Rehab like you mean it!
Focused and concentrating on delibrate practice.
You book a physio appointment for an injury. You’re diagnosed and the problem seems simple enough. You’re given some daily exercises and start your new programme with enthusiasm - well, for a day or two. You continue on autopilot and it all becomes a bit half-hearted, maybe forgetting on some days, gradually falling out of routine. If only we could harness just a little of that super-practice to help.
First, let’s elaborate: what exactly are we talking about? “Deliberate practice” (Ericsson) or “purposeful practice” as Syed calls it are fundamentally the same thing and hinges on a central idea that’s great news for busy patients: the amount of time spent practising isn’t all-important. Instead, progress happens when practice is smart. Firstly, practice is most effective when each activity has its own highly specific and constant aim, which then links back to the overall purpose of the training. Secondly, it should be undertaken with “deep” engagement. That is, with conscious effort, or “to engage so deeply in the task that one leaves the training session, literally, a changed person.” Thirdly, activities should offer the correct level of challenge. Too easy and progress will plateau, too difficult and it will be impossible to have positive feedback. They should also be progressive over time, to keep challenging an improving subject: further, higher, faster… The role of the athlete or performer is to engage fully in practice and provide accurate feedback. The role of the coach is to identify that sweet spot of exactly the right level and progression of practice, and to work with the athlete to evaluate feedback and adjust the programme accordingly.
Adavnced balance exercise on uneven surface!
What does that mean for your treatment? The physio essentially takes on the role of the coach, guiding the patient back towards their desired activity level - be it a return to competition, to work or to being able to enjoy a favourite leisure activity. They need to ensure all exercises prescribed are at the correct level and intensity for each individual patient, and that difficulty is increased over time towards the treatment goal.
Of course, with healing tissues it is particularly important to hit the right balance between reaching high enough to improve without overloading these recovering areas too much too soon. Steering this increasing load requires accurate feedback from the patient of what worked, what was enjoyable and what was a struggle, and the physio uses this feedback to adjust the rehab programme accordingly. Executing the exercises effectively requires the patient to engage in their recovery programme and take on a proactive role. While this is in part up to them, engagement and ownership is helped greatly by understanding the process. This is where the patient should challenge the physio, and the physio should explain: Why are we working on exactly this aspect of strength, flexibility or movement pattern? How are this week’s exercises then going to progress to allow the person to return to sport and stay healthy? Where is it all going?
Knee pain doesn’t mean that you can’t start running, but it is best to seek advice from a physio before you start.
We are not camels. Managing racing in the heat.
Sheffield University Orienteering Club (SHUOC) on their way to smashing the Guinness World record for the half-marathon in one hour and forty minutes.
This Sunday is the 38th London Marathon and it's predicted to be one of the hottest. After the long cold winter this may pose difficulties for some runners.
These potential difficulties are linked to two factors: hydration and overheating.
We all know that we should keep well hydrated. Achieving this is not as simple as you might think. The ideal amount of fluid intake varies depending on the conditions and the individual. Drink too little and you might become dehydrated, too much and you become over-hydrated.
Both have medical and performance consequences and some argue strongly that overhydration has the far more serious consequences. Many people have died from overhydration in numerous situations including marathons.
Feeling thirsty - this is the earliest and most prominent symptom.
Feeling light headed and dizzy. These tend to present as the dehydration worsens.
If you start to feel thirsty or have a dry mouth - DRINK. But drink to thirst - don't overdo it. We are not camels.
How much depends on on individual factors but about 400-800ml per hour (about two cup maximum).
Headache. Note headaches are not a symptom of dehydration.
If you are concerned or start getting the more serious symptoms of nausea / vomiting / headache then go to a medical point.
Overhydration tends to occur in slower runners as they are out for a longer length of time and have more opportunities to drink greater volumes of fluids.
For the vast majority of runners London won't be hot enough for serious over heating or heatstroke to occur .
Heatstroke occurs when the core body temperature rises to a level which is potentially very harmful. The main parameters governing this are speed i.e. energy required per unit time, and external temperature.
Heatstroke therefore tends to occur in very hot conditions and with faster runners racing over shorter distances (5-20 Km). The faster we run the more heat we generate.
In the temperatures at London the speed even the fastest runners race a marathon are unlikely to be be enough to generate the heat required to cause heat stroke. However, whilst very rare, there are documented cases of it occurring in some individuals at slower speeds and in cooler conditions.
Whilst heatstroke is very unlikely, there is a very high probability that many runners will struggle with the far less serious condition of heat exhaustion. Heat exhaustion is caused by external temperature rise i.e. on your skin. Your body does not like this and treats it as a warning signal generating symptoms in order to force you to slow down.
Heat exhaustion occurs when the body just isn't adapted to the hot conditions. This will be the case for the majority of runners on Sunday. Many runners will be physiologically incapable of handling the thermal load and may then experience symptoms of heat exhaustion.
Heat exhaustion is detrimental to performance but normally doesn’t lead to heatstroke as the conditions for the core body temperature to rise to critical temperatures.i.e. speed and external temperature, are not present.
Slow down - the slower you run, the less heat you generate the cooler you'll be.
Use cooling techniques to lower your skin temperature - water over your head, cold drinks, ice, run in the shade etc.
Stay hydrated but don't overhydrate - drink approximately 400-800 ml (1-2 cups) per hour during the race.
Try to avoid getting too hot before you start - stay in the shade, put cold water over your head, on your neck or wrists.
If you know your not good in the heat consider starting at a more sedate pace then planned.
If you start to struggle - slow down, evaluate the cause - dehydration, over hydration, or heat exhaustion and act accordingly. If you are not feeling thirsty it's unlikely to be dehydration.
What goes up must come down - the Sheffield Half.
This years Sheffield Half Marathon will be staged on Sunday 8th April. It’s an unusually hilly course for a half marathon with the first section uphill most of the way from Arundel Gate to the edge of the Peak District followed by a long undulating descent all the way back down to the city centre. Overall there is around 300m of ascent and descent.
compared to a flat half marathon.
The first two sections of the hill - to Banner Cross and then too Knowle Lane are the steepest.
After that it flattens out with some short sections of flat or even slightly down hill running.
A minion tackling the steepest section in 2016.
downhill running for such a prolonged period is tough on your body.
the risk of injury in the lower body - from the hips down to the feet.
This descent catches out a lot of runners with jelly legs setting in around the Prince of Wales pub.
The occasional tumble has been known as legs buckle under a tired runner.
iliotibial band (ITB), calf or foot, then racing ten kilometres mostly downhill on roads is going to test it.
steady pace, especially downhill, before adding some faster hill work.
loading before you put the next load through.
4) Work at your downhill technique. Practice taking shorter strides landing your foot under your body.
This will reduce the load through your legs. Try to avoid over-striding.
Hard knocks on Hard Knott - My monstrous mountain marathon.
What am I doing here? It was the sight of top fellrunner Jonny Malley looking forlorn and in despair after forty five minutes searching for checkpoint nine that made me ask myself that rather obvious question for the first time.
We were about two thirds of the way up the featureless western slope of Scafell in thick mist hunting for the mother of all bingo controls - a sheepfold. At least the driving rain and wind of the last eight hours had calmed a little. We’d endured this foul weather as we crossed much of the central Lake District - from Langdale almost to Thirlmere, across Borrowdale, round Gable and Kirkfell to the back of Yewbarrow and we still had to cross Eskdale and Hard Knott before reaching the campsite at the head of the Duddon valley.
So what on earth made me enter the OMM Elite?
A long long time ago - well February - I was having a Valentine dinner with my dreamboat husband and the romantic talk turned to the Adventure Show and it's rather excellent coverage of last years OMM: https://www.theomm.com/adventure-show-teaser/.
The power of television is such that I came away almost believing that Nick Barber is one of the world’s greatest athletes. But it was International Orienteer Jess Tullie and her partner competing on the Elite course that I found really inspirational.
And there was fell-running legend Nicky Spinks looming larger than life on my TV screen encouraging more women pairs to race the Elite. Why not I thought? There’s months to prepare and I’m already a top navigator - at least that’s what I tell anybody who will listen.
Of course another nice twist would be to run it as a Kim Baxter Physiotherapy Team and Sally agreed to join me, alas only to drop out a few weeks later due to a wedding invitation.
I wracked my brains for another partner who might be strong enough to attempt it and who I’d get along with and came up with ex-junior-international orienteer and experienced adventure racer Lucy Spain (nee Harris). After some thought she said yes - the OMM remained one of those challenges she still had to conquer.
Over the years I have never ceased to be impressed by and often in awe of our many patients who embark upon real challenges; whether it is newbie runners challenging themselves to run five kilometres then building up to half marathons and then even marathons. Or others such as the crazy Hilary Bloor who needs a race as extreme as the Marathon de sables to put herself under a little pressure.
In all my running endeavours over the years I’ve been focusing on winning or pbs. I’ve never before taken on the challenge of wilI I finish this race? Am I actually good enough to do this? Have I bitten off more than I can chew?
Well the OMM Elite is certainly that challenge. Those questions started to haunt me. They haunted me all through the spring and summer. They were still haunting me in the car park on the morning of the event. Can I really do this? Is it possible for me?
Training is about balance. Too much training with too little recovery means no progress and increased risk of injury. Too little training and I might not be good enough to finish.
I am a firm believer that your current ability is not the sum of your previous weeks or months training but the sum of your life's training.
So in my favour I have years worth of running and orienteering in the mountains. I trained hard until I was twenty five. I then had a break for travelling and kids where I averaged about two hours running per week but since 2013 I have slowly built up my hours and going into the OMM build up I was averaging six hours per week plus small amounts of strength work, climbing and yoga.
My goal in 2015 and 2016 had been the Sheffield Half Marathon so my training had been based around regular speed sessions and much of it had been done on roads.
I analysed my current ability and came up with the following areas that I believed were adequate and the areas I needed to improve.
Endurance. I rarely ran over two hours. The OMM could test me over eighteen hours.
Downhill running - I've always been overly cautious, this has been amplified post kids.
Rocky terrain, especially slippery when wet.
Running with a rucksack. I walk a lot with a heavy bag but never run.
Strength session - the goal being increased agility and lower leg strength to improve descending and downhill efficiency.
I dropped interval training and speed sessions as these were less relevant and doing too many sessions would fatigue me and reduce the effectiveness of the key sessions.
That was the plan - but what about the reality.
Endurance: In the eight months of buildup I only managed managed to do four runs around four hours! This was due to a family life limiting available time and also a lack of motivation to get out and do the long stuff on my own.
Hill Sessions: Here I was a bit more successful. Thankfully the West of Sheffield is notably hilly and the majority of weeks I was doing between 1000m and 2500m climb. Still not a huge amount but more than I had done previously.
Strength: In July I discovered Tribe (Trib3) a local gym that runs circuit classes.
For years my strength sessions had been solitary and somewhat soulless, so it was great to join a class that pushed me.
But it was brutal! It even included ten minutes interval training on the treadmill which was great for training my tired legs to keep moving.
The idea was similar to these bench exercises by Claire Maxted of WildGingerFilms.
All was going well up to August and our summer holiday included eight orienteering races at altitude in the Pyrenees and Alps plus some hut trekking near Mont Blanc with the kids. I also managed to slot in a long run which included a 2000m descent. The sessions were working and my downhill legs were coming on.
Using the family hut trek to practice with a rucksack.
In September I lined up two longish fell races - the Totley Exterminator and the somewhat more relevant Three Shires in Little Langdale.
Totley was fine and I recorded a confidence-boosting victory. At the Three Shires I could still feel the Tribe sessions in my legs and realised my descending was still poor compared to hardened Lake District fell runners. Second place and first vet was ok but I left the race feeling quite demoralised.
Over the next few weeks I continued with my training plan but managed to tip the balance into overtraining.
I did too many Tribe sessions too close together with too little recovery causing an old foot injury to flare up.
As we all do I adopted the classic ostrich position and ignored the warning signs. This culminated in a longer than planned run with a friend intent on collecting half a cow from a butcher’s in Hillsborough, He suggested I carry his meat and bone laden rucksack as it would be good OMM training.
But then an aborted long run in the peaks a few days later made me realise and accept my mistakes. I had to stop running and rest.
After four days I was walking pain free so I tried an easy twenty minute test run. This was twenty minutes of phantom pains and paranoia but the pain didn’t increase and there was no adverse reaction after or the next day. During the run I bumped into a long term patient who reminded me what I would be saying to him: stop your CCTV. Look outside yourself. Look at the trees, the birds, the river, the other people. Focus on something else. If the foot is a problem it will let you know. Don’t focus on it.
All was feeling fine for the British fell running relays three days later. This was my last test before the OMM. After only an hour of running the pain started to return and on the final descents I felt like I was running with a big heavy block rather than a foot.
My descending skills were back to being poor and I finished tired, disappointed and scared. At the finish the amazing Zoe Harding bounded off back up the hill to do a longer run declaring it was because she was doing the A at the OMM. I sat fatigued in the tent thinking I’m doing the Elite and I couldn’t run any further today. One hour fifty two isn’t enough. HELP.
By now Lucy had dropped out with a stress fracture. Having run out of women to ask I found the next best thing and teamed up with Dark Peak’s Dave Sykes. With bags of experience of the OMM and long Lake District fell races and also a top descender Dave seemed to be the complete package - although he needed to work on being more imberb.
It was now too late to change anything. I just had to accept my two week taper, rest, recover, manage my demons and hope for the best.
Will my foot be ok? Can I still descend? I’ve not done enough. I’m not ready. How can I run for ten hours and then repeat it when I haven't managed more than fours? How stupid was I to believe I could do such a thing?.
I JUST CAN’T DO THIS!.
I was constantly seeking reassurance from everyone. Patients, friends, Joe Blogs. But the thing about reassurance is the more you get the more you need.
So the final week I was trying to just distract myself. This was helped by our landlady hiking our rent by almost fifty percent so I suddenly needed to find a new work premises.
In these final few weeks the desire to test yourself to check you are able to run x y or z is strong. You want to prove to yourself you are in the shape to reach your goal. For me I was desperate to do a five hour run as this was my goal in training and I’d never done it before. Yet I knew that I was deluding myself. So close to the race there was just no point, no training benefit - nothing to gain and everything to lose.
I spend a lot of time reassuring patients in their final few weeks before their big challenge. I tell them they can do it, they have done enough training already, they don’t need to stick to the schedule printed in Runner’s World or taken from the internet.
All of them look at me as if to say I’m talking nonsense. They all just want to…….
I was having to fight hard against my just want tos.
With a few minor hiccups such as a forgotten waterproof and water bottle we were off.
The weather was awful. We nailed the first but missed the second. I relocated quickly. As we left the control we passed the only female pair in the race - double Bob Graham Round legend Nicky Spinks and her partner. Running away from her over the wild fog-covered moor was a definite morale boost. At Seathwaite Fell last year’s winners Shane and Duncan piled past with Duncan declaring he was already exhausted. I’m not I thought.
We continued on our way and as we ran up the side of Ennerdale I started calculating whether we could make it back in daylight.
Such thoughts were promptly thwarted by the sheep fold on the side of Scafell. But we were luckier than many and found it without too much delay.
I’ve raced orienteering all my life. In 1999 I came back with the leaders in the World Championships Relay on the incredibly tricky Loch Vaa. I needed all that experience and focus to find that last tricky tarn in the dark and mist after 46km and ten hours of running. Not bad I thought.
But there wasn’t much time to enjoy our victory against the weather gods. Food, sleep and all too quickly we were off again, launching into the cold chill of a cloudless but windy dawn.
This day was tough from the start. I’d been protecting my left foot the previous day resulting in a painful right knee and hip flexor. The thought of running all day with this got me down but Dave was a bouncy tigger in the sunshine so I continued to trog behind him.
About half way round I realised we were at risk of timing out even though we were within twenty percent of the winners. At number four south of Wetherlam we were forty minutes from cut off and as we proceeded round the cut off times got closer until by the south side of Langdale we were really having to push to avoid being timed out. We covered the last half just over ten percent behind the leaders as we desperately tried to avoid what would have been a very unjust disqualification - a fate that hit several teams around us.
And then there it was. The Finish. Eight minutes to spare. I went into the tent, sat down and cried.
The mental side of running fascinates me. Studies abound about how we can run farther, faster, longer with different mental cues.
Prior to the OMM one of my ultra-running patients told me it’s ninety percent mental and the rest is in your head.
Long distance running is all about willpower and it seems I’m OK at it, although the distraction of having to navigate in zero visibility followed by the pressure of potentially being timed out certainly helps.
Had it been beautiful hills in beautiful weather with plenty of time and just the thought of having to trog round to finish it would have been a lot more difficult.
Hey - I’ve found I can do eighteen hours of running and not throw my toys out the pram. Who knew? Certainly not my long-suffering husband.
Many of you will have read my blogs about the pain system. It really is all in your head. I never felt my bad foot on the second day. Not once. And once the pressure of racing the course closing times kicked in the knee pain disappeared completely.
The coming weeks and months are crucial for recovery. I will wait until the New Year before returning to structured training. Until then I’ll just do what my body feels like doing.
Longer term - I really should do my physio exercises to get my foot sorted! And in the unlikely event I ever do this again I’ll need some deeper investigation into how to get my 5.25kg pack down to the 3.5kg weight of the leading male runners.
Whilst it’s almost always more fun to have someone else massage your sore bits it’s also expensive and time consuming. That’s why lots of runners are familiar with the strange pleasures and pains of auto-malaxation, or foam rolling as its more commonly know.
Whether gyrating on a tennis ball to release your glute, suspending yourself above the lounge floor on a foam roller whilst watching Mock the Week or driving to work perched on Rover’s Ruffer and Tuffer spikey dog ball, we all feel the need to help it all hang loose from time to time.
Many of you will already be close friends with these torture tools and will use them on a regular basis whilst others may feel more than a little curious as to what exactly they are and what they can and can’t do for you.
Put simply, we’re talking about any implement or tools that allows you to do deep massage to your own fascia and muscle, with foam rollers being perhaps the most well known.
Why might you want to use them?
As an alternative to stretching to restore ‘normal’ flexibility, mobility and range to muscles and fascia (myofascia), or to increase flexibility in chronically tight myofascia.
If you haven’t already you may be interested to read my previous blog on the benefits or otherwise of stretching.
Foam rolling is an even more divisive topic than stretching. Many physiotherapists, coaches and athletes swear by them and use them in an almost ritualistic manner. Others find very little benefit and some find they can aggravate pain and tightness in their tissues.
The general consensus from available research into foam rolling is that it improves flexibility i.e. range of movement.
It can also reduce soreness after a workout. Whether this is a good thing or not is another question - some see this soreness as part of the adaptation process and by easing it you may be reducing the effectiveness of this adaptation process and hence of training. However if you have another race the next day then reducing soreness could be beneficial.
When asked most people you will probably describe how it breaks down scar tissue, knots, adhesions or lactic acid.
But does this really happen? No.
To ‘break down’ tissue in the way described above you would need to apply significantly higher forces than a human is able to exert on themselves.
So what are we actually doing when we roll on foam?
This is one hypothesis, there are other similar or more complex ideas. The short answer is we know it increases flexibility but we don’t really know how it does it.
It’s not necessary for it to hurt to be helping. Applying pressure to the point of mild discomfort results in the same increases in flexibility as more painful rolling.
The more it hurts the greater the risk of you aggravating your symptoms. In particular if your system is already sensitised to pain due to an injury then subjecting it to further significant pain is unlikely to aid recovery.
Try to adjust the pressure so that you get the sensation you want - it should feel like it’s doing something but not too painful.
Which muscles should I target?
The one’s that feel tight.
The one’s that feel tired and used - if you’ve just run a race with lots of downhills then target the quads, if you’ve been doing lots of fast running on hard surfaces or jumping exercises then try the calves.
The one’s above and below an injured site - if you have a sore hip then target the lower back, glutes, quads and hamstrings. Hopefully this may loosen of the surrounding area allowing the injured area to move as it should.
Research suggests two to three sets of thirty to sixty seconds rolling per muscle repeated three to five times per week - although if I’ve learned anything in my career as a physiotherapists it’s that individuals are individual.
Trying to foam roller or use a massage ball on tendons can cause further irritation of the tendon.
I’ve seen patients hardly able to walk after too much foam rolling on already aggravated tendons.
It’s also possible for the pain system to perceive the massage as a threat i.e. something that might damage the tissue. In some cases this can cause muscles to tighten further to protect the area causing more tension and discomfort not less.
So, would you recommend I do it?
If you have a clear reason or aim for trying it then yes.
You may want to improve mobility through tight glutes, loosen off sore spots in your lower back or massage tight calves.
If it's achieving what you want then continue to use it. If you don’t feel it’s helping you then try other methods or see a physiotherapist who can work with you to establish why something is tight or sore and how to address it.
In particular, if you feel foam rolling is making you worse i.e. tighter or sorer, then stop. It’s not helping!