Belief in the need for sodium supplementation during ultramarathons remains strong: findings from the Ultrarunners Longitudinal TRAcking (ULTRA) study.

In the past, ultramarathon runners have commonly believed that consuming sodium supplements, as capsules or tablets, will prevent exercise-associated hyponatremia (EAH), dehydration, muscle cramping, and nausea, but accumulating evidence indicates that sodium supplementation during ultramarathons is not necessary and may be potentially dangerous. In this work, beliefs about whether sodium supplements should be made available at ultramarathons were assessed during 2018 among 1152 participants of the Ultrarunners Longitudinal TRAcking (ULTRA) study, of which 85.2% had completed an ultramarathon during 2014-2018. Two-thirds (66.4%) of study participants indicated that sodium supplements should be made available at ultramarathons, supported by beliefs that they prevent EAH (65.5%) and muscle cramping (59.1%). Of those indicating that sodium supplements should not be made available, 85.0% indicated it is because runners can provide their own, 27.9% indicated it is because they are not necessary, and 12.1% indicated they could increase thirst drive and cause overhydration. In general, there was a tendency for those who were older, less active in running ultramarathons in recent years, and with a longer history of ultramarathon running to be less likely to know that sodium supplements do not help prevent EAH, muscle cramping, and nausea. Novelty Ultramarathon runners continue to have misunderstandings about the need for sodium supplementation during ultramarathons. Few ultramarathon runners recognize that supplementing sodium intake beyond that in food and drink is generally not necessary during ultramarathons or that it could result in overhydration. Continued educational efforts are warranted to help ensure safe participation in the sport.

Functional outcome from sacroiliac joint prolotherapy in patients with sacroiliac joint instability.

OBJECTIVES: Examine the effectiveness of sacroiliac (SI) joint prolotherapy for SI joint instability, and characterize the patients most likely to benefit from this treatment. DESIGN: Retrospective cohort study. SETTING: Department of Veterans Affairs outpatient physical medicine clinic. INTERVENTIONS: Patients referred for low back pain and diagnosed with SI joint instability received a series of three SI joint prolotherapy injections (15% dextrose in lidocaine) at approximately a one-month interval. The outcome of those completing treatment was retrospectively examined, and characteristics were compared between those with at least a minimum clinically important improvement and those without improvement. MAIN OUTCOME MEASURES: Patients completed the Oswestry Disability Index (ODI) before treatment was initiated, immediately preceding each prolotherapy injection, and at 3-4 month follow-up. RESULTS: Of 103 treated patients returning for post-treatment follow-up at a median of 117 days, 24 (23%) showed a minimum clinically important improvement despite a median of 2 years with low back pain and a mean (±SD) pre-intervention ODI of 54 ±â€¯15 points. Much of the improvement was evident after the initial prolotherapy injection, and a 15-point improvement in ODI prior to the second prolotherapy injection had a sensitivity of 92% and specificity of 80% for determining which patients would improve. CONCLUSIONS: A satisfactory proportion of patients with symptomatic SI joint instability as an etiology of low back pain can have clinically meaningful functional gains with prolotherapy treatment. The patients who are not likely to improve with prolotherapy are generally evident by lack of improvement following the initial prolotherapy injection.

A randomized controlled trial of manual therapy and pneumatic compression for recovery from prolonged running - an extended study.

Manual therapy (MT) and intermittent pneumatic compression (IPC) are recovery methods used by endurance athletes with little evidence supporting effectiveness. This randomized controlled trial evaluated effectiveness of four daily post-race treatments of a specific MT protocol and IPC compared with supine rest on recovery following an ultramarathon among 56 ultramarathoners. Groups were comparable across all characteristics examined, including post-race plasma creatine kinase concentration. Subject completed timed 400 m runs before the race and on days three, five, seven and 14 post- race, and also provided muscle pain and soreness ratings and fatigue scores immediately before and after treatments, and during the 14 days post- race. Daily subjective measures and 400 m run times were not improved by either treatment, but both treatments reduced (p < .05) muscular fatigue scores acutely after treatment following the race and on post-race day 1, and MT improved (p < .05) muscle pain and soreness acutely following the race.

A Placebo-Controlled Trial of Riboflavin for Enhancement of Ultramarathon Recovery.

BACKGROUND: Riboflavin is known to protect tissue from oxidative damage but, to our knowledge, has not been explored as a means to control exercise-related muscle soreness. This study investigated whether acute ingestion of riboflavin reduces muscle pain and soreness during and after completion of a 161-km ultramarathon and improves functional recovery after the event. METHODS: In this double-blind, placebo-controlled trial, participants of the 2016 161-km Western States Endurance Run were assigned to receive a riboflavin or placebo capsule shortly before the race start and when reaching 90 km. Capsules contained either 100 mg of riboflavin or 95 mg of maltodextrin and 5 mg of 10% ß-carotene. Subjects provided muscle pain and soreness ratings before, during, and immediately after the race and for the 10 subsequent days. Subjects also completed 400-m runs at maximum speed on days 3, 5, and 10 after the race. RESULTS: For the 32 (18 in the riboflavin group, 14 in the placebo group) race finishers completing the study, muscle pain and soreness ratings during and immediately after the race were found to be significantly lower (p = .043) for the riboflavin group. Analysis of the 400-m run times also showed significantly faster (p < .05) times for the riboflavin group than the placebo group at post-race days 3 and 5. Both groups showed that muscle pain and soreness had returned to pre-race levels by 5 days after the race and that 400-m run times had returned to pre-race performance levels by 10 days after the race. CONCLUSIONS: This preliminary work suggests that riboflavin supplementation before and during prolonged running might reduce muscle pain and soreness during and at the completion of the exercise and may enhance early functional recovery after the exercise.

Does oral buffered sodium supplementation reduce nausea and vomiting during an ultramarathon?

This work examines whether nausea or vomiting during an ultramarathon are due to a fluid or electrolyte imbalance, and if these symptoms can be reduced through the use of buffered sodium supplements. Starters (n = 376) of a 161.3-km ultramarathon underwent body weight measurements, 74.5% completed a post-race questionnaire, and 53.0% also underwent a post-race blood draw. The incidence of nausea or vomiting progressively increased during the race, and affected 60% of runners overall. Weight change and rate of sodium intake in supplements or in buffered sodium supplements did not differ between those with and without nausea or vomiting. Post-race serum sodium concentration also did not differ between those with and without symptoms in the last race segment. We conclude that weight change, the rate of sodium intake in supplements or in buffered sodium supplements, and serum sodium concentration are not related to symptoms of nausea or vomiting during a 161-km ultramarathon.

A Randomized Controlled Trial of Massage and Pneumatic Compression for Ultramarathon Recovery.

Study Design Randomized controlled trial. Background Postexercise recovery techniques are widely used, but little research has examined their effectiveness. Objectives To examine the effectiveness of massage and pneumatic compression on recovery from a 161-km ultramarathon. Methods Participants in the 2015 161-km Western States Endurance Run were randomized to a 20-minute postrace intervention of massage, intermittent sequential pneumatic compression, or supine rest. Each subject completed two 400-m runs at maximum speed before the race and on days 3 and 5 after the race, and also provided muscle pain and soreness ratings and overall muscular fatigue scores before and for 7 days after the race. Results Among the 72 runners who finished the race and completed the study, comparison among intervention groups revealed no significant group or interaction effect on 400-m run time, but there was a significant (P<.0001) time effect. Immediately posttreatment, massage resulted in lower muscle pain and soreness ratings compared with the supine-rest control condition (P<.0001), while both massage (P<.0001) and pneumatic compression (P<.01) resulted in lower overall muscular fatigue scores compared with the control group. There were no significant differences between groups in any outcome 1 to 7 days after the race. Conclusion Single 20-minute sessions of postrace massage and intermittent sequential pneumatic compression provide some immediate subjective benefit. There is no evidence, however, that such treatments provide extended subjective or functional benefits of clinical importance. The trial was registered at www.clinicaltrials.gov (NCT02530190). Level of Evidence Therapy, level 1b. J Orthop Sports Phys Ther 2016;46(5):320-326. Epub 23 Mar 2016. doi:10.2519/jospt.2016.6455.

Sodium Supplementation and Exercise-Associated Hyponatremia during Prolonged Exercise.

PURPOSE: This work examines whether sodium supplementation is important in prevention of hyponatremia during continuous exercise up to 30 h and whether any distinguishing characteristics of those developing hyponatremia could be identified. METHODS: Participants of the 161-km Western States Endurance Run underwent body weight measurements before, during, and after the race, completed a postrace questionnaire about drinking strategies and use of sodium supplementation during four race segments, and underwent analysis of postrace serum sodium concentration. RESULTS: The postrace questionnaire was completed by 74.5% of the 376 starters, a postrace blood sample was provided by 61.1% of the 296 finishers, and 53.0% of finishers completed the postrace survey and also provided a postrace blood sample. Among this population, the incidence of hyponatremia among finishers was 6.6% and sodium supplements were used by 93.9% of the runners. Postrace serum sodium concentration was found to be directly related to the rate of sodium intake in supplements (r = 0.24, P = 0.0027) and indirectly related to the percentage change in body weight from immediately before the race start (r = -0.19, P = 0.010). There was no difference in rate of sodium intake in supplements between the hyponatremic and normonatremic finishers, and none of the hyponatremic finishers lost >4.3% body weight. Hyponatremic finishers were not distinguished from normonatremic or hypernatremic finishers by other runner characteristics considered, drinking strategies, or gastrointestinal symptoms of nausea and vomiting. CONCLUSIONS: We conclude that a low sodium intake in supplements has minimal responsibility for development of hyponatremia during continuous exercise up to 30 h, whereas overhydration is the primary characteristic of those developing hyponatremia. Therefore, avoiding overhydration seems to be the most important means for preventing hyponatremia under these conditions.

Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update.

Exercise-associated hyponatremia (EAH) is defined by a serum or plasma sodium concentration below the normal reference range of 135 mmol/L that occurs during or up to 24 hours after prolonged physical activity. It is reported to occur in individual physical activities or during organized endurance events conducted in austere environments in which medical care is limited and often not available, and patient evacuation to definitive care is often greatly delayed. Rapid recognition and appropriate treatment are essential in the severe form to ensure a positive outcome. Failure in this regard is a recognized cause of event-related fatality. In an effort to produce best practice guidelines for EAH in the austere environment, the Wilderness Medical Society convened an expert panel. The panel was charged with the development of evidence-based guidelines for management of EAH. Recommendations are made regarding the situations when sodium concentration can be assessed in the field and when these values are not known. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks/burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for Treatment of Exercise-Associated Hyponatremia published in Wilderness & Environmental Medicine 2013;24(3):228-240.

Hydration strategies, weight change and performance in a 161 km ultramarathon.

To examine controversies about hydration strategies, participants (383 starters) of a 161 km ultramarathon (maximum temperature 39.0°C) underwent body weight measurements before, during and after the race; and completed a post-race questionnaire on drinking strategies and sodium supplementation use during 4 race segments. Drinking to thirst was the most common (p < 0.01) drinking strategy (used by 67.0% during at least one segment) and most runners (95.6%) used sodium supplementation during at least one segment. There was no difference in the extent of weight loss (mean 2.0-3.1%) or the weight change pattern when comparing groups using different hydration strategies. Among top-10 finishers, half had lost more than 2% of starting body weight by 90 km. We conclude that weight loss greater than 2% does not necessarily have adverse consequences on performance, and use of sodium supplements or drinking beyond thirst is not required to maintain hydration during ultra-endurance events with high thermal stress.

Body mass index and its correlates in 1,212 ultramarathon runners: baseline findings from the ULTRA study.

BACKGROUND: Little is known about the sociodemographics and lifestyle behaviors of ultramarathon runners, and the effects of these characteristics on body weight and body mass index (BMI). METHODS: We cross-sectionally analyzed baseline data of 1212 ultramarathoners on sociodemographics, lifestyle behaviors and BMI from the initial 12-month enrollment period in a longitudinal observational study. RESULTS: The ultramarathoners were mostly middle-aged men who were more educated, more likely to be in a stable relationship, and more likely to use over-the-counter vitamins/supplements than the general population. They appear to gain less body weight with advancing age than the general population. Factors with the greatest effect on current BMI were BMI at 25 years of age and sex, which explained 48% and 3% of the variance. Negligible, but statistically significant direct relationships, with BMI were observed for age, work hours per week, television watching hours per week, and composite fat consumption frequency score. Negligible, but statistically significant inverse relationships, with BMI were observed for running distance during the prior year, and composite fruit and vegetable consumption frequency score. CONCLUSIONS: While lifestyle decisions were found to impact BMI within this group of ultramarathoners, BMI at age 25 was the strongest predictor of current BMI.

Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia.

Exercise-associated hyponatremia (EAH) typically occurs during or up to 24 hours after prolonged physical activity, and is defined by a serum or plasma sodium concentration below the normal reference range of 135 mEq/L. It is also reported to occur in individual physical activities or during organized endurance events conducted in austere environments in which medical care is limited or often not available, and patient evacuation to definitive care is often greatly delayed. Rapid recognition and appropriate treatment are essential in the severe form to ensure a positive outcome. Failure in this regard is a recognized cause of event-related fatality. In an effort to produce best practice guidelines for EAH in the austere environment, the Wilderness Medical Society convened an expert panel. The panel was charged with the development of evidence-based guidelines for management of EAH. Recommendations are made regarding the situations when sodium concentration can be assessed in the field and when these values are not known. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians.

Demographic characteristics of 161-km ultramarathon runners.

Despite considerable recent growth in ultramarathon running, little is known about the characteristics of the participants. This work documents demographic characteristics of 161-km ultramarathoners. Surveys were completed by 489 of 674 runners entered in two of the largest 161-km ultramarathons in North America in 2009. Respondents had a mean (± SD) age of 44.5 ± 9.8 years (range 20-72 years) and were generally men (80.2%), married (70.1%), had bachelor's (43.6%) or graduate (37.2%) degrees, and used vitamins and/or supplements (75.3%). They reported 2.8 ± 20.2 days of work or school loss in the previous year from injury or illness. Body mass index (23.4 ± 2.2 and 20.8 ± 1.8 kg/m2 for men and women, respectively) was not associated with age. The findings indicate that 161-km ultramarathon participants are largely well-educated, middle-aged, married men who rarely miss work due to illness or injury, generally use vitamins and/or supplements, and maintain appropriate body mass with aging.