Take 12 Weeks Off And Come Back Stronger?

Consider the following scenario. You have trained well and have just taken part in the Swimrun World Championships. You then take 12 weeks off from training. You resume training again for 12 weeks and tests show your VO2 max levels exceeded those just before you took 12 weeks off. 

Too good to be true? Can a long break be that good for you? 

A French exercise physiologist and triathlete Romuald Lepers agreed to take 12 weeks off deliberately (for the sake of science) and allowed himself to be tested. With his colleagues' help, he underwent a whole bunch of tests straight after he competed in the World Swimrun Championships in 2022. After that he rested for 12 weeks and the tests were repeated. He then resumed training for 12 weeks and repeated the same tests. 

The results were published in 2 different journals last year showing what happened when you lose and then regain fitness, raising a possiblity that perhaps a long training break is actually good for you.

The first published article documents Leper's changing fitness. After 12 weeks of rest, his VO2 max measured in a treadmill running test dropped by 10.9 percent. In a similar test on an exercise bike, it dropped by 9.1 percent. That's a big drop equivalent to about 15 years of normal aging. For reference, Edward Coyle's famous paper from 1984 saw a 16 percent drop in VO2 max after 12 weeks of laying off training.

Here's the surprising good news. He gained 5.5 pounds of fat and lost 4.6 pounds of muscle during the 12 weeks rest. After retraining, he lost 9 pounds of fat and regained 2.4 pounds of muscle. His body fat levels  went from 10.1 percent to 13.3 percent then to 8.4 percent. A net loss of 5.7 percent at the end of the experiment. 

Cycling VO2 max levels

After 12 weeks of training again, his VO2 max did not just recover, it was better than before he stopped training (5 percent higher). The running test was 4 percent higher than before. In the cycling test it was 6 percent higher (pictured above). 

The fat loss will explain some of the improvement in his VO2 max as it is calculated relative to body weight, so losing weight can create the 'illusion' that you get fitter without changing your oxygen processing abilities. However, his overall oxygen processing capacity did improve, independent of his weight.

Another possibility documented in the second published journal is that something changed in his muscles making them more responsive to training. Lepers had muscle biopsies (ouch - they are very painful!) at each stage to measure the chemical changes occuring. Fast twitch muscle activity was ramped up during detraining while aerobic capacity and mitochondria function decreased. Retraining mostly reversed those changes and in his case resulted in better than baseline muscle properties.

Now, Lepers is an accomplished triathlete. In his younger days he placed in the top 150 at The Hawaii Ironman World Championships. At the time of the study, he was 53, training 10-12 hours a week and consistently placing near the front in his age category in Ironman 70.3 races. Lepers has trained consistently for more than 3 decades, and never missed more than 2 weeks of training at a time previously. 

Sounds good so far? Leper's results also seem to line up, declining with detraining and impoving to be even better with retraining.  If you're in your 20's, you can take 12 weeks off, train hard again and definitely regain your fitness and more. This case study suggest the same can be true in your 50's.

Note that this is just a case study, where n=1 where we may not get the same results as Lepers. This is different as missing 12 weeks through injury since you may not be able to start training full on especially if surgery was needed.

So here are the not so good bits if you read both articles in detail. Leper's cycling efficiency went down and his running economy worsened. He did not recover the muscle mass he lost and that is worrying (note to self : need to maintain strength training). Fortunately for him, his race results in the following season with similar with the previous season. Actually I thought that was remarkable given the fact that he took 12 weeks off.

I really liked Leper's experiment since I am in the same age group as him. Many of my older patients and friends take shorter and less frequent breaks from training because they are afraid they will lose their fitness from too long a break. I am definitely in the same boat. Now we can all be less paranoid about taking long breaks from training. Even if I do not get better than before, just the fact that one can get back to your previous level is reassuring enough.

Reference

Lepers R, Mater A, Assadi H et al (2024). Effect Of 12 Weeks Of Detraining And Retraining On The Cardiorespiratory Fitness In a Competitive Master Athlete: A Case Study. Front Physiol. DOI: 10.3389/fphys.2024.1508642.

Zanou N, Gremeaux V, Place N and Lepers R (02024). Cardiovascular And Muscular Plasticity In An Endurance-Master Athlete Following 12 Weeks Of Detraining And Retraining: A Case vStudy. JCSM Comm. 7:82-90. DOI: 10.1002/rco2.93.

The Rise Of Padel

Picture from Temple of padel

Recently I have treated many patients who play padel and got injured. I think padel is definitely the latest 'flavour' of the month.

What is padel? It is a sport played with rackets that combines elements of tennis and squash. It takes place in an enclosed court (pictured below) about one third the size of a tennis court. Similar to squash, players can bounce the balls off the walls of the court allowing for rebounds. 

Picture from Demeco et al (2022)

Padel was invented in 1969 by *Enrique Corcuera when he and his wife Viviana were in their new vacation holiday home in Acapulco, Mexico. To pass time, the wealthy couple began throwing a ball at the wall and Viviana quickly fell in love with the easy version of the game. Enrique got builders to build a 20m by 10m cement court against the backdrop of the Pacific ocean. 

The court was closed completely to prevent the balls from falling outside due to the unpleasant memory Enrique had while attending boarding school in England. He said he suffered from being in the cold while looking for balls that fell outside the school court.

Over time glass walls and artificial turf replaced the concrete so spectators could watch the game.

Padel racquet picture from Decathlon

Played mostly in doubles (although singles can be played), with solid stringless racquets(above) and a similar tennis ball but with less pressure. Players serve underarm and the ball must bounce once before being returned. The scoring system is similar to tennis.

From the patients that I have seen, there has been little evidence of play patterns and training regimes. It is a high intensity intermittent sport with less demanding requirements when played in recreational settings, which can hide the risk of injury.

The majority of padel injuries I have seen are mostly in the lower limbs. Padel players usually have to shift their stance and require strong leg power to shift the upper body quickly. Achilles tendon injuries and ankle sprains are common when the patient executes a quick change in direction.

There were also upper limb injuries affecting the shoulder and elbow. This is not surprising due to the nature of overhead strokes (e.g. smashes). Since the court is smaller, this increases the frequency of shots taken. This greater repetition of the abduction-extention movements of the arm would explain the upper limb injuries.

A Swedish study (Thornland et al, 2021) suggested that the smaller size court along with the proximity of the players, the size and speed of the ball and the unpredictability of ball bounces would increase the risk of injuries.They proposed the use of protective eyewear.

Viviana Corcuera believes padel took off quickly because it can be enjoyed by the entire family. Grandparents can play with their children and grandchildren which brings the family together. There are estimated to be over 30 million players worldwide. 

Perhaps padel may even surpass Hyrox in terms of popularity in Singapore. This is my prediction for this year. Let's see ....

References

Demeco A, deSire A, Marotta N et al (2022). Match Analysis, Physical Training, Risk Of Injury, Risk Of Injury And Rehabilitation In Padel: Overview Of The Literature. Int J Environ Res Public Health. 19:413. DOI: 10.3390/ijerph19074153

Thornland C and Jakobsson G (2021).  Eye Injuries Related To Padel. Lakartidningen. 118:21001. PMID:34156668

*In the 1960's and 70's, Acapulco was a major destination for Hollywood's stars and that is probably where padel's popularity with celebrities began. Even the American diplomat Henry Kissinger played when he visited as did many high profile visitors. Prince Alfonso developed a passion for the game in 1974 after holidaying with the Corcueras. He built 2 padel courts in Marbella, that's how the game crossed the Atlantic.

David Beckham, Serena Williams and even French President Emmanuel Macron consider themselves fans of padel. Meanwhile in sunny Singapore, Ronaldo and two of our ministers share a padel moment.

Picture from the Daily Mail

Be Grateful

Picture from Wall Decor Plus More

It's the last Sunday of the year and also my last post for 2024. Where did 2024 go? I kept asking myself this question this past month as the year seemed to have zoomed by so quickly.

It's also the time of the year when it is customary to be a little kinder and do nice things for others like donating and giving presents.

I feel it is also a good time to dwell on things that we are grafeful for. When we shift our attitudes to focus on being grateful and giving thanks (instead of harping on things that upset us), it has a direct link to our wellbeing.

The following study had researchers who recruited a group of participants and asked half to take time weekly to write a few sentences about things that they were grateful for that week (Emmons and McCullough, 2003). The other half of the participants wrote about their irritationa and complaints.

After 10 weeks, the group that centered on gratitude felt more optimistic about life than the other group. 

Surprisingly, the group that was grateful saw physical changes as well. They were more active as they exercised more and made less visits to the doctor than the group that focused on the negative aspects of life.

There was another study by Toepfer et al (2012) that tested the effects of writing letters of gratitute to other people. The results clearly showed that those that took time to say thank you in writing made people happier, more satisfied with life and had less symptoms of depression.

Take some time to feel grateful for all the little and big blessings in your life. Write them down too since this active approach to gratitude can have tangible and lasting effects on our mental well being.

A big thank you for following and reading my posts weekly.

References

Emmons RA and McCullough ME (2003). Counting Blessings Versus Burdens: An Experimental Investigation Of Gratitude And Subjective Well-being In Daily Life. J Personality Social Psych. 84(2): 377-389. DOI:10.1037/00223514.84.377

Toepfer SM, Cichy K and Peters P (2012). Letters Of Gratitute: Further Evidence For Author Benefits. J Happiness Stud. 13: 187-201. DOI: 10.1007/s10902-011-9257-7

Exercise For Your Life

I saw a patient earlier this week for her shoulder and neck pain. She goes to Aspire 55 for weight training twice a week. We were chatting about how strength training has made her stronger and able to handle aging better. 

She mentioned that she visited someone she knew who stopped exercising at Aspire 55 for 6 months. She wanted to check in on her and was shocked at how frail her friend had become.

Frailty can occur in older adults and is characterized by a decline in physical abilities and an increased vulnerability to adverse health outcomes. 

If not treated, frailty can lead to a number of adverse health outcomes such as falls, disability, hospitalizations and even death. Its presentation and diagnosis can vary as well as being overlooked or misdiagnosed as part of the normal aging process.

Evidence suggest that the prescription of a comprehensive exercise program which includes strength, endurance training, mobility and balance improves function, targets frailty and improves quality of life (Vazquez-Guajardo et al, 2024).

The picture above shows the cardiorespiratory fitness that we need for our activities of daily living. If our fitness level drops below these thresholds we will not be able to 'afford' the metabolic cost of tasks needed to remain independent. One of many reasons to stay active for as long as possible. 

Exercise is therefore more than just fitness and looking good. It also gives you the ability to stay independent and resilient for longer. Resilience represents the ability to withstand adversity and remain in homeostasis despite the physical, psychological and social challenges of aging.

No matter what age you are , keep exercising to prevent, mitigate and perhaps even reverse frailty's trajectory.

Reference 

Vazquez-Guajardo M, Rivas D and Duque G (2024). Exercise As A Therapeutic Tool In Age-Related Frailty And Cardiovascular Disease: Challenges And Strategies. 4098): 1458-1467. DOI: 10.1016/cjca.2024.01.005

The Power Of Rereading Your Old Books

Picture by Tom Morris

I have always like reading. The Five Find Outers, The Famous Five, Moonface and The Faraway Tree  by Enid Blyton were my favorites when I was growing up. 

When competing in cross country/ track and field and triathlon, I pored over race reports, scientific articles on training, and sports biographies to help my athletic performance.

I also have this habit of rereading the books I like. Some books I've even reread a few times. I've realized that the older and wiser version of myself reads, analyses and understands things differently (and better) than the younger me.

The same applies to treatment and rehabilitation. Everyone seems enarmored with new treatment strategies, answers and solutions. Always looking for the latest flavor of the month.

Of course I do keep up with the latest updates. But do they always work better? Perhaps if we reread our older books/ articles we can better understand things we have have tried, considered or perhaps even ignored previously. You may find that most of the answers are already there. 

My family and I are currently away traveling, hence the short post this week. I am taking the time to read both old and new books. I love the feeling of paper between my fingers.

Have a safe holiday if you are traveling.

Anterior Pelvic Tilt

Picture of APT on the left by Oliver Ludwig

I had a patient come in this week saying he was told by another physiotherapist that he had an anterior pelvic tilt (APT) that was causing his low back pain. 

He was told that his poor posture while sitting for long hours caused it. Sitting for long hours is often thought to shorten the hip flexors while also weakening the core. There is no evidence that prolonged sitting causes APT. Some correlations were reported but lack consistency between left and right sides (Elliot et al, 2021).

However, even after being 'corrected' for his APT, his low back pain did not go away.

Many people will present in our clinic with a pelvic tilt. An article from Manual Therapy found that 85 percent of males and 75 percent of females (from 120 subjects) presented with an APT without any pain or disability. 6 percent of males and 7 percent of females presented with a posterior pelvic tilt without pain or disability too. So is APT really a dysfunction or is it normal?

There are also no agreement or guidelines as to what is too much or too little pelvic tilt. Moreover there is also no reliability between health professionals in clinical testing while assessing if a patient has APT (Preece et al, 2008). One health professional will assess you and say you have an APT while another may say otherwise.

APT is also not related to low back pain. Have a look at this systematic review by Chun et al (2017). In fact, patients that have low back pain had more 'neutral' pelvic (or hip) positions.

For those of you who have been told, APT is also not related to hip flexor tightness (Elliot et al, 2017) or a weak core (Walker et al, 1987). Neither does your hamstrings length or flexibility affect APT (Li et al, 1996).

So do not worry if someone or a health professional tells you that you have an anterior or posterior pelvic tilt for that matter. It may be changeable and may help reduce pain and/ or symptoms. It is not something that you need to be overly focused on. Treating the cause of the problem is much better than just treating the symptoms.

References

Boukabache A, Preece SJ, Brookes N et al (2021). Prolonged Sitting And Physical Inactivity Are Associated With Limited Hip Extension: A Cross-sectional Study. Musculosk Sci Pract. 51: 102282. DOI: 10.1016/j.musksp.2020.102282

Preece SJ, Willan P, Nester CJ et al (2008). Variation In Pelvic Morphology May Prevent The Identification Of Anterior Pelvic Tilt. J Manual Manip Therapy. 16(2): 113-117. DOI: 10.1179/106698108790818459. 

14 Day Lag Period Between Sleep Deficit And New Injury

Picture by Jeffrey Bown from his book Goodnight Darth Vader

Well, it's that time of the year again, where school has ended (for Singapore schools) and work in the office starts to wind down. Many of our patients are already traveling before the Christmas holiday.

Many of us, in this last month of the year, will experience less sleep due to travel, parties, family, children and shift work.

Though we would love to catch up with sleep when sleep is disturbed, even with training/ exercising taking a lower priority, it becomes more difficult with all the committments.

I often tell my patients (who are still training seriously) that there is up to 51 percent increased risk of injury especially for endurance athletes who get less than 7 hours of sleep per day in the last 2 weeks (Johnson et al, 2020).

The study recruited runners, triathletes, swimmers, cyclists and rowers. Subjective health complaints (SHCs) like psychological/ lifestyle factors, cardiorespiratory and gastrointestinal problems to investigated to see if they were associated with sleep quality, training load and new injury episodes.

Applying a 7 day and 14 day lag period, a shared frailty model was used to investigate new injury risk associations with total SHCs and sleep quality.

The investigators found that 7 day lag psychological/ lifestyle SHCs were significantly associated with new injury risk. This was in contrast to cardiorespiratory and gastrointesinal SHCs were not significantly associated with new injury risk. 

New injury risk had a significant increased association with a 14 day lag if there was less than 7 hours of sleep per day. There was no significant association with total SHCs, sleep quantity and training load factors.

The authors concluded that athletes need to be aware of the lag period between low sleep quality and its subsequent impact on new injury risk. In order to minimise the risk of new injuries, psychological/ lifestyle SHCs and sleep quantity should be considered.

Be mindful. Bear in mind that this end year period may be a time when we are most susceptible to new injury if we are deprived of sleep.

Reference

Johnston R, Cahalan R, Bonnett L et al (2020). General Health Complaints And Sleep Associated With New Injury Within An Endurance Sporting Population. J Sci Med Sport. 23(3): 252-257. DOI: 10.1016/j.jsams.2019.10.013