Domhnall MacAuley: Barefoot runners, Western habits, and GP records – more from ACSM

Domhnall MacauleyShould we abandon running shoes? Running shoes are a relatively new phenomenon – primitive man did not wear shoes when hunting in the savannah and would look in wonder at modern running shoes with their huge wedges, motion support, and cushioned soles. They have changed the way we run and, in spite of all the claims, running injury rates remain the same. Daniel Lieberman (Harvard) presented some anthropological and observational work that form the background to his paper in Nature, and Irene Davis (Harvard) took it a step further by advocating that we should try to run without shoes. Gait analysis and force plate studies are quite convincing: runners wearing shoes have a high impact heel strike and large wedges increase the moment arm accentuating pronation. Although the arguments were persuasive, I am not ready to abandon running shoes just yet. And, Irene did introduce some caveats – don’t run in the cold, where your numb feet will not feel injury, don’t run in the dark, and don’t run on a rough surface – which pretty much excludes most of my running opportunities.

Should we promote physical activity in developing countries? Evidence for the benefits of physical activity are overwhelming and the principles are important across the world. A number of sessions addressed global health and the importance of promoting physical activity. But, in a world where basic living conditions are poor, and the major problems are child health, infectious disease, and poor sanitation, I wonder if physical activity is a priority. Diabetes and cardiovascular disease rates are rising, but I doubt if the developing countries really need a lecture from us. I asked Festus Adams (Ghana) who told me that physical activity is an integral part of the traditional lifestyle – their goal is not so much to promote activity but to avoid introducing the worst habits of an inactive western lifestyle.

Should GPs record physical activity? GPs have a lot to do without adding another tick box to the QoF checklist. But, Kaiser Permanante in Southern California is the first major healthcare system to do  it and I guess it will arrive in the UK soon. Since October 2009 patients are asked two questions 1) “On average how many days do you engage in moderate or greater exercise (like a brisk walk) and 2) “On average how many minutes do you engage in exercise at this level.” Bob Sallis (Kaiser Permanante Medical Centre, Fontana) told me that exercise level is now recorded in 81% of  electronic medical records.

Looking around the convention centre, very few had a BMI greater than 25 and it is the only meeting I have been to where, when they ask for volunteers for clinical examination, there is a rush of guys willing to take their shirts off. Not your average medical conference.

Domhnall MacAuley is primary care editor, BMJ

  • Stevenlindleyuk

    “Gait analysis and force plate studies are quite convincing: runners wearing shoes have a high impact heel strike” – have you got references for this? And what is meant by high impact heel strike? As it's thought that it's not actually the peak impact peaks that seem to be the 'problem' and more the vertical loading rate (the initial part of the heel strike, and the time it takes for the body to absorb the impact). The loading rates are considerably lower when wearing shoes as they are acting as a filter and dampener, absorbing the impact at a slower rate. Although once again this hasn't been proven with injury prevalence however.
    Yes the argument for barefoot running is there about how the primitive man used to run for miles and miles a day and never get overuse injuries , however did they run for miles on concrete/Tarmac?

  • Domhnall MacAuley

    Yes, do click on the link above to Daniel Lieberman's paper in Nature for further details on the heel strike and impact. The evidence he presented does show a different pattern of impact between barefoot runners and those wearing shoes and, those wearing shoes greater immediate impact. But, I was much less convinced that, based on this observational evidence, we should abandon running shoes. It did make me think, however, about how shoe design alters our gait.

  • Andrew Murray

    An enjoyable and thought provoking blog.

    In addition to the evidence from trials, a really interesting lay book that looks at running and footwear is “Born to Run” by Christopher McDougall. It looks at a tribe of champion runners from the Copper Canyons of Mexico with their rudimentary shoes, and challenges the belief that fancy modern shoes are of benefit to everyone. It is true that the modern runner may have a lower base of training, and a different body habitus to our predecessors, and that we run on different surfaces. I think it comes down to what suits the individual, and if an individual can't find a shoe to suit them then help from running shops, or health care professionals such as podiatrists can be of help.

    I welcome Kaiser Permanante recording physical activity routinely. Blair et al showed that in the USA that physical Inactivity is one of, if not the biggest cause of preventable mortality and morbidity. Physical inactivity contributes to cardiovascular, respiratory, and a whole raft of other problems, as well as the well documented obesity, diabetes, and depression.  This is not a problem only in the states, and estimates from 4 major surveys in Scotland show 35-45% of people achieve what should be an achievable recommendation of 150 mins of moderate exercise (ie brisk walking) or 75 mins of strenous exercise per week.

    There is robust data to confirm that physical inactivity is a problem that exists, but less on how we address this fundamental challenge of our age in Western Society.  Recongnising the importance of this issue, and acting upon it would be a fitting legacy for the upcoming Olympic and Commenwealth games

    Dr Andrew Murray, GP, Scotland

  • Alex

    Did they touch on recent research (I can't find the study I'm thinking of given that I am using my time more wisely revising for finals) that bare foot runners encounter more mid/fore foot problems? (And that there's not much in the way of longterm evidence, history notwithstanding, for the health impact (pun intended) of said alteration in foot strike in the bare foot crowd).

    Also your last paragraph sparks off what could be a heated debate anyday: should doctors be setting a better example of health?
    Currently the hypocrisy is rampant in the medical world with obesity, smoking and excess alcohol consumption key modifiable lifestyle factors that doctors advocate to their patients yet commonly fail to adhere to themselves.

    The freedom of human choice is a precious thing and should not be called into question but I raise the rather controversial point: shouldn't doctors be held more accountable for their own health behaviours as part of their professional image and responsibility?  As a medical student I realise that this can all come across as naive and quite possibly self-righteous but surely there is a better way out there and that we should be setting a better example?

    (Cue in the retort from the other medical corner pointing out that everything has risks and that sports often carry serious health risks and that smoking or drinking is another man's torn ACL or concussion etc…yet, with my as yet unjaded ideals, still I would argue that healthcare professionals should aim to set the benchmark….)

    -Alex Murray

  • Itzach Stern

    This will be a great reference in my future studies and I bet this will surely a big help for someone looking for some ideas concerning this matter.Thanks.