Running Towards The Facts

Running news and information, reviewed from a medical perspective

7 Major Marathon Mistakes by Dr John Senatore

7 Major Marathon Mistakes by Dr John Senatore

Great marathon advice from Dr John Senatore, a podiatrist at Union Memorial Sports Medicine in Baltimore Maryland. If you are a first time marathoner, heed the advice of #7 Run smart, not more. You will experience “taper madness” at the end of training but trust in your weeks and months of training. Running harder or more at the end will only ruin your race day.

The Courage to Run a Marathon

finish line

That little voice in your head that tells you

it’s too hard,
you can’t do it,
it’s too far,
you suck,
you’re not a real runner,
you’re too slow,
you’re worthless,
you look ridiculous,
you’re gonna kill yourself,
you should stop,
you’re never going to be able to do this
….well, that little voice is a loud bully now, but it gets softer and smaller the more you run. It’s scared you’re going to find out how strong you really are, and it won’t be able to hold you back anymore. The magic of a marathon is, not the million steps you took to reach the finish, but the one step you take across the finish line, when you step on that little voice and crush its weak little head, and from that moment on, it’s afraid of YOU. It knows it doesn’t have power over you anymore, because
nothing is too hard,
you can do it,
nothing is out of reach,
you rock,
you are a runner,
you might be slow but you finish what you started,
you’re priceless,
people admire you,
the only thing you’re gonna kill is self-doubt,
 you can’t be stopped,
you can do ANYTHING!
The medal they give you is not because you finished,
it’s because you had the courage to start and not stop.

Run Safely on the Road (for Meg’s sake)

One week ago, Meg Menzies, a 34 year old Ashland Virginia mother of three young children, was running with her husband, training for the Boston Marathon. Shortly after 8AM, while running on the shoulder of the street towards traffic, an SUV ran off the side of the road while in a curve, and fatally struck her.

road
Her story was heard around the world, in part due to social media. Runners everywhere ran #megsmiles in her memory. This tragic story touches everyone, and runners easily empathize. If you are a runner, you have run along the narrow shoulders of local roads. You’ve had close calls with vehicles, and distracted or careless drivers. Your own distractions while running may have led you to be less than careful. Stories of fatal or serious runner-vehicle collisions are published in local newspapers and national running magazines, but how often do they really occur?

The internet has a lot of incorrect statistics. A Connecticut law firm website states “The most recent national statistics show that over 4,000 walkers or joggers were fatally struck by a car in 2010. “ (This is incorrect, as the CDC reports ~4,000 pedestrians die from crash-related injuries each year in the United States).   One article concluded that “less than 0.5% of all pedestrian deaths involved a jogger and only 6% of jogging deaths were traumatic” (1) Even this statistic seems faslely elevated at 200 runners per year. The bottom line is, there is no national database on runner-vehicle collisions.

While an encounter with a vehicle will cause more damage than an encounter with a dog, how frightened should we be?

injured First, think about how damaging being hit by a vehicle can be. Many runners run on the shoulder of a road, where the speed limit is 25 to 45 mph. Being struck by a vehicle traveling at 25 mph is equivalent to falling off a 2 story building. A 45 mph impact is equivalent to falling off a 6 story building.  You can imagine the bodily damage you would sustain if you jumped off the roof of a 6 story building, but we don’t imagine the same potential trauma as we run with vehicles.

I reviewed the medical and scientific literature and found a 1981 Public Health Reports article entitled When Motor Vehicles Hit Joggers: an Analysis of 60 Cases. The author, a senior behavioral scientist at the Washington DC Insurance Institute for Highway Safety, looked at how widespread the problem is, what factors increase the likelihood of a collision and how could such incidents be avoided. He searched for newspaper accounts of joggers struck by vehicles for a one year period (August 1978 to August 1979), and identified 60 collisions in which 65 joggers were struck. He found that the dangers of jogger-motor vehicle collisions are exaggerated by the news media.Only a tiny fraction of all joggers are killed or injured; they represent an extremely small proportion of the more than 8,000 pedestrians killed and tens of thousands injured every year.” Of the 65 joggers involved in motor vehicle collisions, about half were killed. Young (15 to 24 year old) males were the most likely to be involved, and almost half took place between the hours of 3PM and 9PM. Thirty percent of drivers and 30 percent of joggers appeared to be primarily responsible for the incident. In over half of the cases, the joggers were running with traffic.

wrong wayHe identified risk factors as:

  • jogging after dark
  • jogging with other people,
  • jogging on roadways in the same direction as vehicles.


He recommended joggers
:

  • wear reflective clothing (none in his study wore reflective clothing and several wore dark clothing)
  • run against traffic (unless the jogger is approaching a blind curve that has no shoulders, and then it would be prudent to run on the other side of the road).
  • be alert to vehicles crossing over into the wrong lane
  • groups of joggers should run single file
  • joggers should recognize they are susceptible to being struck from behind AND by oncoming vehicles.

His recommendations “involve common sense adjustment by drivers and joggers to the fact that they are sharing the roadways.”

In the 35 years since his recommendations were published, running has become more popular. According to Running USA’s Annual Marathon Report there were 25,000 marathon finishers in 1976. By 1980, that number grew to 143,000. By 2011, over half a million people finished a marathon.

With more than three times as many marathon runners today than when the article was written, I wondered how the statistics have changed. While not a statistically significant study, I did a Bing search for fatal runner-vehicle collisions occurring in the US in 2013. While not an exhaustive search, I identified 15 news reports of fatal or significant injuries to runners. Here is a synopsis of the results:

  • There were only 4 deaths out of 21 runners struck by a vehicle
  • Women were two times more likely to be involved than men (even though the number of male and female runners is essentially equal: 56% Female 44% Male)
  • 66% of the accidents occurred to people running alone
  • 73% of the accidents occurred while the runner was running on the shoulder of the road
  • Of the 13 cases which reported the exact location, only twice were runners on a sidewalk.
  • More than a third of runners were running with traffic! (This number is probably higher, as only 7 of the 15 cases reported this information.)
  • 53% of the accidents occurred at intersections.
    (According IMG_1533to the Federal Highway Administration “Intersections are planned points of conflict in any roadway system. Motorized and non-motorized users are crossing paths as they travel through or turn from one route to another. In the United States, over the last several years, an average of 21% of the (roadway) fatalities and roughly 50% of the serious injuries have been attributed to intersections.”)
  • 60% of the accidents occurred between 6AM and 9AM, and 20% occurred between 6PM and 9PM.

Some runners remained unidentified for hours to days because they were not carrying identification or a phone.

From the 2013 news reports I found, my recommendations are similar to the 1981 study conclusions, plus:

  • Always run with identification and/or your phone.
  • Wear bright, fluorescent clothing.
  • If you listen to music, keep the volume low enough to hear surrounding sounds. It would be ideal to run without music.
  • Intersections are the most dangerous place. Look in all directions before crossing. Wait until you have a green light or proper crossing signal.
  • Run on the sidewalk whenever possible. While this doesn’t guarantee your safety (1 person was killed while running on a dedicated bike path), it separates you from dangerous drivers.
  • Avoid running on the roads during “rush hours”. People travel to and from work from 6 to 9 (morning and night), and may be hurried and distracted.
  • If you must run on the shoulder of a road, run against traffic. (This recommendation hasn’t changed in the 35 years, but I still see runners on the wrong side of the road).
  • Be aware of all surrounding traffic. You are just as likely to be struck by a car coming towards you as one coming from behind. Always assume the driver does not see you.

I realize there are a lot of suggestions to keep you safe while running, and you’re not likely to remember them all each time you lace up your shoes. In order to keep yourself safe, I suggest you simply remember M.E.G. –

MMonitor all traffic. Vehicles coming towards you AND vehicles approaching from behind can be dangerous.
EEngage intersections carefully. The majority of collisions occur here.
GGo against the flow. Run towards traffic. You are more likely to react to a vehicle coming towards you, and are less likely to be struck from behind.

Remember, it’s better to have to stop running to check your surroundings or allow a vehicle to safely pass, so you can return home to your family at the end of your run. The seconds you lose waiting for a vehicle to pass may add years to your life. Live to run another day, for Meg’s sake.

tribute

Photo by the Richmond Times Dispatch

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Selected references:

1) Thompson, PD, et al. Incidence of Death during Jogging in Rhode
Island from 1975 through 1980. JAMA. 1982; 247 (18): 2535-2538.

2) Traumatic injuries to runners. AMAA Journal. March 22, 2006

3)   Vehicle injuries to joggers. Case report and review. Shephard RJ. J Sports Med Phys Fitness. 1992 Sep;32(3):321-31.

4) Pedestrian Injuries and Fatalities. Guide No. 51 (2007). Justin A. Heinonen and John E. Eck. The Center for Problem-Oriented Policing.

5) Doctor arrested after woman killed jogging in Hanover

6) Runner’s World has a good article on road safety entitled Collision Course.

Stretching the Truth: Is There a Best Way to Stretch?

“Our nature consists in motion; complete rest is death.” – Blaise Pascal

No sport is static or performed without motion. Athletic activity is dynamic, meaning the athlete is active, moving and creating a physical force.

Stretching can be either static or dynamic. Static stretching holds a muscle in an elongated position for a period of time. Imagine bending over to touch your toes, and holding the position for 10 to 30 seconds. That is a static stretch.

stretch

Dynamic stretching is actively moving a joint and muscle through their range of motion. Imagine doing some squats and jogging in place before you run. That is dynamic stretching.

It is important to distinguish between the two, as the results of a “stretching study” may not be applicable to you and your sport (such as the stretch study reviewed last time. 

Recent studies have questioned the benefits of static stretching in the sports warm-up. A recent small study (1) found evidence that dynamic stretching enhanced static as well as dynamic flexibility of the hamstring muscles, where static stretching did not have an impact on dynamic flexibility. They concluded: “This has implications for the use of static stretching in the warm-up for dynamic sport(s). The role of static stretching for injury prevention in dynamic sport is also being questioned.”

This may seem surprising to athletes and coaches but “there is no scientific or medical consensus on the benefits or risks of stretching, either before or after exercise. In fact, most research points out that stretching is not helpful and may be harmful. The basic science literature supports the epidemiologic evidence that stretching before exercise does not even reduce the risk of injury.

An excellent review article is “Does stretching improve performance? A systematic and critical review of the literature” (2). The authors reviewed the literature and found 23 articles examining the effects of an acute bout of stretching (that is, stretching before or after exercise). Twenty-two articles suggested that there was no benefit for the outcomes force, torque (force of rotation), or jumping height. Of 4 articles examining running speed, 1 suggested that stretching was beneficial, 1 suggested that it was detrimental, and 2 had equivocal results. Of the 9 studies examining the effects of regular stretching, 7 suggested that it was beneficial. They concluded that stretching does not improve force or jump height, and the results for running speed are contradictory. Regular stretching improves force, jump height, and speed, although there is no evidence that it improves running economy.

In a recent study “A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury.” (3), they reviewed all relevant randomized clinical trials from 1990 to 2007 and concluded that static stretching was ineffective in reducing the incidence of exercise-related injury. The papers conclusion was “There is moderate to strong evidence that routine application of static stretching does not reduce overall injury rates.”

Of course, you can find articles and studies supporting both sides of the argument, but what I am presenting here are the conclusions of well done studies on whether stretching can reduce athletic injuries. I know I may not change your mind, and there is no good advice one way or the other. Some say it helps. Some say it’s harmful. I can direct you to all the different studies but basically, one review study summed it all up:

“Does warming up prevent injury in sport? The evidence from randomized controlled trials?” (4)  reviewed the latest 5 years of studies on the effects of stretching on preventing injuries. They concluded “There is insufficient evidence to endorse or discontinue routine warm-up prior to physical activity to prevent injury among sports participants.”

In one of the best articles on the effects of pre-exercise stretching (5), the researchers reviewed 104 studies from 1966 to 2010. I won’t bore you with the results of their meta-analytical approach, but their conclusion tells you everything you need to know: “We conclude that the usage of static stretching as the sole activity during warm-up routine should generally be avoided.”

stretching

The bottom line: Research has proven static stretching before physical activity does not prevent injuries and may make you prone to injuries, and decrease your performance. Performing a warm-up with dynamic stretching is beneficial in many ways, and performing a regular stretching routine is helpful in maintaining flexibility.

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Selected references:

1) The effect of warm-up, static stretching and dynamic stretching on hamstring flexibility in previously injured subjects.  O’Sullivan, K. et al. BMC Musculoskelet Disord. 2009; 10: 37. http://thesportjournal.org/article/effect-dynamic-versus-static-stretching-warm-hamstring-flexibility

2)  Does stretching improve performance? A systematic and critical review of the literature. Shrier I. Clin J Sport Med. 2004 Sep;14(5):267-73. http://www.ncbi.nlm.nih.gov/pubmed/15377965

3) A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury. Small K. Res Sports Med. 2008;16(3):213-31. (http://www.ncbi.nlm.nih.gov/pubmed/18785063

4)  Does warming up prevent injury in sport? The evidence from randomized controlled trials? Fradkin AJ et al. J Sci Med Sport. 2006 Jun;9(3):214-20.   http://www.ncbi.nlm.nih.gov/pubmed/16679062

5) Does pre-exercise static stretching inhibit maximal muscular performance? A meta-analytical review. Simic et al. Scand J Med Sci Sports. 2013 Mar;23(2):131-48. http://www.ncbi.nlm.nih.gov/pubmed/22316148

6) The acute effects of various types of stretching static, dynamic,ballistic, and no stretch of the iliopsoas on 40-yard sprint times inrecreational runners. Wallmann HW et al. Int J Sports Phys Ther. 2012Oct;7(5):540-7.  (Conclusions: Sprint performance may show greatest improvement without stretching and through the use of a walking generalized warm-up on a treadmill. These findings have clinically meaningful implications for runners who include iliopsoas muscle stretching as a component of the warm-up.) http://www.ncbi.nlm.nih.gov/pubmed/23091787

7) Static Stretching Can Impair Explosive Performance For At Least 24 Hours. * Haddad M et al. J Strength Cond Res. 2013 Apr 23.  (Conclusion: the positive effects of dynamic stretching on explosive performances seem to persist for 24-h.) http://www.ncbi.nlm.nih.gov/pubmed/23615481

8) Effects of stretching on performances involving stretch-shortening cycles. Kallerud H et al. Sports Med. 2013 Aug;43(8):733-50. (Conclusion: For athletes that require great range of motion (ROM) and speed in their sport, long-term stretching successfully enhances flexibility without negatively affecting performance. Acute dynamic stretching may also be effective in inducing smaller gains in ROM prior to performance without any negative effects being observed.) http://www.ncbi.nlm.nih.gov/pubmed/23681447

9) Static stretching impairs sprint performance in collegiate track and field athletes. Winchester JB et al. J Strength Cond Res. 2008 Jan;22(1):13-9. (Conclusion: performing a static stretching protocol following a dynamic warm-up will inhibit sprint performance in collegiate athletes. http://www.ncbi.nlm.nih.gov/pubmed/18296950

Stretching the Truth…

In 2010, a USA Track & Field Association press release touted their large, randomized, prospective study on the impact of a pre-run stretch on the risk of injury. (You can read the protocol here). It was to be the definitive study on the issue and fully passes our TIN COPS test –

Topic– Does stretching before running prevent injuries? (A good question)

Intervention– 3 to 5 minutes of specific stretches immediately before running, involving the quadriceps (front of the thigh), hamstrings (back of the thigh) and gastrocnemius/soleus (calf muscles) muscle groups.

Numbers– They studied 1,398 runners. From a statistical standpoint, this is an excellent number of participants, which can be generalized to all runners.

Control – Half of the runners were placed in a control group of no stretching before running.

Outcome – Stretching neither prevented nor induced injury when compared to not stretching before running.

Participants – Runners over the age of 13 years who ran at least 10 miles per week. This is a great sample of runners, from across the age spectrum.

Studied – What the researchers studied was the impact of a pre-run static stretch on the prevention of injury.

It received a lot of coverage in the lay press and in running magazines, as the final answer on whether a pre-run stretch is good or bad for runners. It was reported that runners who typically performed a pre-run stretch but stopped were almost twice as likely to have an injury, compared to runners who normally never stretch. Also, runners who didn’t usually perform a pre-run stretch but were assigned to stretch also had an increase in injuries. The researchers concluded a pre-run static stretch neither prevented nor induced injury when compared to not stretching.

Stretching

While it appears to be a quality study, it was never published in a scientific or medical peer reviewed journal. It was only presented at the 2011 annual meeting of the American Academy of Orthopedic Surgeons.

Here’s what you never heard about the study….

1) They only focused on static stretching (holding a muscle in an elongated position).

2) Half of the participants dropped out of the study.

3) An injury was defined as something that prevented running for more than 3 days.

4) 16% of the participants who completed the study reported injuries, and half of these were muscle tears or stress fractures.

5) 48% of injuries were self diagnosed and 52% were diagnosed by a healthcare professional.

6) Individuals who stretched prior to running were 40% less likely to report a short-term injury (< 1 week) diagnosed by a medical professional.

7) Important risk factors for injury were increased weight, increased age, increased mileage and history of chronic injuries.

8) Heavy runners (those with an increased BMI) were more likely to have foot/ankle and back injuries.

The limitation of the study has to do with static stretching, which has been shown to be detrimental to running.

The paper’s conclusion should have been reported as “Static stretching of the leg muscles prior to a run does not prevent or lead to injuries. But if you perform static stretches before running, don’t stop, because you’ll have a higher chance of developing an injury”.

So what’s an athlete to do about stretching? In the next post, I’ll review the latest scientific and medical research so you can stay strong, quick and healthy!

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References:

1) A Large, Randomized, Prospective Study of the Impact of a Pre-Run Stretch on the Risk of Injury in Teenage and Older Runners. Daniel Pereles, MD, Alan Roth PhD, Darby JS Thompson MS

The Most Powerful Performance Enhancement is Legal

I started this blog to document my quest for the truth in exercise claims. As I runner, I wanted to know if there was something that would help me run  faster, recover quicker, or make my running effort seem easier. Something that was proven, with scientific backing. I’ve been a physician for 25 years and a runner for 36 years. I’ve investigated a lot of claims over the years, but recently, I finally found what I have been looking for!

Mo-Farah When athletes use it, they effortlessly outperform their prior efforts. They can run longer, run faster, and recover more quickly. They have a better self image and enjoy their activity more. It can help every type of athletic activity, from weightlifting to endurance cycling.  It just makes you feel better!

How much better? Well, when physicians used it for post operative pain after patients had their wisdom teeth removed, they found it made the patients feel as good as 6 to 8 mg of morphine! But there are no adverse side effects, it’s not illegal, and it’s widely available. Many Olympic athletes use it to boost their performance.

Columbia University and University of Michigan scientists have shown how the neurochemistry of it can relieve pain in humans. Neuroimaging studies have shown it activates specific pathways within the brain, causing release of the body’s natural opioids and dopamine. Opioids are pain killers (similar to morphine), and dopamine is a nerve chemical that plays a major role in reward-motivated behavior, and motor control.

In the experiment, scientists applied it as a cream to the volunteer’s forearms. Next, a control cream (subjects were told it had no effect) was applied to a nearby area. Researchers then placed a painfully hot stimulus (similar to a very hot cup of coffee) to both forearm areas and used positron emission tomography (PET) scans to measure and compare brain activity during each application. They found that the cream treatment caused the brain to release more opioids, which relieved the pain. (7)

The amazing thing is how it can be utilized: it can be a cream, a drink, a food, a pill, tape, clothing, or object. It can be made into anything you want, and will work just as well, as long as you believe it will work. What is it? It’s a placebo.

A placebo is a substance or procedure that is objectively without specific activity for the condition being treated. (9) Although it is inert, it can have a positive affect on how you feel. The opposite is called a Nocebo Effect, which causes unpleasant symptoms. Both the positive placebo effect and the negative nocebo effect are subsets of Expectation Effects. You apply Kinesio Tape because you think it will help, and it does. You think you’ll have a bad race on a hilly course and you do. If you believe it, it will come true.

A good example is ankle taping. Recurrent ankle sprains are common among athletes, and ankle taping reduces the risk of injury. Yet, many studies have shown the tape does not provide structural support. The tape itself or how it is applied has no effect on ankle stability. But it is effective because athletes believe it will protect them from injury. Therefore, it works because taping may have a placebo effect.  One small study looked at whether there was a placebo effect with ankle taping in individuals with ankle instability. The researchers tested the subjects under three conditions: (i) real tape, (ii) placebo tape, and (iii) control (no tape). They found no significant difference in performance among the three conditions, BUT the participants’ perceptions of stability, confidence, and reassurance increased with both real and placebo ankle taping when performing the tasks. They concluded the effect of ankle taping on participants’ perceptions may contribute to its effectiveness in preventing injury. (10)

“In recent decades, reports have confirmed the efficacy of various sham treatments in nearly all areas of medicine. Placebos have helped alleviate pain, depression, anxiety, Parkinson’s disease, inflammatory disorders and even cancer”. (6) There seems to be two intertwined psychological mechanisms which underlie the placebo effects—expectancy and conditioning. If you expect something to give you a positive result (such as consuming an energy drink before a race) and you then happen to have a good race, you have created positive reinforcement. This positive belief about future outcomes can trigger those outcomes the next time you engage them in the same activity. (3)

rossI think this is the psychological basis for superstitions. For example, Sanya Richards-Ross, an American sprinter, wears arm sleeves. Initially worn due to her Behcet’s disease, she now wears them because she associates them with running her fastest times. Whether it is superstition or the power of a placebo, the sleeves “help” her win.

peleThere is a story about the famous Brazilian soccer player Pelé, who gave his soccer shirt to a fan. When his performance began to suffer, he sent an assistant to retrieve the shirt. His expectations that the shirt helped him perform at his best had positive reinforcement, because when he was able to wear it again, his performance improved. The funny thing is, what Pelé thought was his lucky shirt was actually a replica, passed off by his assistant as the original.

Newer research is revealing how knowing you are receiving a treatment or medication increases its effectiveness. From a biological or physiology perspective, you would think a substance would exert its effect in a very specific way, at a very specific level, affecting specific receptors, changing hormones or influencing the body’s biochemistry. Yet recent studies involving covert administration of treatment (hiding the treatment from the subject) has found “that when the patient is completely unaware that a treatment is being given, the treatment is less effective than when it is given overtly (openly) in accordance with routine medical practice.” The difference between open and hidden administrations is thought to represent the placebo component of the treatment. The decreased effectiveness of hidden treatments indicates that knowledge about a treatment affects outcome. (4)

You can harness the power of the placebo effect simply through words. Having an esteemed athlete or coach tell you how incredible your performance will be, will improve your performance. Studies have shown how patients can have the placebo effect without getting a pill, shot, or procedure, and feel better simply from visiting the doctor. Sitting in an exam room, seeing the white coat, or a supportive word from the doctor can change your physiology. This type of placebo effect seems related to the degree of confidence and faith the patient has in the doctor or activity. So, having a stranger tell you how fast you’ll run a race won’t be as effective as Lolo Jones encouraging you.

 Sport success is often dependent on a person’s belief in their ability to be successful, which is reinforced through hard work and perseverance. 

An excellent example of how the placebo effect can influence runners can be found in this short, easy to read article “Mind over Body” by John Porcari, Ph.D., and Carl Foster, Ph.D.

 Here is how you can harness this powerful performance enhancement:

Just believe.

Follow a routine.

Have a lucky object.

Repeat a mantra.

Avoid negative thoughts.

Find something that makes you feel or perform better and use it! (Maybe Sanya Richards-Ross can send you her sleeves).

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 Selected references:

1) Acute psychological benefits of exercise: Reconsideration of the placebo effect. Szabo A. J Ment Health. 2013 Jan 16.

2) The placebo effect: powerful, powerless or redundant? Kamper SJ, Williams CM. Br J Sports Med. 2013 Jan;47(1):6-9. doi: 10.1136/bjsports-2012-091472. Epub 2012 Aug 14.

3) Lessons From Recent Research About the Placebo Effect—From Art to Science. Howard Brody, MD, PhD; Franklin G. Miller, PhD.JAMA. 2011;306(23):2612-2613.  http://jama.jamanetwork.com/article.aspx?articleid=1104739#ref-jco15154-4

(4) Overt versus covert treatment for pain, anxiety, and Parkinson’s disease. Colloca L, Lopiano L, Lanotte M, Benedetti F.

(5) Placebo effects in competitive sport: Qualitative data. Christopher J. Beedie. Journal of Sports Science and Medicine (2007) 6, 21-28. http://www.jssm.org

(6) Placebo Effect: A Cure in the Mind By Maj-Britt Niemi Scientific American.  http://www.scientificamerican.com/article.cfm?id=placebo-effect-a-cure-in-the-mind

(7) Researchers Demonstrate How Placebo Effect Works in the Brain. http://phys.org/news105029324.html

(8) Amino Acids. 2012 May;42(5):1803-8. Effects of red bull energy drink on repeated sprint performance in women athletes. Astorino TA, Matera AJ, Basinger J, Evans M, Schurman T, Marquez R.

(9) Deconstructing the Placebo Effect and Finding the Meaning Response. Daniel E. Moerman, PhD; and Wayne B. Jonas, MD. Ann Intern Med. 2002;136(6):471-476.

(10) The placebo effect of ankle taping in ankle instability. Sawkins K, Refshauge K, Kilbreath S, Raymond J. Med Sci Sports Exerc. 2007 May;39(5):781-7.

11) Placebo effect in sports. Mark Berdi, Doctoral (PhD.) thesis booklet.  http://pszichologia.phd.elte.hu/vedesek/Brdi_Thesisbooklet.pdf

The Risks of Exercise

DangerIf we are searching for the truth about exercise, we have to accept the whole truth. Everything we do has risks and benefits and exercise is no different. As a runner, I often hear the sedentary crowd say “Running is bad for your knees” or “Don’t people die running marathons?”. Most are misconceptions. Everyone  has heard the many health benefits of regular exercise, and I think running is one of the best things you can do. It’s free, inexpensive and can be done anywhere. Yet the risks of exercise, particularly in endurance sports, are less commonly known.

Here are some of the risks and benefits of exercise:

BenefitExercise helps control your weight.

RiskRunning has the highest injury rate of any sport, with up to 75% of runners developing an injury each year. There hasn’t been a significant decline in the injury rate during the last 30 years, despite considerable efforts to reduce them. Neither shoes, diet, nor technology have made any impact on  the how and why runners get injured. Although there are many theories, the reasons seem to be multifactorial.

BenefitRegular exercise can help prevent a large number of diseases.

Risk– Runners have an increased risk of developing skin cancer. Marathon runners in particular have an increased risk for malignant melanoma and nonmelanoma skin cancer, most likely due to increased sun exposure and a decreased immune system from intense training. While melanoma accounts for 5% of skin cancers, it is responsible for 3 times as many deaths as nonmelanoma skin cancers, and is becoming more common. While the lifetime risk of developing melanoma in 1935 was only 1 per 1500, the lifetime risk in 2000 was estimated at 1 per 75.

Sun exposure and high physical strain can increase melanoma markers such as lentigines  (liver spots) and nevi (atypical moles) in marathon runners. Athletes should reduce ultraviolet sunlight exposure during exercising by training during times of low sun exposure, wearing adequate clothing, and regularly using water-resistant sunscreens. Many running shirts now contain UV protection, and you should always wear a hat. One of my favorite running hats is the Headsweats Protech desert hat . REI has good information about sun protective clothing. You can also wash UV protection into your running clothes!

Benefit–  Exercise can enhance your mood and help treat depression.

Risk – People do become addicted to exercise. An individual who is addicted to exercise will continue exercising regardless of physical injury, personal inconvenience or disruption to other areas of life including marital strain, interference with work and lack of time for other activities, and can suffer severe withdrawal symptoms when they cannot exercise. Exercise experts recommend 30 minutes of moderate to vigorous intensity aerobic activity a day, up to 5 days a week. If you have ever trained for an endurance event, you know you need dedication (some call it addiction) to train for many more hours than what the experts recommended.

Benefit–  Exercise can increase your endurance and strength.

RiskToo much exercise may damage your heart. A small study of 12  lifelong veteran male endurance athletes found “an unexpectedly high prevalence of myocardial fibrosis (50%) in healthy, asymptomatic, lifelong veteran male athletes, compared with zero cases in age-matched veteran controls and young athletes.” These data suggest a link between lifelong endurance exercise and myocardial fibrosis. But the study is too small to make generalizations and this premise requires further investigation.

Cardiac fibrosis (scarring of the heart muscle) occurs with normal aging, but the extent of this process and its effect on cardiac function is unknown. The scarring is thought to be due to decreased breakdown of collagen, but the cause of this decrease is unknown. Athletes commonly develop cardiac hypertrophy (enlarged heart muscle) and recent evidence has linked long-term physical activity to the development of cardiac fibrosis. Whether this exercise-induced fibrosis occurs regularly, or only in genetically predisposed individuals, is unknown.

The main problem with an enlarged heart or scarring is it makes athletes prone to the development of EKG abnormalities and irregular heart rhythms. This can lead to sudden death in athletes. The New York Times has an excellent article entitled How Do Marathons Affect Your Heart? (September 30, 2009), which reviewed this issue.

Benefit–  It can help you sleep better.

Risk – Intense exercise can decrease your immune system. Studies have shown intense training in already well trained athletes can result in a depression of immunity. This is due to elevation of stress hormones, particularly cortisol and anti-inflammatory cytokines. This creates an “open window” in the immune system, which may allow for an increase in susceptibility to upper respiratory illnesses. Theoretically, repeated bouts of a decreased immunity may increase your risk for developing cancer, such as malignant melanoma.
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Selected References:

1) Arch Dermatol. 2006 Nov;142(11):1471-4. Malignant melanoma in marathon runners. Ambros-Rudolph CM et al.

2) Sports Med. 2013 Feb;43(2):111-9. Exercise addiction. Landolfi E.

3) Ann Transplant. 2005;10(4):43-8. The T cell and NK cell immune response to exercise. Gleeson M, Bishop NC.

4) Exerc Immunol Rev. 2010;16:119-37. The open window of susceptibility to infection after acute exercise in healthy young male elite athletes. Kakanis MW et al.

“Of course it’s true. Everybody knows that!”

Facts do not cease to exist because they are ignored – Aldous Huxley

Our trainer tells us, so we believe it. Our running partner swears by it. An article in an exercise magazine claims it’s true, so it must be. All these reasons and more prompted me to start investigate exercise claims and write this blog. We often hear a claim so frequently, we assume it must be true. Herein lies the danger.

george-washington-portrait

A recent article in The New England Journal of Medicine (N Engl J  Med. 2013;368:446-454) illustrated our gullibility. Myths, Presumptions, and Facts About Obesity reviewed “some common beliefs about obesity that are not supported by scientific evidence”. Information we believe is true may be a fact (empirically proven and backed by sufficient evidence), but can just as easily be a myth (a belief held to be true despite substantial refuting evidence) or a presumption (a belief for which there is no convincing evidence to either confirm or deny the information). Here are the seven myths presented in the article.

1)“Small sustained changes in food intake or exercise will produce large, long-term weight changes” – We have heard this before: Cut back 100 cal a day or exercise to burn off 100 calories a day, and you’ll lose one pound every 35 days (one pound=3500-kcal). Keep this up and an obese person can lose more than 50 pounds in 5 years! Problem is, when adequately studied,  the true weight loss is only about 10 pounds over 5 years because as one loses weight, it alters the energy requirements of the body. A Biggest Loser contestant can lose 30 pounds in a month. It will take you years to achieve the same weight loss if you are not morbidly obese.

2)“Setting realistic weight loss goals keep people motivated” – There is no evidence to support this. In fact, studies have shown people who have ambitious weight loss goals lose more weight. Hence, the success of The Biggest Loser contestants.

3)“Large, rapid weight loss is associated with poorer long-term weight-loss outcomes” –  Studies show the opposite is true. Randomized, controlled studies have shown losing weight slowly might interfere with the ultimate success of weight loss efforts. People who loss weight rapidly lose more weight in the short-term (<1 year) and have the same weight loss at greater than 1 year when compared to slow  weight-loss dieters.

4) You have to be ready to diet in order to lose weight – It would seem to make sense that if you aren’t mentally prepared to diet, you won’t adhere to it or lose weight. But readiness doesn’t  predict the amount of weight lost or adherence to the diet.

5) Physical Education classes  help reduce or prevent childhood obesity – The studies say No. While there must be a certain level of physical activity that would be effective in reducing or preventing obesity, it isn’t attained in a PE class.

6) Breast feeding protects against obesity – If you Google that sentence, you’ll see lots of web sites supporting this claim. Yet recent randomized, controlled trials involving thousands of children have found no compelling evidence this is true.

7) A bout of sexual activity burns 100 to 300 calories – I’ll spare you the math but the average 6 minute sexual activity burns around 14 calories, fewer calories than a cup of celery.

Other claims for which there is neither supporting or discrediting proof include:

Skipping breakfast makes you eat more later. (Studies show no effect)
Our exercise and eating habits learned in childhood influence your weight throughout life. (Studies have shown it has more to do with your genetics)
Eating more fruits and vegetables results in weight loss. (If you increase your fruits and vegetables without other behavioral changes, you are more likely to gain weight due to increased calorie intake)
Yo-yo dieting is unhealthy. (There is no proof of this and animal studies don’t support this conclusion)
Snacking leads to weight gain and obesity. (No studies have found this to be true)
Living near parks or sidewalks decreases obesity. (You would think being able to be more active by having access to sidewalks or parks would help you maintain your weight, but there is no proof)

The article authors list 9 facts about obesity but I find some of them (meal replacement products or medications) a conflict of interest, as some of the authors receive consulting fees from Jenny Craig, receive funding from pharmaceutical companies,  or are otherwise involved with nutritional or weight loss companies. This makes their recommendations suspect.

Despite this, I think it’s an interesting article, as it reminds us to seek the truth and not simply believe everything we read or hear.

Man will occasionally stumble over the truth,
but most of the time he will pick himself up and continue on.
Winston Churchill

What do Kinesio Tape and Power Balance hologram bracelets have in common?

During my last Marine Corps Marathon, I noticed a lot of brightly colored kinesio tape. Some for sale at the expo, some on runners, some on the ground. It seemed every possible joint could be treated with this elastic therapeutic tape. As a physician, I wondered how one simple thing, such as the unique tape, could be so effective in treating so many different problems.For me, the truth wasn’t surprising.

Kinesio tape (KT) was developed by a chiropractor, Dr. Kenso Kase in the 1970s, to support injured muscles and joints, and to help relieve pain by lifting the skin and allowing improved blood and lymph flow. The elastic tape reportedly works by providing “external support that helps to prevent injury and speed recovery” and “augments tissue function and distributes loads away from inflamed or damaged muscles and tendons, thereby protecting tissues from further injury.” “By applying KT Tape over affected tissue, athletes experience an external support which helps to prevent further injury and allows the body’s damaged tissue to rest and heal naturally despite continued activity. KT Tape also reduces inflammation and increases circulation which prevents muscle cramping and lactic acid buildup.” It can also make you thinner, more attractive, wealthier and you’ll live longer…oh, wait, I made up that last sentence.

According to tSnake Oilheir website:
“Here is how it works, KT Tape is applied along muscles, ligaments, and tendons (soft tissue) to provide a lightweight, strong, external support that helps to prevent injury and speed recovery. KT Tape works differently for different injuries. KT Tape can lift and support the knee cap, holding it in place for Runner’s Knee. KT Tape can support sagging muscles along the arch of the foot, relieving the connective tissues for Plantar’s Fasciitis. And KT Tape can lift the stress off of shin splints to allow pain release and give the body a better opportunity to recover. Depending on how it is applied, KT Tape supports, enables, or restricts soft tissue and its movement. By stretching and recoiling like a rubber band, KT Tape augments tissue function and distributes loads away from inflamed or damaged muscles and tendons, thereby protecting tissues from further injury.”

This safe, non-toxic, no side effects, cure-all became popular during the 2008 Summer Olympic Games in Beijing, when it was seen on high-profile athletes. How did so many top athletes in every country become aware of this amazing tape? What did the top athletic trainers and coaches know that the rest of the world was unaware of? The fact is, this panacea had no scientific merit, but was donated to 58 countries for use on their athletes. The brightly colored tape became an instant trend among athletes. If it was good enough for U.S. women’s beach volleyball gold medalist Kerri Walsh, it was good enough for Joe Jogger! (Walsh later became a paid spokesperson for KT Tape).

kinesio-tape

It didn’t take me long to prove the old adage “If it sounds too good to be true…” Reviewing the scientific literature, there was little quality evidence to support the use of KT over other types of elastic taping in the management or prevention of sports injuries. (2) All the studies fail the TIN COPS test….not enough subjects in each study, no control groups to address the placebo effect, etc.

If you look at the Kinesio Tape “Articles & Stories” website (4), you’ll notice the articles in support of Kinesio Tape are general media reports, not scientific studies and support. And they only promote articles which support the tape. You won’t find the full Wall Street Journal article (April 27, 2010) where George Theodore, Massachusetts General Hospital surgeon and team physician for the Boston Red Sox is quoted as saying “There’s no evidence of a long-term or medium-term clinically significant effect but kinesiology taping is not harmful and over the short term, it can have a beneficial effect on pain and range of motion. It isn’t clear if the effect is psychological.”

I think Dr Theodore sums this up nicely. There is no scientific support or proof kinesio tape does what it claims to do. But it may do whatever you want it to do. The placebo effect is a powerful thing.

Which brings us back to the question “What do Kinesio Tape and Power Balance hologram bracelets have in common?”.

Power_BalanceA Power Balance hologram energy bracelet is a small silicon wristband fitted with a hologram which claim to optimize the natural flow of energy around the body, and so improve an athlete’s strength, balance and flexibility. According to the company’s FAQ “While we have received testimonials and responses from around the world about how Power Balance has helped people, there is no assurance it can work for everyone. We make no claims and let the consumer decide based on their experience.”Unfortunately, Power Balance bands are going the way of Snake Oil, as they have filed for bankruptcy after having  to pay a  $57 million dollar settlement.

In other words, if you think it will help you, it will.
Just like kinesio tape (or a lucky rabbit’s foot!)

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Selective References:

1) Kinesio Website http://www.kttape.com/what-is-kt-tape/

2) Kinesio taping in treatment and prevention of sports injuries: a meta-analysis of the evidence for its effectiveness. Williams S, Whatman C, Hume PA, Sheerin K. Sports Med. 2012 Feb 1;42(2):153-64. http://www.ncbi.nlm.nih.gov/pubmed/22124445

3) A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. Mostafavifar M, Wertz J, Borchers J. Phys Sportsmed. 2012 Nov;40(4):33-40. doi: 10.3810/psm.2012.11.1986. http://www.ncbi.nlm.nih.gov/pubmed/23306413

(4) http://www.kinesiotaping.com/global/corporation/about/articles/region-us.html

(5) Putting on the Stripes to Ease Pain. Wall Street Journal, April 27, 2010
http://online.wsj.com/article/SB10001424052748703465204575208193178227952.html

The Truth about Plantar Fasciitis (For Phil)

Perform an internet search for ‘heel pain’  and you’ll find over 4 million pages. The first thing you’ll notice is a lot of conflicting advice. Heel pain (the medical term is plantar fasciitis) is often considered trivial by most physicians but it affects ~2 million Americans every year. It is considered a self-limited condition, but it can take up to 10 months for 80% of the cases to resolve. Anything that causes a runner to stop or alter their training is not trivial or self-limited in my book. The insidious pain of plantar fasciitis can thwart an athletes dreams. Just ask Caitriona Jennings.

heelHeel pain was thought to be caused by “heel spurs, a sharp, bony outgrowth on the heel bone. Heel spurs are red herrings. They don’t cause heel pain but can be associated with plantar fasciitis. Up to 25% of asymptomatic people have heel spurs. The plantar fascia (plantar=bottom of the foot; fascia= thick connective tissue) stretches across the arch of the foot, from the heel to the base of the toes. Since it goes from bone to bone, it meets the definition of a ligament. The ligament can become “inflamed” (the Greek suffix -itis means inflammation, like tonsillitis means inflammation of the tonsils) from too much walking or running, prolonged standing, being overweight, poor arches,reduced range of motion of the ankle, tightness of the calf or hamstring, or repeated trauma (ramping up your training too quickly). The truth is, plantar fasciitis isn’t an inflammatory condition, but more of a degenerative condition (which is partially reversible) due to repeated micro trauma. This information is vitally important, as treatment is based on the cause. Inflammation is treated with anti-inflammatory modalities: NSAID’s (Ibuprofen, Aspirin), ice, and steroids (More on this in a later post).

Figuring out if your heel pain is due to plantar fasciitis is usually a straightforward diagnosis, but other conditions can be to blame, so if there isn’t any improvement with your home care, a doctor’s visit is worthwhile.

How do you treat plantar fasciitis? I reviewed the literature and was surprised to find that high quality evidence for the various treatments is lacking. There are no proven treatments backed by a meta-analysis of multiple, well conducted, randomized controlled trials. What this means is there are lots of treatment options, but not all of them will be successful in all patients. Here are your options:

– Footwear Modification: This is the most common treatment.Wearing shoe inserts have been shown to provide moderate improvement.Custom made inserts have not been found to be any better than the prefabricated, store bought models.  You should avoid walking barefoot, as this puts the plantar fascia under a lot of stress.

-Taping the foot: One way to “unload” the plantar fascia is to tape it. The low-dye taping method can be very helpful if done prior to exercise.

low dyw tape

-Stretching: Stretching the entire lower extremity, particularly the calf muscles, can provide some relief, although studies have shown stretching has limited success. A well done study (7) evaluated a specific plantar fascia-stretching program. The studied 82 patients with chronic proximal plantar fasciitis for a duration of more than ten months, who  completed a randomized, prospective clinical trial of either a plantar fascia-stretching protocol or an Achilles tendon-stretching protocol. After 8 weeks, there was a substantial difference noted in the group managed with the plantar fascia-stretching program.

Here is how it was done: Cross the affected leg over the other leg while seated, so your affected foot is resting on your other knee. Pull the toes upward toward the shin until a stretch was felt in the sole of the foot. Tension in the plantar fascia (bottom of the foot) is massaged while performing the stretch. Hold the stretch for ten seconds and repeat it ten times. Do this three times per day, and prior to any weight-bearing.

stretch

-Night Splints: Treatment with a night splint has shown especially encouraging results in well-designed, prospective, randomized studies. Night splints allow your plantar fascia to be stretched all night long. When we sleep, our feet naturally relax and our foot points or drops down, allowing the plantar fascia, Achilles tendon and calf muscles to shorten and tighten during the course of the night. A night splint keeps your foot at a 90 degree angle and maintains  a continuous stretch.

splint

–Extracorporeal Shock Wave Therapy: ESWT is the most researched treatment option, but results are inconclusive. A 2007 review of the studies found mixed but generally favorable results. High energy sound waves are aimed at the heel, in order to induce inflammation and stimulate new blood vessel growth and tissue regeneration. Here is a good video example of the procedure.

-Injections: In the opposite direction of ESWT, injections of steroids (such as cortisone) or platelet rich plasma aim at reducing inflammation. Cortisone injections in the plantar fascia are very painful, and have been shown to provide only short term relief.

-Surgery:  A frequently used surgical approach, partial plantar fascia release with nerve release, has resulted in mixed outcomes. Less than 50% of patients with chronic heel pain were totally satisfied with the results of surgical intervention. There is no evidence from randomized control trials to support surgery.

-Weight Loss: This is a Catch-22. Being overweight puts more pressure on your feet, so losing weight lessens the pressure. But to lose weight, you need to exercise, thereby putting more pressure on your feet! Non-weight bearing exercises, such as cycling or swimming, are good alternatives while your plantar fascia is healing.

The Bottom Line:  In searching for the truth on the best treatment for plantar fasciitis, tissue specific stretching (as described above, with the use of a night splint and shoe insert) is the preferred method of treatment. If there is no improvement in symptoms after several months, the advice of a foot specialist is helpful.

The one and only thing that has been shown to cure the pain in the majority of people is time (80% of the cases resolve after 10 months). While you are waiting for time to pass, try some of the above options…

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Selected References:

1) Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons. DiGiovanni BF, Moore AM, Zlotnicki JP, Pinney SJ.Foot Ankle Int. 2012 Jun;33(6):507-12. http://www.ncbi.nlm.nih.gov/pubmed/22735325

2) In the clinic. Plantar fasciitis.Young C.Ann Intern Med. 2012 Jan 3;156(1 Pt 1) http://annals.org/article.aspx?articleid=1033486

3) Plantar fasciitis. Orchard J. BMJ. 2012 Oct 10;345:e6603. doi: 10.1136/bmj.e6603. http://www.bmj.com/content/345/bmj.e6603

4) The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies. Yusuf Ziya Tatli and Sameer Kapasi. Curr Rev Musculoskelet Med. 2009 March; 2(1): 3–9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684947/

5) Plantar Fasciitis.Janet M. Torpy, MD; Cassio Lynm, MA; Robert M. Golub, MD. JAMA. 2011;306(17):1940. http://jama.jamanetwork.com/article.aspx?articleid=1104581

6) Current concepts review: plantar fasciitis. League AC. Foot Ankle Int. 2008 Mar;29(3):358-66.http://www.ncbi.nlm.nih.gov/pubmed/18348838

7)  Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Digiovanni BF et al. Bone Joint Surg Am. 2006 Aug;88(8):1775-81. http://www.ncbi.nlm.nih.gov/pubmed/16882901

8) Low Dye Taping http://www.ncbi.nlm.nih.gov/pubmed/18710520

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