“When can I resume my cycling training?” and “How soon can I race again?” were two of the key questions on my mind when I was first diagnosed with #DVT (Deep Vein Thrombosis) in June. I knew I was not going to get the answers I wanted, being Little Miss Impatient it was never going to be soon enough. Each DVT case is different, but perhaps this blog about how I approached my slow journey back to race fitness, can give some useful insight to others unfortunate enough to be faced with the same questions.
The NHS doctor at the hospital seemed to think it was ‘fine’ to commute to work by bike again as soon as I was pain-free, but I should avoid strenuous activity until the medication was completed. Does she realise that commuting in London is likely more dangerous than participating in a time trial? I don’t think she understood the role cycling plays in my life or how, as an athlete, I may need a little more specific guidance than your average person who just gets told to ‘move a bit more’.
I was dismissed from the hospital before I knew it and perplexed to hear that I wouldn’t actually be rescanned once I will come off the anti-coagulants at the beginning of September. It is somehow assumed that the blood clot should have disappeared by then without any need to check? It all felt a bit lackadaisical. I was basically put on anti-coagulants and sent home, assumed to be fine. A matter of money I guess, but it does not give much confidence.
I begged my GP to see a particular NHS thrombosis specialist (one of the best in the country) who has treated a lot of cyclists and other endurance athletes. I understand it is my right to ask for a referral to any NHS specialist, but this request was refused twice by my GP as the hospital where this specialist is based is ‘outside the catchment area’. A pity, as without a referral letter from my GP, I cannot see the specialist.
Having heard from other endurance cyclists about recurring DVTs because of genetic reasons (e.g. Factor V Leiden), I also asked my GP for a referral for genetic testing. Again, my request was refused by the central committee, because a) there appeared to be a logical cause for my DVT (extreme dehydration followed by prolonged periods of sitting down), b) it was ‘only’ my first DVT and c) testing while on anticoagulants could be dangerous. I should wait until September and put in another request, but was told that my chances of it being approved would be small. Great.
I then tried my luck through my private health care who referred me to a consultant in Sport and Exercise Medicine with experience of DVTs. The consultant had worked with many athletes, but predominantly on muscular, rather than vascular problems. His view was that after an initial period (up to 4 weeks) of careful training, I should be able to train as hard as I like indoors. But, because of the lack of a reversal agent for the anticoagulant I take (Xarelto aka Rivaroxaban), he recommended to avoid all cycling outdoor until I have completed my medication. Obviously that was not what I wanted to hear. I know that the risk of falling while cycling is small, but it is always there. The risk of falling off in the sort of long-distance and endurance events I compete in is possibly greater too (darkness, fatigue, sleep deprivation). The problem is that while on Rivaroxaban the bleeding (certainly when involved in a serious crash) may take longer than usual to stop. It is not a risk I want to take. After all, what is 3 months in the scheme of a life-time of cycling?
So below goes my diary of training indoors with DVT. Before you read on, this comes with a massive health warning. I am not a doctor. What is fine for me may not be fine for others. And I have always been slightly mad about long (turbo) training sessions 😉
Week 1: Without official guidelines as to when and how quickly athletes can return to training, it is generally advised to refrain from more strenuous activities for the first 2 weeks, until the blood clot is more attached to the vessel wall (and the risk of the clot breaking loose and potentially causing a pulmonary embolism has decreased). So week 1 of anticoagulants mostly consisted of very easy turbo sessions (less than 70% intensity) and gentle walks. Whenever I felt the slightest niggle in my left leg I would stop or back off and I was constantly drinking (and consequently taking a lot more toilet breaks). The ‘deconditioning’ effect (i.e. higher than normal heart rate for what I perceived as very gentle exercise) was a bit of a shock at first. I was extremely careful and would pretty much wear my compression tights whenever I could. I even slept in them. I am not sure how effective they were though as it was a 4-year old pair of 2XU recovery tights that had probably lost all compression by now.
Week 2: In the second week I was getting more and more frustrated with how little I could train (or rather the low intensity levels I had to stick to), so I tried to mix it up with some cross training: gentle yoga classes, core stability, circuit training etc (but avoiding anything more strenuous).
Week 3: Apparently it is OK to slowly increase activity again between week 2 and week 4 to return to pre-clot activity levels by week 4, unless I would experience any pain. My coach wanted to make sure we rebuild slowly, so during week 3 I still only trained at about 75% intensity. Physically this was fine (no pain), but mentally is was tough. I was screaming out for something a bit more challenging.
Week 4: Week 4 still involved a lot of cross-training (circuits, light weights, Swiss ball etc), but for the first time I saw some more tasty power numbers on my Garmin screen again. Intensity went up to about 80-85%, but intervals were still short and rest periods longer than I would ever have taken before. I didn’t feel like I needed the rest, but better safe than sorry.
Week 5: It appears that being highly active one month after a DVT is not detrimental; it may, actually be beneficial and lead to fewer symptoms of post-thrombotic syndrome. Week 5 saw intensity going up to session of around 90% and with it my mood started to lift again. I still wasn’t fully back to the levels I would train at pre-DVT, but the sessions were a bit more challenging and fun again at least. I would normally spend between 12 and 20 hours per week on the bike in the summer. Now I only spent about 10 hours, but all 10 hours were ‘quality’ training. No slow commutes, all targeted training. I did short sessions during the week (1-1.5 hours) and longer session at the weekend (up to 4 hours, but all at modest power). And I felt good for it. The sessions were easy. Apparently Rivaroxaban can cause some athletes to feel more easily fatigued and they thus find it harder to hit their power numbers. It didn’t seem to affect me in that way. By now, I had also slowly learned to accept and embrace my indoor training rather than sulking and being jealous of others setting PBs and winning races outside.
Week 6: During week 6 the turbo sessions would still not exceed 90% of intensity, but the interval period became a bit longer and rest periods a bit shorter. Somehow witnessing my ‘A’ race for 2016 from the side of the road was not as difficult as I had anticipated. Squeezing in a few turbos and supporting others partaking in the 24-hour race still gave a lot of satisfaction.
Week 7: Having reached the half-way point of my medication felt good. Week-day training sessions felt a bit easy this week (power-wise), but instead I was working on getting more comfortable with higher cadence. At the weekend I ‘upped’ the long session from 4 to just over 6 hours, but made sure to take a short break at every whole hour to stretch my legs and walk about a bit. I drank plenty and experimented a bit more with bottles in behind-saddle cages.
I was also scanned for custom-fit compression socks by Isobar, a company that had approached me to become a brand ambassador. It would still be a few weeks for the delivery of the garments, but I was excited by the prospect of being able to wear compression socks that perfectly fit my ligaments and are thoroughly tested to provide the right level of compression in the right places.
I was given an extra boost to stay focused and committed to my solitary indoor training by being used as a case study for an article in Cycling Weekly on mental toughness. Haha – now that is what I call an achievement. Getting a mention in cycling weekly without even pinning a number on my back!
Week 8: I knew that I had done lots of endurance miles in the months before my DVT and that somehow my stamina is naturally always there. So I was happy to adjust my training in the lead up to my first race post DVT medication to more threshold stuff and speed (high intensity) work, thus ‘sharpening’ me up somewhat.
Unfortunately, it had been a bit of a mad week at work, so I ended up having to catch up with all these harder workouts towards the end of the week. Not ideal, but I managed. It actually felt really good to do some shorter harder intervals and reach some more encouraging power numbers. On Sunday I did another longer turbo (5 hours) at lower intensity (but with a little burst at slightly higher power at the end of each hour) and experimented with a few other things to eat on my long races (still not sure if cold boiled new potatoes with a bit of mayonnaise and plenty of salt is really for me).
Week 9: Another busy week, including travel for work, meant a slightly less intense training week. I went back to ‘medium’ efforts and shorter sessions, but also shorter rest periods. I didn’t realise how many hours on the turbo I had clocked up and it was time to replace the chain on my TT bike as a result. Nice to get all equipment sorted before my first race on the road again in September.
A pleasant surprise this week was a telephone interview with the editor from the Mail on Sunday’s YOU Magazine. She had heard about my story and was keen to include it in an autumn edition of the magazine to help spread awareness of DVT and particularly that it is something that can happen to all of us, irrespective of how healthy you are. I hope to update this blog with a link to the publication soon.
At the weekend it was time to stop hiding in the turbo room and instead make time to see friends at a lovely BBQ on Saturday, while Sunday was spent learning some new skills (1-star kayaking course) and enjoying some quality time with Chris.
Week 10: Not a great week for training, in other words, I didn’t get much training in at all. Since I stopped taking the anti-conception pill (because of DVT risk) my periods have been quite irregular and, perhaps partly because of the anticoagulants, they have been a lot heavier too. I could list a lot of reasons why I didn’t do any training (busy at work, other events to attend to, period etc), but ultimately, the honest truth is just that I didn’t feel like it. At the weekend I finally forced myself to get back on the turbo again. I am starting to have a real love-hate relationship with the bloody thing after all these weeks now. I guess it did not come as a surprise that I had to cut my long session short and my legs just felt crap. Oh well… that teaches me.
Week 11: It was nice to do a few threshold and harder efforts this week to get back on top of things, but a funeral and a short break with my mum who was visiting from France meant training got paused again towards the back end of the week. But as they say, a change is as good as a rest and a fresh mind is as important as fresh legs. We went for a few long walks along the coast and had a great sea kayaking trip too. I was quite worried by pain in my left leg over the weekend, but on reflection I think/hope that was from the shock of wearing high heels at the funeral after months of wearing only flat shoes.
Week 12: The final count down! Just a few last sessions on the turbo to keep my legs ticking over. Unfortunately life and work getting in the way of training meant I did not get as much training in as I would have liked to during this last month, but it is what it is and I still have a few months to get fully fit again for my key race in November.
If you are curious to see what exactly I have done training-wise over the last 12 weeks, check out my Strava.
RACE DAY: I took my last Rivaroxaban tablet today (2nd of September) and will compete again this Sunday (4th of September), straight back in at the deep end with a 12-hour time trial… I have little expectations for a good result in the race; just getting back out on the road again will be an achievement.
REFLECTIONS: I still feel a little scared about getting another DVT, but I guess evidence from various other endurance athletes happily resuming their training and taking part in all sorts of long-distance challenges should give me some confidence.
Could I have raced again sooner? Possibly. Each case of DVT is different. According to the guy who did my ultrasound scan at the hospital mine was ‘as good as it gets’ (i.e. a very small blood clot and only in one place in the lower leg).
I was absolutely gutted to miss my key races this year, but I will have all the more motivation to do my utmost best next year to take care of unfinished business. If I succeed in achieving my goals, it will mean even more to me than it would have done this year.
TRAINING WITH DVT DOS AND DON’TS:
- Insist on seeing a thrombosis specialist with experience treating athletes
- Remember that exercise is good (keeping the circulation going). Build in at least one hour of physical activity every day (gentle to start with).
- Have plenty of water and electrolytes within reach (more than you would normally have).
- Get a sweat test to accurately assess your sweat rate and sodium concentration
- Listen to your body; stop as soon as you feel discomfort, particularly if it is only in the leg with the blood clot
- Take ice baths and wear compression socks after training sessions.
- Keep your legs moving whenever you can, even while resting.
- Wear flat shoes. No need to put additional strain on your calves.
- Be patient and embrace indoor training.
- Make the indoor training more fun by treating yourself to some new shoes or ultra-comfy shorts – if you are going to spend a good few weeks/months on the turbo, you may as well be as comfortable as you can be.
- Mix up your turbo training with cross training (be it swimming, light gym work, yoga etc) – it can be THE opportunity to build a super strong core.
- Set yourself a new goal to work towards – perhaps literally display an image of your new goal in front of you on the wall to remind you why you are doing all the turbo training.
- Download a few inspirational podcasts and some big tunes to keep you motivated.
- Keep a diary (not just of your physical training schedule and how your body responded to it, but also keeping track of how you were feeling mentally).
- Talk to others who had DVTs. Sharing is caring and you may learn a few things about how best to approach your recovery. More importantly, talking to others gives hope. All of the cyclists I spoke to who had DVTs in the past, have gone on to do some pretty amazing things in cycling afterwards. Some unfortunately discovered that they carry a gene that means they need to take anticoagulants (mostly warfarin) for life, but manage very well regardless.
- Support others at races and events. You may not be able to partake, but that doesn’t stop you from enjoying the social side of things.
- Avoid prolonged sitting or standing in one position. Scrutinise every element of your life. Not just your exercise. Take the stairs when you can. If you have time, walk rather than taking the bus. Invest (or get your employer to invest) in a vari-desk. You spend enough hours at work as it is. It is worth making sure your employer can continue to benefit from your hard work.
- Take my experience of training with DVT as a guideline for your own situation. Every DVT case is different and I am not a doctor!
- Exercise vigorously during the first 4 weeks
- Overdo it – remember that 1 hour on the turbo can be as much as 1.5 hours on the road
- Push through pain
- Take pain killers (unless you really need them). Your doctor will inform you to avoid aspirin and ibuprofen while on anticoagulants, but I also avoided paracetamol as I wanted to be able to feel the changes in my body (e.g. less pain as medication starts to work or more pain in case I overdid something in training)
- Dwell on what could have been
- Despair that you may never get back to your previous fitness levels again
- Cross your ankles or legs while sitting or lying
- Go for a massage if you have or suspect a DVT – massage can cause the blood clot to break loose and travel to the lungs, potentially causing an embolism.