A review of progress

It is time for a review of progress. Following several decades in which I did no regular exercise apart from cycling to and from work, I made a brief return to regular running in my late fifties.  After running a total of about 300 miles spread over a period of sixteen weeks, I ran a marathon.  I started the race with little idea what pace to set, but optimistically settled on a pace around 7:10 per mile (4:30 /Km) and reached the halfway mark in 93 minutes.  Not surprisingly considering my inadequate preparation, I hit the wall at around 20 miles and struggled home in 3:27:35.     In the subsequent few years I did a little sporadic running.  Those years marked the passage from my fifties – that decade of early middle age in which it is possible to remain blithely unaware of the aging process – into my sixties, the decade in which it becomes increasingly hard to ignore the accumulating loss of strength and flexibility.  At the beginning of 2007, I began running fairly regularly again.  For nearly three years I covered a distance of 15-20 miles per week, mostly at an easy pace.   In contrast to my experience during the brief return to running in my late fifties, I no longer found running at 7 minute mile pace (around 4:20 /Km) to be easy.  My leg muscles struggled to sustain a stride length much longer than a metre.  It was clear that I had to do something about the deterioration of my leg strength if I was ever again to run with any semblance of grace and power.

Nine months go I decided to embark on a systematic program to rebuild my leg strength and also to increase my aerobic capacity. Because I have a job that I enjoy but nonetheless leaves me exhausted, I decided that I should aim for a gradual build-up towards the goal of  running a good marathon in 2012 – a year after my expected retirement.  For the first three months – November and December of last year and January this year, my program went well.  I made appreciable gains in leg strength and aerobic capacity (as recorded in my posting on 30th January).  But then the first problem emerged.  In mid-January I had suffered an exacerbation of arthritis, a problem from which I have suffered intermittently for about 45 years.  This episode started with the worst of the pain in my neck but then it moved to my left knee, and did not resolve for many months.  The effects linger even now, seven months later

And then other problems emerged.  I have been puzzled by some chaotic recording from my heart rate monitor, suggesting possible atrial fibrillation.  That issue is not yet fully resolved and I will return to a more detailed account a little later in this post. Then, in early summer I developed a debilitating viral illness similar to the illness I had suffered last summer.  Last year my doctor had decided it was chicken pox, despite the evidence that I had had chicken pox as a child, and most people develop immunity after one attack.  I had also had an apparently similar episode of illness in my twenties.  I have now had a total of four such episodes.  Blood tests reveal that my immune system has mounted a good long-term defence against chicken pox – probably a consequence of my childhood episode, and that immune response has been maintained in recent years, so I am very skeptical of the suggestion that the more recent episodes can be chicken pox.  More recently, I developed left patello-femoral pain – irritation of the under surface of the knee cap – which was probably a consequence of adjusting my gait to minimize pain from the lingering bout of arthritis, together with loss of strength in my thigh muscles due to the reduced activity.

As a result of this series of problems I have not trained systematically for many months.  In the past six weeks I managed to run an average of 5Km per week, together with about 2 hours per week on the elliptical cross trainer.

Fortunately at this stage, all of these problems have dwindled into the background, though none have disappeared entirely.  Two days ago I did an easy 8Km run, at around 6 min/Km pace with no appreciable pain in my knee.  I did a similar run today.  My average pace was 5:49 min/Km and my average heart rate 118 bpm.  While this heart rate is about 5-6 bpm higher than I would have expected at this pace a few months ago, my loss of aerobic fitness has not been catastrophic.  As I sit here typing I am aware of a slight pain behind my left patella, but I am reasonably hopeful that the worst of the patello-femoral syndrome is behind me.  So I hope I can begin training regularly, though cautiously, again.

What are the lessons to be learned from the tribulations of the past 6 months?

Overall  stress

Despite the multiple mild health problems that have afflicted me since childhood , including mild asthma and arthritis, I am generally a healthy person.  Prior to last summer’s mysterious viral illness which kept me off work for a week, and left me debilitated for a month, I had never missed a day’s work in my life.  I have almost never required medication.  In contrast, during the past year I have been to see the doctor more times than the total number of occasions in the preceding 60 years.  I do not think this can be dismissed simply as a consequence of aging. The accumulation of multiple problems, all of which are likely to reflect underlying excessive inflammation, suggests that I am too stressed too much of the time.  This can scarcely be due to the running, as I do so little.  It is probably mainly attributable to the fact that I can no longer cope so easily with a 60 hour working week, as I did in my younger days.  This problem will be resolved by retirement next year, but meanwhile it is crucial that I make sure that my training program does not add appreciably to my level of stress.  To monitor my stress level, I measure my heart rate and heart rate variability (HRV) while standing shortly after rising most mornings.  My standing pulse is typically around 48-50 and my high frequency heart rate variability (assessed by calculating the quantity known as RMSSD) is typically in the range 60-90 milliseconds,  when standing.  This indicates a fairly good level of activity in the parasympathetic nervous system – the system that regulates recovery.  However when RMSSD drops to 30 millisec I look for additional ways of  reducing stress level and do my best to get enough sleep.

Heart rhythm

As a result of the chaotic recordings from my heart rate monitor over the past year, I am still undergoing investigation.  On balance, I think that the evidence indicates that I do not have atrial fibrillation (AF).  The main reason I believe this is that there have been several occasions when I have had really chaotic recordings which I was able to demonstrate, by adjusting the chest strap, were definitely due to poor electrode contact.  On other occasions I have  discovered similarly chaotic recordings retrospectively, when I examined the R-R recording after the training session.  The most noteworthy feature of these records is that within the wild fluctuations there are discernible periods in which both average heart rate and also heart rate variability persist at a level virtually identical to that before the onset of the chaotic rhythm. If the chaos was due to AF, I doubt that the heart would recover its equilibrium so immediately.

However, while I think it is probable that I do not have AF, there are some other features of note.  Sometimes there are sharp spikes suggesting premature atrial contractions and on other occasions, missed beats, which might reflect premature ventricular contractions. Premature ventricular contractions would be expected to produce a broad R wave in the ECG, and so might not be detected in the monitor which is designed to identify the normally sharp R waves.  As far as I can judge I do not have an excessive number of premature beats compared with a typical 64 year old man, but I regard the frequency of these ectopic beats as a potentially useful indicator of the status of rogue pacemaker sites.

As a result of my focus on chaotic rhythms, I have developed increased awareness of the high prevalence of AF in middle aged male endurance athletes.  While this awareness is disconcerting, I do not believe ignorance is bliss. The evidence suggests that many middle aged men have rogue pacemaker sites, mainly near the locations where the pulmonary veins enter the left atrium.  Furthermore, the onset of AF is frequently associated with disturbance of the balance between the sympathetic and parasympathetic nervous systems. This suggests that rogue pacemakers create a predispositon to AF and disturbance of the autonomic nervous system can precipitate an episode.  In endurance athletes, the relevant disturbance is usually an excess of parasympathetic activity.  Therefore, my own speculative conclusion is that it is especially important for a middle aged or elderly endurance athlete to avoid the parasympathetic overtraining syndrome.  As described above, I record my heart rate and HRV while standing most mornings.  Although the most frequent feature of note is a decrease in HRV due to excess stress, the really important sign to watch for is atypical increase in HRV, possibly indicating the more dangerous parasympathetic phase of overtraining.

I have also discovered that whenever I am stressed, I tend to exhibit excessive heart rate variability while exercising.  In contrast to HRV at rest, which is generally an indicator of good recovery and a healthy heart, a large amount of variability during exercise is not a good sign – it is associated with a higher risk of premature death.  Therefore I monitor the evidence of excessive variability during exercise with some interest, though unfortunately the mechanism underlying HRV during exercise remains something of a mystery and there is little published information about how it should be interpreted.

Overall, I am fairly confident that careful observation of HRV recordings can provide useful information to allow me to detect possible development of significant problems with heart rhythm.  However, I am also well aware that the unreliability of these recordings makes it essential to undergo more reliable investigation by a qualified cardiologist or electrophysiologist before jumping to any conclusions.

Musculo-skeletal issues

While I suspect that stress and the associated  inflammation have played the major part in the problems with my left knee, the lingering patello-femoral pain re-emphasizes the importance of maintaining adequate strength and flexibility of the muscles and tendons  around knee and hip.  In particular, weakness of gluteus medius (which allows sagging of the unsupported hip during stance) and weakness of the quadriceps can contribute to poor alignment of the patella on the femur . Therefore, I think it is worthwhile to continue the regular body-weight resistance exercises that I had started last November.  Although I am not a strong advocate of vigorous stretching of muscles and tendons, in view of the risk of iliotibial band problems when knee alignment is not perfect, I am also stretching the ITB regularly.

In summary, the past six months have been frustrating, but I think I have learned some useful lessons.  I am still aiming to run a good marathon in 2012.

7 Responses to “A review of progress”

  1. Andrew(AJH) Says:

    Do you really think that stress (of the type you get from work) can lead to physical inflammation symptoms?

    • canute1 Says:

      Thanks for your question.

      I believe that work-related stress can make a substantial contribution to inflammatory responses. The role of stress in triggering exacerbations of rheumatoid arthritis was described by Affleck and colleagues several decades ago. (Affleck G, Pfeiffer C, Tennen H, Fifield J: Attributional processes in rheumatoid arthritis patients. Arthritis Rheum 1987, 30:927-931.) But, as with most mind-body interactions, the accumulation of increased scientific knowledge has shown that the picture is complex.

      First there is the question of the different effects of acute stress and chronic stress.

      Acute stress increases activity in the adrenaline system and also the cortisol system (the ‘HPA axis’) leading to mobilisation of lymphocytes (a type of white blood cell) involved in the inflammatory process, On the whole, this is mainly a protective response, though it might possibly produce damage in tissues that are subject to auto-immune damage.

      Prolonged stress leads to a weakening of this defensive response by the adrenalin and cortisol systems and the development of chronic inflammatory responses which are generally harmful. In a recent review article, Ho and colleagues conclude; ‘In chronic stress, the activity of the HPA axis may decrease, leading to fatigue and increased activation of immune-mediated inflammation’ (Ann Acad Med Singapore 2010;39:191-6). I think that chronic inflammation is probably closely related to both chronic fatigue and to the parasympathetic phase of the overtraining syndrome.

      In a recent article on regulation of inflammation by the nervous system, Waldenburger and Firestein specifically address the pathways by which stress acting thorough the central nervous system can affect the joints, They conclude: ‘The central nervous system can also signal the periphery to modulate inflammation through efferent hormonal and neuronal pathways. The brain and spinal cord are involved in this bidirectional interaction. A variety of neuronal pathways that modulate synovial inflammation have been implicated, including the sympathetic and the parasympathetic branches of the autonomic system’. (Curr Rheumatol Rep 2010, Jul 30 , Epub ahead of print)

      Eskandari and colleagues also provides a good review of this topic (Arthritis Res Ther 2003, 5:251-265) that is readily available online at http://arthritis-research.com/content/5/6/251.

      The next question is whether or not work stress alone would be enough to produce a substantial inflammatory response. It is possible that a moderate amount of stress from my training program might have compounded the effect of work stress to tip the balance. I think that in the early months of this year work was likely to have made a larger contribution to my total stress level than my modest training program at that time. It is probable that retiring from my current job will have a more beneficial effect on my health than cutting down on my training, though clearly it is sensible for me to avoid substantial stress from training at least until after I retire. l hope my current level of training serves to alleviate stress rather than compound it.

      • canute1 Says:

        Perhaps I should make it clear that despite my belief that mental stress can promote an inflammatory response, I do not think mental stress alone would cause a condition such as arthritis. Other factors ranging from physical wear and tear to infections or genes also contribute. Most illnesses in the body are de to a combination of predisposing factors interacting with precipitating factors. I believe that mental stress over a period of weeks can be a precipitating factor in the presence of predisposing factors, while long term mental stress can add to other predisposing factors.

  2. Ewen Says:

    Thanks Canute. I’m pleased to see you’re still looking forward positively to running a good marathon in 2012.

    That’s interesting about stress and inflammation, also stress and overtraining. I know in my current situation long hours of work are tiring and there’s also stress with the work to get the job done on time. I couldn’t imagine working regular 60 hour weeks. 50-55 seems to tip me over the edge. However, I’ve found that easy running (not too long) is a positive rather than a negative addition to the overall ‘life stress’.

    • canute1 Says:

      I am sure you are right that easy running is beneficial even when one is facing a lot of stress at work. Pent up adrenaline is almost certainly destructive. Putting some of that adrenaline to good use by moderate elevation the heart rate and increasing tissue blood flow when running is much more likely to lead to an adaptive response.
      I am eager to continue my current moderate level of exercise until retirement. I will not push my self towards any ambitious goals in the next 12 months. I have still got a ‘soft’ goal of getting my HM time below 100 minutes this year, but if my health does not improve, I will not push myself too vigorously in pursuit of that target.

      • Ewen Says:

        Sub-100 is a good goal – maybe something near your Robin Hood time of last year? I’d be over the moon with sub-100 – haven’t given up on it yet. Funny, it was training run pace not that long ago.

  3. Paul Says:

    Hi Canute. When I was 20 I had a friend (still know him) who was forty and he regularly would tell me of all the things I could get away with then that I wouldn’t when I was his age. Now I am that age – and of course he was right.

    One of the things I always try to take from your writings is ‘what should I do now to help minimise the impacts of ageing?’ Not working 60-hour weeks seems to be one of them!

    I am also interested in your comment about the “weakness of gluteus medius (which allows sagging of the unsupported hip during stance)” as I notice this in my own style and cringe when I see it in others. Would love a post in due course on this topic (if you think it has a significant effect on running efficiency).

    Best regards, Paul

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