What Is The Right Way To Train?

ST 040226

Controversial topic this week everyone. Earlier in the week (4/2/26), there was an article in the Life section of the Straits Times on page C3 with the headline "You can get away with minimum exercise". It was originally published in the New York Times on 150126.

And you often see such headlines in Tik Tok, X or Facebook. When such a study, article, post or reel does well, the exercise scientists, coaches, influencers comment to critique, nitpick or praise the wording, arguing that the study, article, post or reel is being "oversold" or interpreted wrongly.

Are these exercise scientists, coaches, fitness influencers and keyboard warriors just argumentative or is it something else? The above mentioned groups will never see eye to eye. And that is fine since we all learn or at least get entertained by them (pictured above and below).

I think they are disagreeing about different things. "Training" is thought to be the same for everyone. It actually isn't.

When a coach or exercise scientist (or physiologist) talks about training, they are referring to training for sporting performance, or a race. A 40 km cycling time trial, a marathon, a 10 km race or a Hyrox competition. There is an objective measure, or the outcome has a clear definition of who is first or second.

When a fitness or health influencer talks about training, they are not talking about training for a race or competition, they are referring to wellness, losing weight, longevity, reducing falls and perhaps looking or feeling good. It does not require one to revolve their whole life around exercise, training and competing.

Is exercise just exercise? Both their perspectives overlap. Health focused training can improve performance. Training for performance improves health, until you overtrain, which then can be harmful.

However, the time constraints and success metrics are totally different. If one does not say which you are referring to (health or performance), then that's when you will have both sides disagreeing passionately when they are in fact talking about 2 different things.

The exercise physiologists and coaches will treat the study as giving instructions for how to train like an athlete. The fitness influencers will translate it into something the average person can understand and apply. 

Same data, different interpretation.

Remember my article about Zone 2 training? The endurance coaches and exercise physiologists will get their athletes to train easy mostly in Zone 1 or 2. Build the aerobic base. Then 10-15 percent of high intensity work. Are they correct? Definitely. If their athletes are training in excess of 20 plus hours a week, they cannot go hard all the time. They will get burned out and most likely injured.

The fitness influencers are advising humans and mere mortals who are maybe exercising just once or twice a week, definitely under 5 hours total. They are not deciding whether to train at altitude or to periodize their training. They are probably trying to find time and convince themselves to exercise after a long day at work. 

So when they read or watch online reels about exercising mostly at Zone 2, they will think they need to devote a LOT of time exercising at low intensity.

For the athlete, that's super sensible. For the mere mortal and weekend warrior with limited time and motivation, it is impractical or even impossible.  Not because Zone 2 is bad. For Zone 2 to work, you have to accumulate hours. To have super powers, you have to put in the hours.

This is why Zone 2 versus HIIT (high intensity interval training) arguments get so heated. The 2 sides are debating 2 completely different cases but using the SAME lingo and assume that studies on athletes apply to studies on the average population and vice versa.

Studies on interval training, HIIT etc to improve VO2 max are designed to be time efficient. All the research says that if someone has limited time, what is the smallest dose of exercise that gives meaningful results? Or like the picture I posted on top "You can get away with minimum exercise".

If you do not have enough time, you need higher intensity training to provide a stimulus that is large enough to make a difference. This is why the coaches give their 2 cents worth and say that HIIT alone will not prepare you for a marathon.

The coaches are correct, but the fitness influencers were also not getting their readers to race marathons. A study that shows HIIT improves VO2 max does not automatically become a training plan for a marathon even though it is about aerobic fitness. 

Here is what confuses everyone, myself included sometimes. When we take research designed for the elite athletes and try to apply it to the general population and vice versa. Then we act surprised when different groups object for different reasons.

A 6 hour easy ride for a Tour De France rider is simply not normal, realistic, nor repeatable and effective for a weekend cyclist given the time and motivation they have. Remember my 160 km ride to Kukup, it took me almost half a day to recover.

The problem is we cannot communicate on the same wavelength when it comes to exercise. There are disagreements because we keep failing to clarify the context.

So if you are just exercising for general health and do not have plenty of time and motivation, high intensity training will be time efficient for improving your aerobic fitness, metabolic health and help you live longer. Not because easy training is useless, but you are trying to get meaningful adaptation out of limited time.

For athletes and those who have time to accumulate volume, Zone 2 exercise is sustainable, easier to recover from and foundational. It becomes really powerful as Zone 2's super power is accumulation. It improves durability, helps support overall training volume and makes you better at endurance and also to handle the high intensity training when you need to.

Coaches can tell you how their athletes build great endurance while not being helpful for the average Joe or Jane whose main goal is getting started. 

Fitness or health influencers can be correct about time efficient fitness strategies while being totally inadequate with regards to an athlete's performance in a specific sport.

An exercise physiologist and sports scientist can be super accurate about what a study shows but missing how the lay person will interpret it in the real world.

I hope this explains things better so we know that there is no one 'best' way to achieve fitness, health or performance goals.

How Much Running Is Too Much?

I had a patient earlier this week who's an ultra runner. She did an ultra race in December last year and then took 3 weeks off running. Her first run back was a 20 km run and she started having left knee pain since.

I told her about an interesting article I read last week about the "single-session paradigm" for running injuries (Frandsen et al, 2025). 

The study tracked 5,205 runners over 18 months. Their average age was 46 years and 22 percent of the runners were females. The runners accumulated 588,071 run sessions via the Garmin GPS watches during the study period. The researchers were interested in self reported running related overuse injuries rather than traumatic injuries.

The runners were categorized into training load "spike" states. If mileage was <  10 percent increase, it was categorized as regression. A small spike would be greater than 10 but less than 30 percent increase. A moderate spike would be greater than 30 percent but less than 100 percent while a large spike would be greater than 100 percent increase.

Weekly changes in mileage using acute : chronic workload ratio (ACWR) - 1 week versus past 3 weeks. Week to week ratio, that is change from week to week were also analyzed.

For the ACWR (weekly changes) and week to week ratio, the study did not find any clear positive association with injury. In fact in some runners, a "negative dose response" was observed meaning a higher ACWR did not always mean more injury.

They found that when there was a spike in running mileage in a single session (rather than a gradual weekly increase relative to the longest run in the previous 30 days, many injuries occurred. This was named a shift to a "single-session paradigm" for running injuries.

This matches exactly with how my patient was injured. No running for 3 weeks, then in her first run back she had her longest run in the past month. The body needs time to adapt, big increases in mileage overloaded her muscles, bones, ligaments and connective tissues.

Please note that this study had runners who self reported their injuries, they were not diagnosed, so we need to be cautious and sensible when interpreting the results. Please do not think 'never increase mileage', it is more about progressing and moderating.

Those of you who are wearing smart watches, other tech devices and perhaps using Strava, note that this study suggests that algorithms that measure your weekly mileage load rations (or ACWR) may be under calculating risk. Your devices may need to include "single session spike" metrics or at least be able to compare with longest session in the last month.

Whether you train under a coach or are self coached, plan sessions so that large increases in distances are avoided. Or make sure you monitor carefully and plan extra recovery. Do not just tally weekly mileage, look at how the session distances compare to your maximum long run in the past month. Monitor your "David Goggins /monster sessions" that deviate from your regular training.

The average mean age of the runners was 46 and 76 percent were male. Younger athletes and elite athletes may be different. Other than distance, I will also include running pace, prior fatigue levels, surface of run and shoes to be monitored.

For healthcare professionals working with ultra runners, you can educate them about the single session spikes having higher risk than weekly totals, like I did with my patient. Ask them in detail about their training regime and pay close attention to the longest run in the recent 30 day window.

Reference

Schuster Brant Frandsen J, Hlme A, Parner ET et al (2025). How Much Running Is Too Much? Identifying High-Risk Running Sessions In A 5200-Person Cohort Study? BJSM. 59 (17): 1203-1210. DOI: 10.1136/bjsports-2024-109380

Can CT Scans Cause Cancer?

Picture by webMD

How many of you have had CT (computed tomography) scans done before? I have had at least 2 so far, both after each of my 2 bike accidents. They are vital to give doctors a quick and detailed look inside our bodies to diagnose internal injuries, strokes, cancer and lots more. They are a crucial part of modern medicine and are found in every hospital and many private clinics.

However a recent study suggests that CT scans performed in USA alone in 2023 could eventually lead to over 100,000 extra cancer cases. If the current rate of scanning carries on, the researchers say that CT scans can be responsible for around 5 percent of all cancers diagnosed each year.

The researchers reported that the number of CT scans done in the US has increased by 30 percent in just over a decade. In 2023, there were an estimated 93 million CT scans done on 62 million people.

Note that the risk from a single CT scan is low, but not zero. The younger the patient, the higher the risk. Children and teenagers are more vulnerable because their bodies are still growing and developing. Any damage caused by the ionising radiation may not show up until years later.

Hence it is fortunate that more than 90 percent of CT scans are done on adults, so this group will probably face the most impact.

The more common cancers linked to CT exposure are bladder, colon, leukemia, and lung. For females, breast cancer is a significant concern.

This latest estimate is much higher than a previous similar analysis. That analysis, published in 2009, projected 29,000 future cancers linked to CT scans. The current estimate  (100,000 cases) is more than 3 times higher. It not just because of more scans done but also newer research allows for a more detailed analysis of radiation to specific organs.

This study also suggested that if things stay the same, CT related cancers could match the number of cancers caused by alcohol or excess weight, 2 well known risk factors.

Note that not all CT scans carry the same levels of risk. Abdomen and pelvic CT scans are thought to contribute the most to future cases in adults. In children, it's head CTs that pose the biggest concern. This is especially for babies under one year of age.

Despite this, doctors ordering them stress that CT scans are essential in many cases and they have saved lives by catching potentially fatal conditions early and also to guide treatment. They are often crucial during emergencies. The big challenge is making sure they are used only when really needed.

Please note that this study by Smith-Bindman et al (2025) does NOT prove that CT scans cause cancers. The estimates are based on risk models, not direct evidence. The American College of Radiology released a statement to say that no study has yet linked CT scans directly to humans getting cancer, even after multiple scans.

The idea that radiation can cause cancer is not new. It is scientifically sound, especially with the huge number of scans done. Small risks do add up. 

Personally I hope that hospitals (here in Singapore) switch to photon counting CT scanners since they deliver smaller doses of radiation. The researchers also suggest using MRI's or ultrasound scans when necessary or possible instead of CT to reduce radiation.

CT scans definitely save lives, but they are not risk free. Hopefully as medical technology evolves, we too will change how we use them by cutting down unnecessary scans or use safer alternatives.

Reference

Smith-Bindman R, Chu PW, Firdaus HF et al (2025) Projective Lifetime Cancer Risks From Current Computed Tomography Imaging. JAMA Intern Med. 185(6): 710-710. DOI: 10.1001/jamainternmed.2025.0505

Super Shoes Or Super Placebo?

Thinking of buying a pair of Nike Vaporfly's (pictured above) for your next racing shoe? Or another super shoe from another brand? Here's a really interesting study I read on super running shoes.

Researchers in that study (Hebert-Losier et al, 2025) recruited 24 female recreational runners. All ran in Nike's Vaporfly Next% 2.

Here is what is so interesting, the shoe was not changed or manipulated. It was how the shoe was described. For the first shoe, the narrative was a "super shoe" description. carbon plated, energy return foam, elite level technology and expensive ($400).

For the other pair, a "basic/ knock-off" (or counterfeit) description with  no carbon plate, standard foam, lower price, ($100) and the idea that elite runners will not race in them.

Nothing changed in the shoe, just the "story" or description of the shoe.

All the participants did four 6-minute treadmill runs at 10km/h on a 1 percent incline. The researchers measured their running economy (V02 and energy cost). Cadence and contact time on the ground and perceptual responses were also investigated. These include comfort, enjoyment of run, ease, expected performance and perceived injury risk.

When the runners thought they were running with the Super shoes, perception changed noticeably. Reported comfort was significantly higher. They also felt running was easier and more enjoyable. Expected performance was higher and their perceived injury rate was lower.

To summarize, the subjective experience of running improved even though the shoes used were exactly the same.

What about the objective measures? There were NO significant differences in running economy, oxygen consumption, lactate responses or even biomechanically.

Whilst running at 10 km/h pace for 6 minutes, belief alone did nothing to translate into measurable physiological or even biomechanical differences.

Does this mean you don't have to buy a super shoes for your next attempt to beat your marathon personal best? 

Personally I don't think so. 6 minutes at 10 km/h pace using recreational runners may not be totally accurate. It shows that expectation plays a big role in how running feels even though performance metrics remained unchanged.

Comfort, confidence, enjoyment and perceived safety matter so one can train consistently and push themselves harder when there is less fear of injury. These may not show in data measuring running economy, but may still influence outcomes over time.

The message for runners is NOT that they do not need to buy super shoes. Instead it's that shoes cannot replace training and price tags do not guarantee performance. Perception changes a runner's experience, even when physiology does not change.

Technology helps sometimes. Sometimes the story helps too.

So are you buying Nike's Vaporfly or Decathlon's Kiprun (pictured above)?

Reference

Hebert-Losier K, PfisterA, Finayson SJ et al (2025). Are Super Shoes A Super Placebo? A Randomised Crossover Trial In Female Recreational Runners. Footwear Sc. 17(2): 79-88. DOI: 10.1080/19424280.2025.2458330

Is This You?

Who thinks that the above and below postures lead to neck pain or discomfort? They are a common sight now since smart phones have become widely available.

There is a general consensus that the flexed (or forward bending) posture of the neck and head while reading and typing, also known as text neck is harmful, and is related to neck pain and other physical discomfort.

This impression that neck pain is caused by excessive smartphone use started after one computational model study in 2017 suggested that the greater the neck bending forward, the greater the overload. The theory is based purely on biomechanics and does not consider that pain is multifactorial and modulated by several factors.

Previous studies did not find an association between text neck and neck pain. Bertozzi et al (2023) also did not find an association between neck posture and time spent on smartphones with neck pain or disability.

The present study aims to investigate whether text neck is a risk factor for neck pain, while considering the influence of psychosocial and lifestyle factors. This longitudinal study with a 12 month follow-up using a self reported questionnaire and objective assessment of posture while sending messages on a smartphone. 

396 participants (87 percent) completed the 1-year follow-up. Average age of the participants was 27 years. 319 (70 percent) were female. The average neck flexion angle using the smartphone was 34 degrees. Only 4 subjects (1 percent) had neck pain "very often", 20 subjects (5 percent) had neck pain "often". 129 subjects 33 percent) had neck pain "occasionally", 158 subjects (40 percent) rarely had neck pain 85 subjects (21 percent) "never" had neck pain.

The researchers concluded that neck flexion posture was not a risk factor for neck pain or frequency of neck pain. They found that psychosocial factors like low sleep quality and insufficient levels of physical activity were contributing factors of neck pain.

So it's not really just what position you neck is in or how long you spend on your phone that can cause your neck to hurt. However, if you spend a lot of your time on your phone, please make sure you get in enough exercise and sleep well to avoid neck pain.

Reference

Correia IMT, Ferreira ADS, Gomes JFM et al (2025). Cervical Flexion Posture During Smartphone Use Was Not A Risk Factor For Neck Pain, But Low Sleep Quality And Insufficient Levels Of Physical Activity Were. A Longitudinal Investigation. Braz J PT. 29(6): 101258. DOI: 10.1016j.bjpt.2025.101258

Exercises Or Manual Therapy Better For Persistent Neck Pain?

Neck exercise

Assuming you have persistent neck pain, would you prefer to very diligently do 13 exercises (pictured above) or would you prefer to have a physiotherapist treat you with hands on manual therapy? 

Manual therapy

Research by (Villanueva-Ruiz et al, 2025) shows that both help patients with chronic neck pain. Manual therapy in this case refers to both myofascial and joint mobilization techniques (Guo et al, 2022 and Zabala-Mata et al, 2024). Please read on for a twist at the end. 

The authors randomly allocated 65 patients with non specific chronic neck pain into a manual therapy or exercise group. They received 4 treatment sessions of either performing 13 specific neck exercises with supervision (plus home exercises) or manual therapy once a week for 4 weeks.

The following outcomes were measured at baseline, 2, 4 and 12 weeks post treatment. Pain intensity, disability, quality of life, patient-perceived improvement, fear of movement and also the cranio-cervical flexion test (CCFT). 

Patients were also categorized into responders or non-responders according to their pain intensity, disability and their perceived improvement at 4 and 12 weeks post treatment. Commitment to exercise was also recorded.

After reading so far, which group do you think fared better? Note that both groups of patients had 'general physio' before and not gotten better.

Ready for the results? The manual therapy group had much more responders than the exercise group at all follow up periods. Treatment outcome in the exercise group was linked to exercise adherence. So manual therapy is more effective? Here's the twist.

When the researchers looked only at patients who were ≥ 95 percent diligent at doing their home exercises (60 percent of the exercise group), the treatments were equal. 

So, a 4 week manual therapy intervention was more effective than exercises for chronic neck pain patients. However, when exercise adherence was ≥ 95 percent, both interventions were equally effective.

Manual therapy may be superior to doing strengthening exercises for chronic neck pain when patients are not able or not motivated to do their home exercises.

For healthcare professionals whose patients are motivated and are likely to do their strengthening exercises then you can dole out the exercises out and send videos to aid them. For patients who are not compliant with the exercises perhaps due to challenging home or work situations, then manual therapy is evidenced based and effective.

References

Villanueva-Ruiz I, Falla D, Saez M et al (2025). Manual Therapy And Neck-Specific Exercise Are Equally effective For Non-Specific Neck Pain But Only When Exercise Adherence Is Maximized: A Randomized Controlled Trial. Musc Sci Pract.77: 103319. DOI: 10.1016/j.msksp.2025.103319