Thursday, July 26, 2012

Triathlon rewards the patient

 I had a very interesting conversation with an athlete the other day. He made a very astute observation, a concept that I try to impress upon my mentees, but often is ignored or forgotten. He said, “You know, I have a question. It seems that triathlon rewards those that wait. A lot of guys I know have made really big gains over the last 5 years. What are your thoughts?” I thought, “Gee, I better write a blog about this!”

Excelling in three different sports at one time is no easy task. Each discipline of triathlon has its own nuances in technique, training, and recovery. It is no wonder, then, that I view training for triathlon as a long term project. That is not to say an athlete won’t or can’t make incremental improvements, but, often the biggest gains take place over years. It is not feasible, for example, to drop one hour in an Ironman in a period of 3 months and qualify for Kona, unless previous races were contested with one leg tied up. Yet, I still have athletes ask me if that is a possibility.

Meteoric improvements are rare and are reserved for those with a phenomenal athletic background. This is true both in the professional and amateur ranks. For most of us, reaching our potential, whether it is an 8 hour or 12 hour Ironman time, requires precision in training. It is a matter of learning how to swim faster and more efficiently. Athletes need to hone their skills on the bike so they execute the fastest ride possible without damaging their ability to run well. This means a steady, controlled, leave the ego at the start line kind of ride. And, perhaps the hardest part of all is discovering how to run off the bike without melting down. Plus, there is the nutritional component which if not resolved can undermine even the best prepared athlete. Putting all of these pieces together takes a Herculean effort that can only be achieved over time.

Athletes want to take shortcuts. There is the faulty notion that training more or harder will get one to their goals more quickly. In reality, anybody can train hard. It takes a special someone to delay the gratification of short term glory in an effort to achieve their long term goals. Just think about the training monsters who kill it during workouts yet fail to produce on race day? Why does this happen? Because the body only has a finite ability to produce and to suffer and if one chooses to use this up during training there is nothing left on race day physically or mentally. Trying to bypass the laws of triathlon will not work.

My theory is that consistency is the key. It sounds obvious and simple. But, I still see people ignoring this simple principle all the time. There are the “weekend warriors” that train HARD all weekend and spend the rest of the week recovering. There are the “cyclers” who train HARD for a few weeks and then limp into a rest week or two. And then there are those who know how to mete out efforts over time so that they can train well for an extended period, taper and then go HARD on race day.

Improvements come from good ‘ole fashioned training day in and day out, week after week. It is not any one workout that makes an athlete better. It is the conglomeration of workouts over time. It may be months or years, but it is having a long term plan and realizing that triathlon does reward the patient. And the athlete who precipitated this very post? He was very patient in his training (and on race day) and set a massive PR at Ironman Lake Placid.

Monday, July 23, 2012

Let's get physical

There should be a requirement that doctors must have a sense of humor. It really makes the doctor/patient interaction so much more comfortable when you can share a laugh. This morning I paid a visit to my internist whom I will heretofore refer to as Dr. Drab, for a pre-op physical; his stoicism really reinforced my need to lighten up a situation with some sarcasm. In fact, I almost felt as if I was being challenged. Can I make this guy laugh?

Dr. Drab is a stodgy, older gentleman who is nice enough. I have only been to visit him on one other occasion, so we have never established any kind of rapport. For all intents and purposes, I am a complete stranger to him.

The first order of business was getting weighed. I don’t care who you are, getting weighed at the doctor’s office sucks. I made sure to wear my lightest clothes and removed my shoes. Somehow I was still 2 pounds heavier than I was on the scale at the gym and one pound heavier than the one at home, both of which I tried out this morning, wearing the same outfit, just for comparison. I am a scientist, so I like reproducibility. Somehow, there is a major fail going on here. Three scales, three different weights. It is like how all of the clocks in my house tell a different time.

Next up was blood pressure (100/62), heart rate (42) and temperature (96.4). Those look the vitals of a nearly dead person.

I was then queried about the nature of my injury. I gave Dr. Drab the abridged version, explaining how my 12th rib has been impinging a nerve. Of course, he had to put in his two cents; it seems everyone has an opinion, but no right answers.

Dr. Drab: Well, have you tried Neurontin or Lyrica (medications that help with nerve pain)?

JZ: I looked into those drugs, but they have nasty side effects. And, it doesn’t make sense to go on a systemic medication for a localized problem.

Dr. Drab: How about lidocaine patches?

JZ: I tried those. They didn’t work. In fact, I have tried everything. I’ve had nerve blocks, cortisone injections, and physical therapy. I even danced around a totem pole. Nothing worked.

Then he asked a barrage of questions about my family history. When I told him, yes, my sister is healthy, unless you count insanity Dr. Drab didn’t even crack a smile. What does a person have to do to get a laugh?

The physical exam was almost innocuous. He was palpating my abdomen and suddenly, without warning, he jabbed a finger in my side, directly into the pain epicenter. I was so startled by the intrusion that I jumped up quickly nearly causing us to knock heads. “Oh, did that hurt?”, was all he could muster.  No shit!

Then, to make matters worse, he started poking around the area, each time asking if it hurt. I wanted to ask him, “Would it hurt if I slowly pulled out each hair in your mustache, one by one?” What I did say was, “I think you have sufficiently found the offending spot.” He took the hint and stopped prodding.

Finally, it was done. Even though I passed my physical, I failed in my mission to get Dr. Drab to loosen up. I just hope I do not need Dr. Drab’s services any time soon, but if I do, I will be certain to bring along a sense of humor and gift it to him. 
Now this doctor has a sense of humor!

Tuesday, July 17, 2012

Preparing for Surgery

A little surgery humor. 
 Who knew that getting ready for surgery would be so difficult? I figured I would fly to Minneapolis, get my rib fixed, and jet right home. It is not quite so simple. It turns out that I have to stay in Minneapolis for a week so I can go to a post-op visit. What a nerve, the surgeon, the aforementioned Dr. Grail, wants to see me after surgery.

A mad search was initiated by my parents (who are accompanying me) and me to locate an appropriate post-surgical abode. A quick look on VRBO, a vacation rental site, brought up some interesting finds.

Here is a complaint from one reviewer on what looked like a perfectly reasonable condo:

"When we walked down in the basement to the 3rd bedroom, it was quite disgusting to see dog poop on the bedroom floor! When I told owner of this the next morning, she acted as though that could not be. We had no pets with us so it did not come from us."

Can you imagine walking into a rental condo and finding a pile of crap on the floor? That does not sound like a very sanitary way to convalesce from surgery!

Another rental met our criteria and we were about jump on it until we received a cautionary email from the listing site:

"As part of our quality control procedures, we have suspended this listing until we can obtain more information from the advertiser. If we do not receive information that is sufficient to reinstate the listing, it will no longer appear on our site."

If you are like me, than your curiosity is brewing over, wondering what heinous act the people who listed this property committed. Obviously it is much worse than dog poop on the floor. Dead body, maybe?

We decided, ultimately, to stay in a hotel about 20 minutes away from the hospital. It is near a lake and a bike path that you can run, bike or rollerblade on. It sounds perfect... for the one run I will be able to do the day before surgery.

Speaking of the hospital, did I mention that I am seeing a pediatric surgeon and that I am having the surgery done at a Children’s hospital? I have images of going to clinic and sitting in an itty-bitty chair reading Highlights magazine. I think I am required to bring a stuffed animal with me.

As a registered patient at a Children’s Hospital, I am receiving mail addressed to “the parents of Joanna Zeiger.” One of the letters from the clinic informed the parents of Joanna Zeiger, “your child needs to have a physical within 30 days of the surgery”.

I cannot remember the last time I had a routine physical, but I am thinking it might be the mandatory athletes’ physical I had my sophomore year of college. At that time, all I had to do was touch my toes, which I could easily do, impressing the doctor who had just seen the football team. I heard from another athlete those guys couldn’t even see their toes. In this instance, I need an EKG, a chest x-ray, and to answer a host of probing questions. I hope I pass; otherwise the house hunt was for naught.

I really want to run to the hospital the morning of the operation, but I have to be there at 5:30am making this an untenable option. I just think that would be so cool. I would say to Dr. Grail “Sorry I am a little stinky, but I ran here this morning. Hopefully, you slept in, though. You have a big day.”

Thursday, July 5, 2012

JZ and Dr. Grail: A Tale of a Quest

I have been dealing with this rib injury for 2 years and 8 months. At some point during that time frame it became evident there was dysfunction in the rib and it would not heal without surgical intervention. I hunkered down with my father and began a quest to find a surgeon who was willing and able to fix my rib.

And, who doesn’t love a good quest? One of my favorite films in high school was Monty Python and The Holy Grail. The Indiana Jones and Lord of the Rings movies have made a killing at the box office. The common theme in these movies, and what makes a quest so enthralling, is that there is adversity, good guys, villains, moments of comedy, uncertainty and ultimately, a satisfactory conclusion. Quests often drag on and on and on and on, exemplified by the Lord of the Rings trilogy which lasts an astounding 682 minutes on 15 DVDs.

My quest has been no different. There has been a huge cast of characters, with heroes (those who have bent over backwards to help) and more nefarious types (those who have brushed me off with the wave of a hand or even worse, told me this was all in my head). There have been incredible highs, such as qualifying for the Olympic trials in the marathon, and incredible lows, such as not being able to ride a bike. I have laughed and cried. I have moved forward and backward and in circles. But, I have never lost sight of the quest, even if sometimes the quest was put on hold due to lack of information or decreased motivation.

And, now, my quest is hopefully coming to its terminus. On August 1, I will have surgery to repair my rib. After speaking with no less than a dozen surgeons, I have found a very capable one in Minneapolis. I affectionately call him Dr. Grail in homage to my favorite questing movie. I spoke with him 2 weeks ago and his kindness and compassion over the phone brought tears to my eyes. He is the chief of pediatric surgery at the University of Minnesota Children's Hospital. In the midst of our conversation Dr. Grail said to me, “You know, I generally work on kids.” I replied, “I am a kid at heart. And, I am not very big.” We had a good laugh, and I knew instantly that we clicked.

Upon describing my symptoms and the treatments I have undergone, Dr. Grail believes I have an unhealed fracture in my 12th rib, or in doctor speak a pseudoarthrosis. This has caused instability in that rib making it move around like a loose tooth causing an impingement on the T12 intercostal nerve that sits behind it. Insertion of a titanium plate into the rib should stabilize it thereby taking away the impingement on the nerve or he may even need to shave off part of the rib. The exact procedure will not be known until the surgery itself when Dr. Grail can assess the exact problem. Nothing like making a game day decision!

I have no idea what the recovery time is, or how long the procedure will last, or any other information for that matter. You see, Dr. Grail said this to me, “I can make you pain free.” After he uttered those glorious words, my brain shut down and I was rendered mute. It seems like an unbelievable end to this grueling quest.

Tuesday, July 3, 2012

Age related declines in performance

 It's no secret that declines in performance occur with age. In fact, the mantra I hear over and over is, “Once I reached 40, everything changed.” And, for those of you 50 and beyond, the sentiment about diminished performance is even stronger. Mounting research into Master’s athletes, and triathletes in particular, has delved into the particulars of the changes in performance with age.

Performance loss in triathlon occurs in a curvilinear fashion with relation to age. This means that initially, peak performance slowly drops with age, but the process of performance loss from year to year gets faster and faster. According to a study on master’s triathletes by Dr. Tanaka in 2008, there are relatively modest decreases until 50–60 years of age, with progressively steeper reductions after that. No one is immune from this: males and females as well as elite and non-elite athletes show similar patterns of decline, and in all three sports!

Another important question was asked by Dr. Brisswater’s group in 2010: What are the sport specific and distance specific declines with age? Perhaps unsurprisingly, this study found that cycling showed the least amount of age related changes at the Ironman and ITU / Olympic distance, and that there was less steep decline in overall performance over the Olympic distance than Ironman. Again, the sharpest declines seem to occur after age 50. Swimming showed the highest rate of decline in performance compared to cycling and running.

Why do these drops in performance occur with age? There are the obvious circumstances such as injury, but there are also interesting physiological changes that come with advancing years.

VO2max, the maximum amount of oxygen the body can process during hard exercise, has been shown in some studies to be the best predictor of age related changes in performance in Masters athletes. As you might expect, VO2max declines with age. It occurs at a rate of approximately 1% per year after the mid-30’s. Interestingly, this drop in VO2max is even higher in well-trained individuals compared to sedentary individuals.

I spoke to Dr. Phil Skiba about this. Dr. Skiba coached me during my World-Championship season, and is board-certified in sports medicine. “We do not completely understand the mechanism by which VO2max declines with age,” He told me, “However, it is important for athletes to know that it is possible to slow the decline by as much as ten-fold through hard, consistent training.” So, that means, do not neglect workouts that have short, hard intervals of 30 seconds up to 3 minutes for about 12-15 minutes of total work.

Since there are decreases in VO2max over time, we might question what happens to the lactate threshold (LT).  LT denotes the point at which the muscles begin to become progressively more inefficient in terms of oxygen use, and begin to use greater amounts of carbohydrates for fuel. “LT is a very good predictor of exercise endurance and exercise performance, in some ways more important than VO2max per se.” said Dr. Skiba, “Importantly, it does not seem to decline in the same way with age, especially in athletes who remain fit and well-trained.” A healthy dose of LT intervals incorporated into your training program is a highly efficient way to delay drops in LT. These types of intervals are much longer in length than VO2 max intervals and can last from 10-20 minutes for about 40-60 minutes of total work depending upon one's level of fitness and the time of year.

A related subject is exercise economy, which is a measure of the amount of oxygen the body uses to do a particular task. For instance, if two athletes weigh the same, and are running at the same speed below LT, whichever athlete is using less oxygen is the one who is more economical. This does not seem to change very much with age, which is very good news indeed!

Now, of course, these are generalizations with respect to physiology, as not everyone experiences the same rates of decline for the same reasons. And, many Masters athletes report best times late in their careers, which would seem to suggest that most athletes are working so far below their true potential that they can manage to improve their performance in the face of a declining physiology. Dr. Skiba often uses the analogy of a ladder with his master’s athletes. “Imagine that your fitness is a ladder. The top of the ladder is VO2max. With age, you lose rungs from the top of the ladder.  If you keep training, you can still climb higher and higher. Most people never get anywhere near the top, so they keep setting PR’s. They never realize they have lost the rungs above, because the ladder was so tall to begin with.”

As a master's runner, I have set PR's in the half marathon and marathon by incorporating a mixture of intervals from 30 seconds up to 20 minutes. While my VO2 max speed is slower than it was 10 years ago, I still make sure to work that high end to minimize the losses. And despite this slow down at the top end, I am clearly faster over the long distances. I just have to hope that none of my races come down to a finish chute sprint. But, then again, I never really had good top end speed. At the 2000 triathlon Olympic trials, my coach warned me, "If you are running neck and neck with someone, start sprinting with a mile to go."

Are you maximizing your potential? With a proper training program, you can certainly get closer to it!