible, it appears to be a back up to the other measurements and as such, outside of the 80% rule of most efficient use of resources.

To conclude, eat to meet your nutritional needs, train efficiently and recover effectively. Then start making the 20% changes.