Repeat The Same Training?

I started keeping a handwritten training log (pictured below) after I started running at 13. Back then there were no apps to keep such records for you. I will record how far I ran, time taken, how I felt, what shoes I used, etc. 

I found it useful so I could look back on what training I did when taking part in a similar event. Say my key interval workout for a 1500m track race that I had won previously was 8x200m with 30 seconds rest. I would replicate those sessions along with deciding if I could handle more. Back then, I was a teenager and was able to run personal bests in all my events every year.

I assume that when I responded well to a training program once, I'd respond similarly or better the next time. However, a recent study suggested otherwise.

A group of researchers had subjects do the same 8 week endurance training program twice, but separated by a period of detraining that had to return to baseline. 42 out of the 53 recruited completed the study.

Each 8 week period had 24 supervised 45 minute interval cycling sessions at moderate to maximal intensity. Identical training instructions were applied such that the same training program was repeatedly prescribed to the same individuals. Exercise intensity was individually prescribed relative to performance and adjusted every second week to mainatin a comparable training stimulus across periods.

Results show very poor reproducibility of adaptation. One athlete increased VO2 max by about 600mL min⁻¹ after the first training period. However, there was no improvement at all after the second training period. Yes you read correctly, zero improvement.

Same athlete, same program, but very different outcome. I asked a few coaches whom I treat if this was similar to the athletes they coach. They told me they see it all the time. Training response varies.

The training may be the same but the variations in external factors such as sleep, diet, work stress, travel and illness contributes to the variability in individual training adaptations.

That's what the researchers concluded too. The substantial within-individual fluctuations were largely consistent between training periods and they suggest that this  within-individual fluctuations does not reliably reflect their capacity to adapt to the same training stimulus in the future.

So low stress plus good training leads to adaptation while high stress plus the same training may lead to very different outcomes.

Take away message? Do not assume that because a program worked once, it will work the same way the next time. Monitor the state of your own life stresses and modify accordingly.

Reference

OddenIV, Hamarsland H, Odden TU et al (2026). Limited Reproducibility Of Individual Physiological Adaptations To Repeated Endurance Exercise Training. J App Phy. DOI: 10.1152/japplphysiol.00154.2026

Can You Trust AI With Nutritional And Athletic Performance Advice?

Picture from Sixminutemile.com

I was reading about how 2024 Olympic road race cycling winner Kristen Faulkner built her own artificial intelligence (AI) model to analyse 9 years of her own performance data to help her uncover what's missing from women's sports science. It allowed her to have data that helps explain not just what happened but why.

Faulkner said she coded to build the AI technology that can learn from data, spot patterns and make decisions. These are skills that we usually associate with human intelligence. 

AI is already in our everyday lives. We get Google Maps directing our commute, Spotify suggesting songs on your playlist and hit ChatGPT with any question we might have.

Many people use AI for everyday health, exercise and medical queries. Are these AI driven chatbots reliable and accurate? Our patients already use AI to self diagnose their pain and injuries. Some studies show chatbots are largely accurate, while others reported frequent errors and even a risk for transmitting inaccurate information.

The following research investigated 5 popular AI driven chatbots to evaluate their responses to everyday health and medical queries across 5 categories: cancer, vacines, stem cells, nutrition and athletic performance. Both open ended and closed ended questions were used.

Gemini, Meta AI, DeepSeek, ChatGPT and Grok were the 5 chatbots used. They were each presented with 50 prompts across the 5 topics mentioned above. The researchers used an adversarial framework to strain models towards misinformation or contraindicated advice.

An adversarial framework refers to a system, process or analytical model structured around opposition, competition or conflict. This is a cybersecurity approach used to test the vulnerabilities of AI systems.

Responses were then independently rated by 2 domain experts as non-problematic, somewhat problematic or highly problematic. Citations were assessed for authenticity and completeness while readability evaluated using the Flesch Reading Ease score (100 point scale with higher scores being easier to read).

Results showed that nearly half of ALL responses (49.6 percent) were problematic, 30 percent somewhat and 19.6 percent highly problematic. Nutrition and athletic performance topics had the weakest performance and Grok generated significantly more highly problematic responses than expected.

Reference quality was poor across all chatbots. The median completeness score was 40 percent. No chatbot came up with a fully accurate reference list. Misleading, unreliable or fabricated citations were common. So please be careful if you use them.

All the 5 chatbots produced responses that were rated "difficult" on the Flesch Reading Ease scale, equivalent to university-level reading. Chatbots answered consistently with confidence regardless of accuracy, while rarely declined to respond (2 refusals to answer across 250 total responses).

The researchers concluded that continued deployment of AI chatbots without public education and regulatory oversight risk amplifying health misinformation. Especially in the field of nutrition and athletic performance. They also suggested that public education, professional training and regulatory oversight to ensure that generative AI support rather than replace professionals.

My suggestion when searching for health information is to treat these AI chatbots with a good amount of skepticisim and to verify information with qualified professionals or peer-reviewed sources. There will be some benefit seeking ideas and initial information from a chatbot, but beyond that you will need a real human expert.

Reference

Tikker NB, Marcon AR, Zenone M et al (2026). Generative Artifical Intelligence-Driven Chatbots And Medical Misinformation: An Accuracy, Referencing And Readability Audit. BMJ Open. 16(4): e112695. DOI: 10.1136/bmjopen-2025-112695.

New Way Of Grading ACL Tears

A group of researchers have introduced a new way of grading anterior cruciate (ACL) tears that are relevant to ACL healing potential. This is based on the results of managing 1080 active individuals and athletes using the Cross Bracing Protocol

Remember the Cross Bracing Protocol (CBP)? These are patients who are managed conservatively without surgery, they are put in a brace to allow ACL healing to occur.The injured knee is kept at 90 degrees of knee flexion to reduce the gap between the ruptured ACL remnants. Research shows that 90 percent people regain continuity of the fibers after 3 months of treatment in the CBP. 

Yes, the torn ACL can heal when both ruptured ends attached to each other while the knee is in a bent position. However, more severe ruptures are the least likely to achieve optimal healing.

Not all ACL's that heal (or regain continuity of fibers) in studies had a normal appearance on MRI. 50 percent of subjects in the KANON trial had a normal appearance ACL, the other 50 percent had a thinner/ elongated continuous ligament (Filbay et al, 2023). 

56 percent of those with a continuous ligament 3 months post CBP treatment had a thick ligament with normal course. The other 44 percent had a thinned/ elongated continuous ligament.

In this currrent study, subjects with a thick ACL with normal course at 3 months had better 12 month outcomes when it came to knee function, quality of life and return to sport.

In addition, the following characteristics may affect the likelihood of achieving an optimal healing outcome. Patients with partial avulsion of ACL tissue from the femoral attachment are more likely to have a suboptimal healing or even no healing compared to those with the femoral origin intact (pictured above).

Displacement of the ACL ligament outside the intercondylar notch is also associated with suboptimal healing when managed with CBP. This may be due to a significant disruption to the synovial sheath that encapsulates the ACL. Disruption of this sheath negatively impacts healing potential.

If the distance of the gap between the 2 ends of the ruptured  ACL is too wide (assessed by measuring the largest distance between the torn ends of the ACL), optimal healing is less likely to occur. Among the first 80 people in this study, 7 out of 40  (18 percent) patients achieved a thick/ taut ligament healing had a gap of ≥7mm on MRI.19 out of 32 (59 percent) had a thinned/ elongated ligament while 7 out of 8 (88%) had no ACL healing at 3 months.

When one or both ends of the ACL stumps appear rounded or retracted, also know as ACL involution, it is usually the early stages of a 'non-heal' and may correspond to poor or no healing. This is observed commonly in patients who present for MRI more than 3 weeks post ACL tear.

Besides the above, meniscal injuries, another ligament injury, articular cartilage damage, osteoarthritic features, bone bruising and joint swelling may also affect the likelihood of achieving optimal healing.

The authors concluded that with further research they may be able to assist people in making an informed treatment decision of the likelihood of individuals achieving optimal healing with nonsurgical management.

Reference

Filbay S, Dowsett M, van Haeringen M et al (2025). A New Way Of Grading Severity Of ACL Rupture On Acute MRI To Consider Potential For Noin- Surgical Healing With Cross Bracing Protocol: ACL Acvute Rupture  Characteristics For Healing (ACL-ARCH) MRI Criteria. J Sci Med Sp. 29: 145-148. https://www.jsams.org/article/S1440-2440(25)00411-6/fulltext

Is Your Evening Workout Costing You Sleep?

Picture from Sitnsleep.com

I read that the Kenyan runners usually ran at least twice a day. The first run when it's still dark between 6 to 630 am to beat the heat. It is usually an easy progressive run though sometimes long runs or fartleks can take place. 

A second session often takes place between 10-11 am. This is usually reserved for track interval sessions. Typically they do 2-3 key interval sessions a week with most of the runs really easy so they can recover. When asked why they do the second run before lunch, the reply is so that they have more time to recover before the next day's sessions. 

Sometimes they even do a lighter recovery run between 4 to 5 pm to add to their weekly mileage.

So I was not surprised when I read that the timing of our workouts can affect our sleep (Akhtar and Eleftheriou, 2026). To avoid confounding factors, sleep and activity data from the same day through a model with fixed effects and terms for activity time, activity-sleep gap and the interaction between these terms. 

Data collected from users sleep looked at how sleep was affected by when they decide to exercise. The focus was on cardiovascular exercises, specifically walking, running (outdoor and treadmill), cycling (outdoor and stationary) and hiking. They studied over 100,000+ workout sessions and found that the later you train, the worse you recovered (pictured above).

When you exercise later in the day, your sleep heart rate is higher, your heart rate variabilty (HRV) is lower and you get fewer REM sleep events. You may sleep quicker with later workouts, but it is not better sleep. It is falling asleep faster while recovering less.

The benefits plateau around the 10 hour mark. The sweet spot is a 11 to 14 hour gap between your workout and bedtime. If you can exercise earlier in the day, you can capture most of the benefits. Perhaps that's the reason the Kenyan runners do their second run at 9 am. 

What about those people who can only exercise at 8pm onwards or later? Should you worry about this?  My take is no. Majority of people should NOT worry. I think it is more important to exercise where it fits in your life. 

Don't worry too much about HRV scores or perfect recovery. You are only working out at 8 pm or later because that's the only time when family and work gives you an opportunity to. Many people do not have the luxury to choose the time to exercise and exercising at any time is better than no exercise.

Our bodies are remarkably adaptable too. I am sure if you exercise at 8 pm or later long enough your body will get better sleep. Not perfect sleep but the detriment is less.

Showing up and exercising is way more important than perfect conditions. Consistency beats optimization every time. That is what will compound.

Reference

Akhtar F and Eleftheriou K (2026, May 24). Your Evening Workout Is Costing You Sleep. Terra API. Https://trryterra.co/research/best-time-toworkout--for-sleep#the-honest-takeaway

Warming Up Body And Mind

Picture from Healthywomen.org

All of us are familar with warm ups. Before you run, exercise and especially before a race. You are trying to increase your core temperature, send more blood flow to the limbs and 'wake' the muscles up. Before a running race you may even try some race pace striding so the actual start of the race does not feel like a shock.

So I was surprised to read that combining mental and physical warm ups can improve running times. Curious? Please read on to find out more.

Researchers in that study investigated whether combining cognitive tasks with a standard physical warm up could improve 1-mile performance in runners. 25 runners (11 male, 14 females) with an average weekly mileage of 20 miles (32 km) and 5km personal best timing of 23:31 min were recruited for the study. Each runner completed 3 separate testing sessions.

First was with only a physical warm up which included a 1200m easy jog, 800m alternating 100m jogs and 100m strides and 3 minutes of active stretching drills. 

Next was the same physical warm up plus a low load cognitive task and finally same physical warm up with a high load cognitive task.

In the cognitive warm up conditions, the runners completed four 3-minute cognitive tasks before and between the physical components.These tasks targeted mental functions like switching between tasks, decision making, inhibiting responses to stimuli and memory. They were doing short bursts of focused mental work designed to activate the brain without exhausting it.

 

After that all the runners ran 4 laps of a 400m track with their watch face covered so that they could only rely on feel rather than constant pace feedback.

Ready for the results? The runners were faster after both cognitive plus physical warm ups compared to only doing the physical warm up. The  low load cognitive task improved 1-mile timing by about 8 seconds (2.3%),  while the high load cognitive task improved performance by about 11 seconds (2.8%).

The runners did not appear to muscle their way to faster timings since their perceived effort was lower after the combined warm ups and their average heart rate during the time 1-mile run was also lower. Their readiness to perform was higher, meaning the runners felt more prepared to run hard.

Stride length and cadence did not change meaningfully suggesting that performance boost was not explained by obvious mechanical changes.

Take home message? No, you do not need to download an app to challenge your cognitve skills before every workout or race. However, this study does suggest that the best warm up should prepare both mind and body.

Before you do your track interval sessions, time trials or short, hard and fast sessions or even up to a 5 km race, it may be useful to add a small cognitive task that perhaps include coordination games, quick reaction tasks, fast feet with visual cues to make you engage attention before you start running hard.

The important thing to note is dose. A few short mental tasks coupled with jogging, drills and race pace striding may help you feel sharper and more ready for your workout. A long, draining task may do the opposite.

This sharpens the nervous system rather than stressing your brain. Keep it brief and engaging and please try it in your training first before trying it on race day.

Reference 

Mortimer, H Dallaway N, Diaz-Garcia J et al (2026). Warming Up The Body And Mind: Bombined Cognitive And Exercise Priming Improves 1-Mile Time Trial Performance In Recreational Runners. Eur J Sp Sci. 26(5): e70163. DOI: 10.1002/ejsc.70163

New Guidelines For Fueling

I was sharing with some my patients this past week how I found it amazing that Sebastian Sawe was able to consume 115 grams of carbs an hour in his sub-2 hour marathon. Previous recommended guidelines were between 60-90 grams an hour.

Lo and behold, a patient shared that in the Nice Ironman last year, Casper Stornes (1st place) and Kristian Blummenfelt (3rd) took 120 grams of carbs while running and up to 180 grams on the bike.

Intrigued by what he sent me, I found a recently published review article by Morton et al (2026) which revisits carbohydrate guidelines for endurance athletes. So are the previous fueling recommendations enough?

When training and/ or racing for prolonged periods, carbohydrate intake will spare liver glycogen while maintaining your blood glucose levels. Most importantly, it helps one to sustain higher intensities nearer the end of your race. When everyone else is going faster, you do not want to run out of fuel and slow down.

Fueling is not to just avoid bonking (or hitting the dreaded wall). It is also to delay the shift from using carbohydrates to fat. That shift is not bad, but when you are trying to go fast without carbohydrates it is going to be very difficult. Note that if you are doing Zone 1 or 2 for many hours (like in an ultra marathon) at low intensities, then this shift may not occur.

When one consumes enough carbohydrates during endurance exercise, long ultra race, Ironman event etc, it delays the "crossover point".  This is when carbs stop being the predominant fuel due to glycogen depletion or low carb availability.

You can see from the diagrams above that if no carbs are consumed (0 grams each hour), this happens around 2 hours. With 45-90 grams/ hour, it delays the crossover point by 30-60 minutes. If 120+ grams/ hour of carbs are consumed, there is no crossover point since carbohydrates remain the predominant fuel source while exercising. At least not in cycling studies as the subjects exercised at 90 percent lactate threshold for 3 hours. It may still occur in longer races.

For runners, the review looked at elite male marathoners with personal bests under 2:30 hrs. They completed a 2 hour treadmill protocol close to marathon race intensity while consuming 60, 90 or 120 grams of carbs each hour. 

Those who ingested 120 grams used more of the ingested carbs leading to higher carbohydrate oxidation. They had a roughly 3 percent improvement in running economy compared to 60 grams per hour. There was also greater carbohydrate contribution to total energy expenditure late in the run. Now you know why Sabastion Sawe never slowed down in his sub-2 hour London marathon. 

There's a catch. Gastrointestional (GI) symptoms were also higher at 120 grams/ hour. Nausea, stomach fullness, and cramping were worse in the highest carb intake. More carbs may offer an advantage, but only if your gut can absorb and tolerate them.

The researchers say that runners should use 90 grams of carbs or more per hour as a realistic target for long, hard events. For trained athletes, the range may extend closer to 120 grams per hour. Fueling should be treated like a trainable skill, provided the gut has been trained to handle it.

Runners will find it more challenging compared to cycling since it's much easier to eat on the bike. All the moving, reduced blood flow to the gut, heat stress may lead to higher rates of GI distress.

This is an exciting review for fueling, but do note that most of the research comes from cyling, male athletes and in controlled lab settings. Female athletes are under-represented as well as real world running/ racing conditions.

My takeaway message? For some of you runners, 90-120 grams/ hour will most certainly help your times. Others may benefit from 60-75 grams/ hour. For other runners, it may be just progressing from under-fueling to consistently fueling and getting a personal best no matter how many grams of carbs that may be.

Reference

Morton JP, Fell JM, Gonzalez JT et al (2026). From Metabolism To Medals: Contemporary Perspectives And Revisiting Carbohydrate Guidelines For Fueling Endurance Athletes During Exercise. J Nutrition. 156(5). DOI: 10.1016/j.tjnut.2026.101442

Sub 2 Hour Marathon

Back in 2017, renowned sports scientist Dr Ross Tucker wrote that a sub 2 hour marathon was unlikely to occur for generations. Then Nike introduced the Breaking 2 project which resulted in Eliud Kipchoge running under 2 hours albeit in a paced setting, not in an official race. 

The 2 hour barrier was finally broken last week at the London marathon when winner Sabastian Sawe and runners-up Yomif Kejelcha achieved the breakthrough, the latter running only his first marathon.

The podium

Sawe beat the previous world record by 65 seconds, finishing in 1:59:30 hrs. He ran an amazing negative split, 60:29 for the first half and the next half in 59:01 min. Kejelcha finished 2nd in 1:59:41 hours. The race was so fast that third place finisher Jacob Kiplimo also broke the previous world record (set in 2023) by 7 seconds. He clocked 2:00:28 hrs.

What lead to the breakthrough? Perhaps due to a "perfect storm" or convergence of many of the following factors. 

Sawe's team said he was running in excess of 200 km a week in the 6 weeks leading up to London, with a maximum of 241 km (150 miles). The volume of his training runs is likely an important factor for him to break 2 hours. Not many elite runners can tolerate that sort of volume, especially when most of it is done at low intensity (or Zone 1). High training volume done at relatively low intensity (Zone 1) is associated in faster marathon performances (Muniz-Pumarez et al, 2024).

Sawe's 5 km splits from 30 km onwards were superb. 30-35 km : 13:54 min, 35-40 km : 13:42 min. His final 2.2 km was 5:51 min. His 24th mile was 4:12 min - the fastest single mile ever run in a marathon. As the finishing line beckoned, he was still accelerating. No way he could have done this if he was not fueling well.

Sawe's nutrition was exceptional. I'm not plugging names here, in fact I've not even tried their products, but Sawe is a Maurten athlete. Elite athletes train their gut take up to 120 grams of carbs while competing without GI distress. The previous recommendation was 60 grams per hour previously. Sawe's reported intake was 115 grams an hour. Maurten's research team was with Sawe in Kenya for 32 days across 6 trips between last year and this April to train his gut to absorb that amount. 

Please note that 120 grams of carbs are NOT recommended for the recreational athlete. That is probably why cycling races and marathons are getting faster since there is no depletion in carbohydrate levels.

Sawe also used sodium bicarbonate (also from Maurten) to buffer his lactic acid build up during the race. He took the sodium bicarbonate early since it peaks in the bloodstream  roughly 60-90 minutes after ingestion so the timing of 2 + hours before the race would put peak buffering capacity at the start.

What about his shoes? Adidas says those were the fastest and lightest super shoes ever made. Actually, Adidas had a great day as 4 of the top 5 men were wearing the same Adizero Adios Pro Evo 3. It weighs 97 grams (for men's size 9), 30 percent lighter than its predecessor with a stack height of 39 mm (below the 40 mm limit by World Athletics). 

The Lightstrike Pro foam used is 50 percent lighter than the previous version, along with the carbon plate. Research suggests that the foam and carbon plate can affect the "spring like" bounce of the body as the foot strikes and leaves the ground. The shoes help to store and release energy and acts like the runner is pushing off a springboard so less energy is needed for the run.

London is considered a relatively fast course (though not as fast as Berlin) and the weather conditions was between 13-17 degrees Celsius, close to ideal.

There you have it, exceptional athlete physiology, high mileage training without injury, efficient biomechanics, super shoes , optimized fueling and favorable conditions. The recipe for success for running marathons.

Reference

Muniz-Pumares D, Hunter B, Meyler S et al (2025). The Training Intensity Distribution Of Marathon Runnersd Across Performance Levels. Sports Med. 55: 1023-1035. DOI: 10.1007/s40279-024-02137-7

Flat Feet And Overpronation

On Friday night, a patient sent me a message with pictures (above) regarding her daughter's flat feet. She was worried that it was affecting her knee, hip and lower back. Subsequently, she brought her daughter into the clinic to see me yesterday. 

Her daughter has increased her running and training more recently for her National School Games bowling competition in the first week of May. She just started having mild pain in her left foot on Friday. Because of the pain, my patient was worried about her daughter's "over" pronation. 

The readers following this blog will recall that I have written before that children from 11 months to 19 years old with flat feet are perfectly fine and do not need orthotics. You can view the Cochrane review here. 

"Over" pronation is a word that is often used by many healthcare professionals to tell their patients that it is a cause of their foot pain. However EVERYONE has to pronate when they walk or run. When you take a step forward while walking, you often land on your heels. After heel strike, the whole foot lands on the ground and this is when your foot pronates. Now imagine having insoles or orthotics to block that movement. That is what happens when you try to limit pronation.

This mechanism is very necessary otherwise no load will be distributed up the leg. In fact, it often does not cause issues in runners. And yet, patients are somehow steered and asked to avoid, limit or alter pronation at all cost.

Of course there may be occasions when you have pain in your foot or arch, and healthcare professionals may have to take the load off the area temporarily to alleviate the structures that have been irritated.

The following study by Nielsen et al (2013) published in the British Journal of Sports Medicine investigated whether newbie runners with different foot positions had more or less injuries by wearing a neutral shoe regardless of their foot type or mechanics.

The 927 newbie runners with different pronation types were followed for a period of 12 months. All the runners received the same pair of neutral running shoes regardless of whether they had neutral foot pronation or not.  

The runners accumulated a total of 163, 401 km that year. 252 runners suffered a running injury in that period. In addition, the number of injuries per 1,000 km of running was significantly lower among runners who under or over pronate than among those with neutral foot pronation.

The authors found "no risk that overpronation or underpronation can lead to running injuries through using neutral shoes for this special group of healthy beginners." The authors "compared runners with neutral foot pronation with the runners who pronate to varying degrees, and our findings suggest that overpronating runners do not have a higher risk of injury than anyone else."

The authors thought their findings were 'controversial', since it has been assumed for many years that one would risk injuries to run in shoes without the necessary support if you under or over pronate.

The study also found that the risk of injury was the same for all their runners after the first 250 km, irrespective of their pronation type. 

Note that the study did not look at what can happen if runners run in a pair of non neutral shoes nor did they investigate what runners should consider with respect to pronation and choice of shoe if they are already injured.

So as I explained to my patient and her daughter whose foot pain has gone away, that pronation or more accurately, overpronation is not to be feared.

References

Nielsen RO, Buist I, Parner T et al (2013). Foot Pronation Is Not Associated With Increased Injury Risk In Novice Runners Wearing A Neutral Shoe: A 1-Year Prospective Cohort Study. BJSM. DOI: 1136/bjsports-2013-092202.

How I Train My Breathing Muscles

My respiratory muscle trainer

Over the Easter weekend, my family and I were away in Lake Toba. Since I would be missing my regular Saturday ride, I brought along my inspiratory muscle trainer, so I could at least train my inspiratory muscles while away. I had previously written about training your breathing muscles.

I do not run with mine, just sit and breathe with it

There are different ways to train your breathing muscles. The 2 most common techniques are voluntary isocapnic hyperpnoea (VIH) and inspiratory pressure threshold loading (IPTL).

VIH involves breathing at high volumes and rates so it is similar to intense exercise while maintaining carbon dioxide at stable levels to avoid dizziness. It is primarily done using specialized devices like the Breathe Way Better device which allows you to rebreathe exhaled carbon dioxide from a bag. This creates a close loop to keep blood gas levels balanced when allowing you to strengthen your inspiratory muscles.

IPTL strengthens the breathing muscles using a device with a calibrated, spring-loaded valve like the Power Lung or the Power Breathe that requires a consistent force to open. Users breathe in forcefully through the mouth against this resistance. It creates a "threshold" that must be overcomed to be able to breathe in. That was the device that I brought along.

Where did I get this idea from? Thanks to Kowalski and colleagues (2023) who investigated 16 well trained triathletes (7 females, 9 males) for  6 weeks using the VIH or IPTL program with progressive overload. 

Both subjective and physiological responses were monitored across sessions. Blood markers, muscle oxygenation and cardiac indices were all measured before, during and after the training sessions to track adaptation and load.

The results show that both VIH and IPTL training increased physiological load. Blood gas analysis showed larger post respiratory muscle training differences in females compared to males. VIH induced smaller changes in blood gasometry compared to IPTL.

VIH produced higher subjective training load and perceived exertion compared to IPTL. IPTL caused greater metabolic stress, altering acid-base balance, elevated lactate and caused dizziness and headache.

The authors concluded that respiratory muscle training added measurable mental and physiological load in well trained triathletes. Usage of such training should be individualized depending on method and training context since this study suggests that the load (30 breaths twice a day) is significant enough to add to training load.

Even though the protocol is short and easy to fit into a training regime, my suggestion is to take it slow and use lower loads and progression to complement your regular training. 

Did it help my following Saturday ride after my Easter trip? I think it did. I fared better than I expected.

References

Kowalski T, Kasiak PS, Rebis K et al (2023). Respiratory Muscle Training Induces Additional Stress And Training Load In Well-Trained Triathletes - Randomized Controlled Trial. Frontiers in Physiology. 14: 1264265. DOI: 10.3389/fphys.2023.1264265

Farewell Physio Solutions

Thank you to our patients for supporting us through the years since we opened in 2007.

We bid goodbye to our first clinic, Physio Solutions, after 19 years at Singapore Shopping Centre. This space provided us with the opportunity to grow our patient base and train young physiotherapists. 

It gave us the space to learn how to manage a small clinic, allowing us to open a bigger second clinic in Amoy Street, 2 years later. It has been a great run and we could not have asked for more.

Will miss this room with a view

This year, when our lease came up for renewal, Gino and I decided to streamline and simplify now that we are in our 50s. We will both see our patients at our clinic in Holland Village, Sports Solutions, together with our team of physiotherapists.

Here’s to a new season of life!

To start with, it has been a nice change to be able to walk to work since April!

With the receptionists from the dental clinic next door

Being In Nature Helps

View of Lake Toba

I hope you are enjoying your Easter long weekend as you read this. My family and I are away this weekend in Lake Toba, in Medan, Indonesia

Last week, we discussed how being fit may protect us from depression and dementia. This past week I came across another article that shows how a 90 minute walk in nature also helps.

Pictures taken by walkers comparing their walks

In that study, participants who went on a 90 minute walk in nature reported lower levels of rumination. Rumination is the subjective, conscious recognition of dwelling on negative feelings, distress and their causes. It often links stress to depression and anxiety. Rumination is a know risk for mental illness.

These participants also showed reduced neural activity in an area of the brain linked to risk for mental illness compared to those who walked through an urban environment.

These results suggest that accessible areas in nature may be vital for mental health in our repidly urbanizing society.

Especially since more than 50 percent of  people live in urban areas. It is estimated that by 2050, this proportion will be 70 percent.

Not a cure-all to be in nature, but a good reminder that environment can shape mental well being. 

Reference

Bratman GN, Hamilton JP and Gross JJ (2015). Nature Experience Reduces Rumination And Subgenual Prefontal Cortex Activation. PNAS. 112(28): 8567-8572. DOI:10.1073/pnas.1510459112

That's our >90 min nature walk

Does Better Fitness Protect Us From Dementia And Depression?

I'm not a mental health expert. I only know that I always feel better after I run, cycle or do any other form of exercise. Especially if I've been particularly stressed about something or everything.

We know for sure that having good cardiorespiratory fitness is a strong indicator of overall physical  health. However, is someone with good cardiorespiratory fitness less likely to have mental health disorders or dementia later in life?

A newly published systematic review and meta-analysis provides new updates on this link across all age groups in their study (Diaz-Goni et al, 2026). 22 studies (out of 27 chosen) with 4,007,638 participants were studied in that review. 

The participants were between 18 and 64 years old, who had fitness measured at baseline and followed for 4 to 29 years. Different methods were used for measuring fitness. Some studies used VO2 max, others used indirect or submaximal exercise tests while others measured peak workload and exercise duration. Note that this paper talks about cardiorespiratory fitness and NOT about VO2 max values.

Higher cardiorespiratory fitness was associated with substantially lower future risk of depression, psychotic disorders and dementia. However it did not show to clearly help with anxiety.

Each 3.5 mL/kg/ min (or 1 MET) increase in cardiorespiratory fitness was associated with a 5 percent lower risk of depression and 19 percent lower risk of dementia.

Overall, those with higher cardiorespiratory fitness had a 36 percent lower risk of depression, 39 percent lower risk of dementia and 29 percent lower risk of psychotic disorders compared to those with lower fitness.

The authors discussed a few potential mechanisms that may explain why higher cardiorespiratory fitness helps mental or neurocognitive disorders.

From a physiological perspective, improved brain blood flow, vascular function induces structural, cellular and molecular adaptations to enhance neuroplasticity which then support cognitive and emotional regulation.

Exercise and higher cardiorespiratory fitness has been shown to help maintain the size/ volume of the hippocampus. The role of the hippocampus is linked to emotion regulation, memory and cognitive resilience. Atrophy of the hippocampus has been consistently linked to mental and cognitive disorders.

Mental health disorders and neurodegeneration are definitely complex and multifactorial. Please note that the authors also did not just conclude that "exercise is the answer". They concluded that higher cardiorespiratory fitness appears to be associated with a lower risk of several mental and neurocognitive disorders and cardiorespiratory fitness may be a useful marker to sort out groups at risk.

This is also interesting to note. Because only 1 or 2 studies were available, the authors were not able to study them as a group. Those individual studies suggested that higher fitness may be associated with lower risk of bipolar related disorders, dissociative, obsessive-compulsive and stressor-related disorders, sleep apnea as well as anxiety and ADHD in children. Depression in girls also appeared lower with higher fitness.

If the fitness influencers do pick up on this topic, I hope they do not simplify it by making it as easy as doing "some exercise or sports". 

So taken at face value, higher cardiorespiratory fitness seems to lower risk across a wide range of psychiatric and neurocognitive disorders. Do note that genetic predisposition, chronic pain, social support, smoking and diet are definitely confounding factors.

The evidence does continue to add up showing that higher cardiorespiratory fitness helps with physical disease and premature death, but also with better mental health, lower dementia risk and other mental disorders. 

Reference

Diaz-Goni V, Lopez-Gil JF, Rodriguez-Gutierrez E et al (2026). Cardiorespiratory Fitness And Risk Of Mental Disorders And Dementia: A Systematic Review And Meta-Analysis. Nat Mental Health. DOI: 10.1038/s44220-026-00599-4

New Strength Training Guidelines From ACSM

Earlier this month the American College of Sports Medicine (ACSM) revised its strength training guidelines for the first time since 2009. Needless to say there are plenty of changes after 17 years.

Especially since strength training is still treated like a recipe by many healthcare professionals. Sets, reps, rest periods, percentage of 1RM (rep max).

This new stand came from a review of 137 systematic reviews and data from more than 30,000 participants making it the most comprehensive evidenced based review on strength (or resistance) training prescription.

Strength training definitely works. It improves strength, power, hypertrophy, muscular endurance, walking speed, balance and daily tasks.

Also an update that many forms of strength training can be effective. Not just lifting weights in a gym, but also elastic bands, circuit training, home based and speed based training.

To improve strength, the evidence suggests that one needs to strength train at least 2 times a week using heavier loads. Exercise through a meaningful range of motion with 2-3 sets doing the key lifts (exercise) at the start of the session.

For hypertrophy, what matters most is doing enough work. High volume weekly, especially more than 10 sets per muscle group each week. Eccentric overload would be most effective to enhance growth.

If you are training for power, moderate loads of 20 to 70 percent of 1RM max moved fast with low to moderate volume are suggested. Olympic style lifting and power focused training seems to be most effective.

Just as interesting to note is what did not consistently matter. Time of muscle under tension, training to failure, equipment type, set structure, periodization and blood flow restriction did not consistently show improvement across the studies reviewed.

Surprised? The best strength training program is definitely not the most complex or complicated one. It is one that you can do consistently and progress reasonably and sensibly over time. And to be able to do it long term.

No need to obsess over set structure, exercise selection, home gym or public. There is no perfect strength training program, the results come from what you can do regularly over time and not what looks best on paper. Adherence is what helps you progress.

Reference

Currier BS, D'Souza AC, Singh MAF et al (2026). American College Of Sports Medicine Position Stand. Resistance Training Prescription For Muscle Function, Hypertrophy, And Physical Performance In Healthy Adults: An Overview Of Reviews. Med Sci Sports Ex. 58(4): 851-872. DOI: 10.1249/MSS.0000000000003897.

You can read the whole article here.

Should Runners Get Running Gait Analysis?

My patient who's training for a marathon came to me this past week telling me she had a friend who had just gone for a paid running gait analysis. Stride length, cadence, gait symmetry were all filmed after checking for muscle imbalance, flexibility and joint alignment. She was tempted to go too.

I shared with my patient a really interesting article I read this past week (Cochrum et al, 2021). The study assessed if running coaches could visually assess a long distance runner's running economy. These 121 running coaches were coaching high school runners to runners at international level.

Running economy was measured in 5 trained recreational runners at about 12.8 km/ hour. The runners were filmed from the front, side and rear while running on a treadmill. There was a minimum VO2 difference of 2 mL.kg/ min between adjacent runners that the coaches visually assessed.

The coaches viewed each video and ranked the runners on a scale from 1 (most economical) to 5 (least economical). They also completed a demographic questionnaire and listed running style biomechanical observations they used in determining each ranking. 

There was also a statistical algorithm to determine the effect of coaching level, years of coaching, training experience, competition level, certification status and educational level on the ability to accurately rank running economy.

Get ready for this, NONE of the coaches ranked them all correctly. Only 6 percent (or 7 out of 121 coaches) managed to identify 3 correctly.

In our clinics, we sometimes blame running economy (due to cadence, stride length, running style, gait) as a cause of problems or injuries. From the research paper, it is surprisingly difficult to judge visually.

Perhaps most runners do not have a "wrong" running style or form. Running mechanics are definitely self organized. As one trains more regularly, their body would gradually find the path of least resistance. The running style would then suit their anatomy and training load after accounting for their injury history, and strength. 

Much research suggests that runners often become more economical simply by running regularly, without needing to consciously change their running style and technique (Van Hooren et al, 2024)

Does this mean most runners do not need running gait correction? Since biomechanical measures did not reliably predict injury suggesting that we cannot so easily "see a risky/ wrong running gait" and fix it. 

Most healthcare professionals may disagree (since it means they cannot charge their patients more) and I would encourage you to pause and take a step back. Do not assume your running style is the problem however fancy these "advance" running gait analyses may promise. Especially if you are not injured.

I am also not saying running gait analysis is useless. It can be helpful when a runner is already injured. Small adjustments like shortening stride length, width or increasing cadence can easily help runners with knee pain and help them return to running more comfortably while the underlying tissue settles.

So, if you are a healthy, non injured runner looking to run faster or even prevent injuries, it's better to work on your strength, recovery, consistency, training load and progression. Your running style may not need correction. Your body would have already figured that out, especially if you are a serious runner with more than 5 years of consistent running.

I may look at and discuss running gait in our clinic as part of my assessment, but it is usually not a immediate area of concern. Personally I do not like looking at running gait on a treadmill since it will be different compared to running outside. I would get my patients to run outside while watching them if I need to.

Unfortunately there are many other healthcare professionals who do not understand this or choose not to understand (so they can make more money), to keep up with this misconception.

References

Cochrum RG, Conners RT, Caputo JL eyt al (2021). Visual Classification Of Running Economy By Distance Running Coaches. Eur J Sp Sci. 21(8): 1111-1118. DOI: 10.1080/17461391.2020.1824020

Van Hooren B, Jukic I, Cox M et L (2025). The Relationship Between Running Biomechanics And Running Economy: A Systematic Review And Meta-Analysis Of Observational Studies. Soorts Med. 54(5): 1269-1316. DOI: 10.1007/s40279-024-01997-3

Running Associated With Good Intervertebral Discs Adaptations

Remember how I previously wrote that running helped eased my back pain after my compression fracture following my first bike accident. Well, this is not just coming from me (n=1) who has 2 compression fractures in my spine. A recently published article this past week (on 5th March 26) shows that running is associated with good intervertebral disc (IVD) adaptations (Samanna et al, 2026) too and thus may help those suffering from chronic low back pain.

The authors, in their randomized controlled trial, showed  how a 12 week run-walk program affected the spinal health of 40 adults with chronic low back pain.

The subjects either followed a digitally delivered progressive run-walk interval program of doing 3 run-walk days each week at 30 minutes a session or in a waitlist control group.

 

MRI were used to track changes in the health of the T11/12 to L5/S1 IVD relaxation times. This is a reliable way to assess IVD hydration and structural integrity. This was done at the start, 6th and end of the 12th week of the run-walk program. T2 values were tracked since it is influenced by IVD composition and water content, with higher values indicating higher hydration and better IVD health.

The results surprisingly showed that the subjects with more significant multi level IVD degeneration actually showed more favorable improvements in the IVD health after 12 weeks. Even more improvement than those with healthier discs.

This suggests that even IVD's that have already undergone degenerative changes still have the capacity to adapt and rehydrate when exposed to regular, dynamic movement. The "degenerated" IVD's with lower baseline hydration may also show greater potential for rehydration and measurable improvement since they are starting at a lower base.

A person's body mass index (BMI) did not significantly change how they responded to the program.

The study showed that a total running volume between 28.6 to 46.1 km over the 12 weeks led to best results for the IVD T2 changes. That is a manageable weekly average of 2.4 to 3.8 km.

Moderate running speeds between 10.5 km/h and 11.7 km/h was associated with better outcomes at the 12 week mark. 

Running on grass was also identified as a positive factor for improving disc health. Possibly because of a lower biomechanical load compared to running on concrete.

There was also some negative effects briefly seen at the 6 week mark with lower running speeds or those with mild degeneration, but they disappeared by week 12. This implies that the initial weeks may involve a temporary "adjustment" phase as the body adapts to new movements from a new exercise. Sticking with the program leads to long term benefits.

Do note that the sample size is fairly small and an improvement in T2 values may not necessarily reflect physiological or therapeutic improvement. The subject has to feel less back pain. I definitely have less back pain after running. Your discs definitely need the gentle loading from running.

Reference

 

Samanna CL, Neason C, Tagliaferri SD et al (2026). Running Is Associated With Intevertebral Disc Adaptations : A Pre-Planned Secondary Analysis Of The ASTEROID Randomised Controlled Trial. Eur Spine J. Epub 5 Mar. DOI: 10.1007/s00586-026-09759-7.

Inflammaging Across Human Populations

Aging is more than just getting gray hair and wrinkles. It is a gradual decline in how our cells in the human body function.  This can result from various metabolic, environmental and genetic factors. When our cells accumulate damage, important systemic processes in our body become dysregulated, and this leads to an increased rate of disease and mortality.

Inflammaging, a combination of inflammation and aging is when there is a chronic, low grade persistent  inflammation occurring in the body without infection or obvious injury. 

This is characterized by increased levels of inflammatory markers in the blood. The term was first coined by Claudio Franceschi to detect the systemic, hard to detect inflammation that creeps in with advancing age.

Inflammaging stems from an immune system that is malfunctioning, when there is overstimulation of our natural immune system and when damaged cells there do not die (cellular senescence). 

Increased tummy fat, genetic predisposition, accumulated cell damage and lifestyle factors like chronic stress and poor diet can contribute to it. It is a sterile and persistent process not triggered by acute infection. It accelerates aging and contributes to age-related diseases like Alzheimer's, diabetes, arthritis and cardiovascular diseases.

It then leads to functional decline, frailty and increased mortality.

A study published recently suggested that low grade chronic inflammation may be actually tied to environmental factors in industrialized countries. This suggests that inflammaging may not be equal in different parts of the world.

The researchers analyzed data from 4 different populations. Italy and Singapore (industrialized) and 2 non-industrialized (indigenous communities) in the Bolivian Amazon and Malaysia (Orang Asli). 

Orang Asli

They found that inflammation levels increased with age in industrialized societies while this was absent in the non-industrialized societies studied. In the non-industrialized societies, inflammation appeared mostly linked to short term infections rather than chronic age-related diseases.

Their findings suggest that the persistent inflammation seen in wealthier nations may be more influenced by lifestyle and environmental factors such as pollution, diet, levels of physical activity rather than aging itself. 

This shows the need to consider both environmental and cultural contexts while studying the causes of aging. 

The human species have gone from increasing lifespan over the past 150 years to extending lifespan and living well. 

Before falling from grace recently because of ties with Jeffrey Epstein, Peter Attia and American entrepreneur Brian Johnson have been at the forefront of the "living forever" (or longevity) movement. Johnson has even organized the Rejuvenation Olympics to get participants to find ways including exercise and dietary supplements to slow biological aging. 

Johnson's tactics have been labeled extreme in cost and nature especially when he gets regular injections of blood from his teenage son. Perhaps he needs to go live in indigenous communities for a while to help him in his quest.

Reference

Franck M, Tanner KT, Tennyson RL et al (2025). Nonuniversality Of Inflammaging Across Human Populations. Nat Aging.5 : 1471-1480. DOI: 10.1038/s43587-025-00888-0

Still Think It's The Thigh Muscles?

I have seen many patients who have had an anterior cruciate ligament (ACL) tear over the years.  Some patients chose not to go under the knife but most had reconstruction done. ALL of them were taught to focus their strengthening on their quadriceps (or thigh) muscles.

So not surprising that a recently published study by Alzobi et al (2026) found that patients who did not opt for surgery exhibited progressive hamstring muscle atrophy.

A total of 1,207 thighs were examined. There were 92 with ACL tears and the other 1,115 acted as controls. The average age of the subject group was 61± 9 years.

Over 4 years, the ACL deficit thighs were smaller by an average of 28.18 mm, all due to progressive hamstring atrophy. The differences ranged from 13.92 to 42.43 mm smaller. The sartorius muscle also atrophied by an average of 3.02 mm.

There were no significant differences in the quadriceps or adductor cross sectional area. hamstring force was decreased significantly whereas quadriceps force showed no significant change.

The researchers concluded that muscle deterioration occurred in the posterior thigh muscles (hamstrings) with minimal changes in the front thigh muscles (quadriceps) over time. And for ACL deficient knees, it is really important to target long term rehabilitation strategies focusing on hamstring preservation. 

We already know that one of the reasons women sustained ACL tears is that their hamstrings were significantly weaker than their quadriceps muscle strength.

If you have been reading our previous blog articles, you already know that the quadriceps (thigh muscles) and gastrocnemius (calf muscles) increases load on the ACL due to anterior shearing forces at the tibia (shin bone). This is especially so when the knee is straightened (Maniar et al, 2022).

The hamstrings and soleus (deeper calf muscles) help to unload the ACL by generating posterior tibial shearing forces (Maniar et al, 2022).

So for those of you who have torn your ACL, whether or not you choose to go for surgery, make sure you focus on your hamstrings and soleus muscles instead.

References

Alzobi O, Mohajer B, Fleuriscar J et al (2026). Thigh Muscle Changes In The ACL-Deficient Knee: A 4-Year Lonitudinal MRI Study of 1,207 Patients. JBJS Am. 108(3): 219-226. DOI: 10.2106/JBJS.25.0064

Maniar N, Cole MH, Bryant AL et al (2022). Muscle Force Contributions To Anterior Cruciate Ligament Loading Sports Med. DOI: 10.1007/s40279-022-016743