To Be a Champion of the 24-h Ultramarathon Race. If Not the Heart ... Mosaic Theory?

ensive case analysis aimed to identify the features enabling a runner to achieve championship in 24-h ultramarathon (UM) races. A 36-year-old, multiple medalist of the World Championships in 24-h running, was assessed before, one and 10 days after a 24-h run. Results of his extensive laboratory and cardiological diagnostics with transthoracic echocardiography (TTE) and a one-time cardiopulmonary exercise test (CPET) were analyzed. After 12 h of running (approximately 130 km), the athlete experienced an increasing pain in the right knee. His baseline clinical data were within the normal range. High physical ef ciency in CPET (VO 2max 63 mL/kg/min) was similar to the average achieved by other ultramarathoners who had signi cantly worse results. Thus, we also performed genetic tests and assessed his psychological pro le, body composition, and markers of physical and mental stress (serotonin, cortisol, epinephrine, prolactin, testosterone, and luteinizing hormone). The athlete had a mtDNA haplogroup H (HV0a1 subgroup, belonging to the HV cluster), characteristic of athletes with the highest endurance. Psychological studies have shown high and very high intensity of the properties of individual scales of the tools used mental resilience (62–100% depending on the scale), openness to experience (10th sten), coherence (10th sten), positive perfectionism (100%) and overall hope for success score (10th sten). The athlete himself

belonging to the HV cluster), characteristic of athletes with the highest endurance. Psychological studies have shown high and very high intensity of the properties of individual scales of the tools used mental resilience (62–100% depending on the scale), openness to experience (10th sten), coherence (10th sten), positive perfectionism (100%) and overall hope for success score (10th sten). The athlete himself considers the commitment and mental support of his team to be a signi cant factor of his success. Body composition assessment (%fat 13.9) and the level of stress markers were unremarkable. The tested athlete showed a number of features of the champions of ultramarathon runs, such as: inborn predispositions, mental traits, level of training, and resistance to pain. However, none of these features are reserved exclusively for “champions”. Team support's participation cannot be underestimated. The factors that guarantee the success of this elite 24-h UM runner go far beyond physiological and psychological explanations. Further studies are needed to identify individual elements of the putative “mosaic theory of being a champion”. Int. J. Environ. Res. Public Health2021,18, 2371.

Int. J. Environ. Res. Public Health2021,18, 2371 2 of 24 Keywords: ultramarathon; mental and physical stress markers; VO 2max; polymorphism; psycholog- ical features; pain resistance; body composition; cardiopulmonary exercise test (CPET); team support; winner's gen 1. Introduction Attempts to nd the key to success in each sports discipline date from the beginning of sports competitions [1]. The key to achieving championship results in endurance sports, especially in ultramarathon (UM) runs, seems to be particularly dif cult to identify due to the multifactorial nature of a success [2]. In 24-h and longer running races, in addition to the normal running endurance, the competitors must be resistant to lack of sleep and pain, have special endurance after years of preparation, and maintain a generally good health with resistance to changing weather conditions, infections, and many other factors, as well as support, special commitment, and professionalism of the team. The professionalism of the team should be understood as several behaviors that contribute to the creation of optimal conditions for the runner during the marathon (appropriate temperature and volume of meals served, strict supervision of the runner's service time, ability to motivate, and so on) [3]. According to Jason Koop, a coaching director and the author of “Training Essentials for Ultrarunning”, despite their diverse backgrounds, elite ultrarunners share the follow- ing three common characteristics: (1) talent: all elite ultrarunners (and elite endurance athletes in general) have high genetic potential for aerobic power; (2) toughness: which can be harnessed with focused training; and (3) emotional engagement: the best runners have an emotional attachment to the races they compete in. They perform best when they have a genuine, visceral attraction to a race, the type of attraction that makes them excited, giddy, and apprehensive simultaneously. The best UM runners possess the highest levels of talent, toughness, and emotional engagement. For the rest, the key is to optimize what they have by tapping into and leveraging and developing their own innate talent, toughness, and emotional engagement [4]. In the case of endurance sports, three physi- ological variables such as maximum oxygen consumption (VO2max), workload at lactate (LA)

best UM runners possess the highest levels of talent, toughness, and emotional engagement. For the rest, the key is to optimize what they have by tapping into and leveraging and developing their own innate talent, toughness, and emotional engagement [4]. In the case of endurance sports, three physi- ological variables such as maximum oxygen consumption (VO2max), workload at lactate (LA) threshold (LT), and ef ciency (the amount of oxygen needed to generate a certain running speed) play key roles [5]. However, while the athletes run with approximately 90% VO2maxin a 10-km run [1], this intensity decreases to approximately 75–85% VO2maxas well as their %VO2maxat 42 km (i.e., the marathon distance) [5]. The body's adaptations to training that contribute to high VO2maxvalues include an increased cardiac stroke volume, an increased blood volume, and an increased capillary and mitochondrial density in the trained muscles [6]. In runs shorter than an UM, the most dominant factor is a high stroke volume [7]. Apart from sports training, which has a fundamental impact on the parameters mentioned, genetic predispositions, which until now have not been unequivocally de ned as “champion's genes,” should also be of importance [8]. A fundamental question is the role of genetics in the attainment of world class sta- tus and truly elite athletic performance [9]. Several studies have reported that the key elements of the response to training in sedentary persons are widely variable and have a genetic component [8]. Genetic potential plays a role, and mtDNA variability, in uenc- ing mitochondrial activity, is expected to be of importance. Hence, interest in mtDNA seems justi ed. Assuming that there is a limited set of genes causally related to sports performance, the interdependence of the genetic regulatory networks of the cell and the interactions at higher levels of the organization from cell to organism mean that a large part of heritability may result from genome-wide variability [10]. However, to date, there are no genetic markers identi ed in humans that have been clearly shown to be more frequent in elite endurance athletes [11]. However, the usual psychological, sociological, economic, and cultural factors

the interactions at higher levels of the organization from cell to organism mean that a large part of heritability may result from genome-wide variability [10]. However, to date, there are no genetic markers identi ed in humans that have been clearly shown to be more frequent in elite endurance athletes [11]. However, the usual psychological, sociological, economic, and cultural factors may be much more important than the “genes'” themselves in determining the factors to achieve

Int. J. Environ. Res. Public Health2021,18, 2371 3 of 24 a championship in UM running [12]. For example, Burns et al. investigated Olympic and Paralympic champions who attributed their success to psychological factors [13]. Some models try to explain how environmental conditions, sleep deprivation/mental fatigue, pain-killers or psychostimulants, cognitive or nutritional strategies may affect UM performance [14]. In the ability to run up to 1000 km in one stage, fatigue resistance is critical. Fatigue is generally de ned as strength loss, which is known to be dependent on the type of exercise [14]. The evaluation of neuromuscular function requires measurements of max- imal voluntary contractions and maximal electrical/magnetic stimulations to elucidate the factors affecting the central nervous system and the muscles implicated by fatigue. However, such measurements do not necessarily predict how muscle function may in u- ence ultra-endurance running and whether this has an effect on speed regulation during a real competition. The nature of the relationship between fatigue as measured using maximal contractions/stimulation and submaximal performance limitation/regulation is questionable. Millet et al. suggested a holistic ush model that can be applied to all endurance activities, but this is speci cally adapted to ultra-endurance running [14]. This model had the following four components: the ball-cock, which can be compared with the rate of perceived exertion and the increase or decrease based on it; the lling rate; the water evacuated through the waste pipe; and a security reserve that allows the subject to prevent physiological damage. They suggested that central regulation is not only based on afferent signals arising from the muscles and peripheral organs but also dependent on peripheral fatigue and spinal/supraspinal inhibition (or disfacilitation) since these alterations imply a higher central drive for a given power output [14]. This holistic model further explained how environmental conditions, sleep deprivation/mental fatigue, painkillers or psychos- timulants, and cognitive or nutritional strategies may affect ultra-running performance. In conclusion, the following two phenomena categorize fatigue: the diminution of mus- cular force (the physical aspect that can be measured and compared) and the sensation of fatigue (a psychic aspect that could not be measured).

This holistic model further explained how environmental conditions, sleep deprivation/mental fatigue, painkillers or psychos- timulants, and cognitive or nutritional strategies may affect ultra-running performance. In conclusion, the following two phenomena categorize fatigue: the diminution of mus- cular force (the physical aspect that can be measured and compared) and the sensation of fatigue (a psychic aspect that could not be measured). The performance of elite athletes is likely to defy the types of easy explanations sought by scienti c reductionism and remain an important puzzle for those interested in physiological integration well into the future [9]. Therefore, further research is needed to determine the factors that allow UM runners to achieve championship in a 24-h run. In our previous papers, we analyzed several factors related to physiological and biochemical adaptation to extreme endurance exercise in order to demonstrate that or- ganism of elite, endurance-trained athletes is able to adapt to strenuous long-lasting run (marathon, UM, triathlon) or swimming [15,16]. In some of our previous publications, we used the unique occasion to analyze various aspects of adaptation to 24-h UM in an elite runner, a previous winner of several prestigious international UM during the National Championship in 24-h run [17,18]. The aim of the present study was to analyze several key factors responsible for champion achievements in a 24-h UM race in the same very successful athlete. The analyses comprise body measurements, cardiac morphology and function, cardiopulmonary exercise test, markers of physical and mental stress, genetic factors, and battery of psychological tests. We also included a live story interview and analyzed the role of team support. We were not able to nd in the available scienti c literature a similar comprehensive study describing so many aspects of potential UM performance in a champion ultra-endurance runner. Although we acknowledge that a case study does not allow us to generalize the results obtained, we believe that a thorough investigation of one, but outstanding, athlete makes an important step in the further discussion about ultra-endurance performance, bringing us closer to the relevant answer of the question “What are the key factors of elite performance in

champion ultra-endurance runner. Although we acknowledge that a case study does not allow us to generalize the results obtained, we believe that a thorough investigation of one, but outstanding, athlete makes an important step in the further discussion about ultra-endurance performance, bringing us closer to the relevant answer of the question “What are the key factors of elite performance in 24-h UM run?”.

Int. J. Environ. Res. Public Health2021,18, 2371 4 of 24 2. Materials and Methods 2.1. Sports Biography and Main Achievements In this case study, we evaluated a multi-awarded Polish UM runner (36 years, body height, 1.73 m; body mass, 63 kg; body mass index, 21.05 kg/m 2 ) on the day of a competi- tion. He has a sedentary profession and worked Monday to Friday from 8:00 to 16:00 h and runs regularly for 20 years and approximately 100,000 km in his lifetime. As part of his daily training over the past year, he had run an average of 22 km/day from Monday to Friday and approximately 37 km on Saturdays and Sundays. His activities included swimming, gymnastics, and cross-training in the gym. For many years, he represented Poland in UM races, and his performance over the past several years can be found on his of cial website [19]. This athlete participated in approximately 50 UMs, the longest of which was a 48-h run (362-km crown distance, 24-h UM). He had never been injured or seriously ill. He was one of the most successful UM runners in the world, a two-time Polish champion in the 24-h UM (2017, he ran 258.228 km during the UM), the winner of the Spartathlon in Greece (2016, 246 km), and the runner who set the Polish record for 12-h races in 2014 (145.572 km). He won medals in four 24-h UM World Championships. In 2019, he won the 48-h race in Athens (362 km). Other best personal results: 100 km, 7 min 37 s; marathon: 2 min 42 s; half marathon: 1 min 16 s; 10 km: 35 min 28 s. The top ten UM races are listed in Table. Table 1.Athlete's top 10 races. Athlete's Top 10 Races. Date of the Competition Name of the Competition Distance Time Open Place 9–10 June 2012 Polish Championships in 24-h run (POL) 235.542 km 24 h III 8–9 September 2012 IAU 24-h WC/EC Katowice (POL) 249.809 km 24 h X 19–20 October 2013 Polish Championships in 24-h run (POL) 251.113 km 24 h I 26 April

races. Athlete's Top 10 Races. Date of the Competition Name of the Competition Distance Time Open Place 9–10 June 2012 Polish Championships in 24-h run (POL) 235.542 km 24 h III 8–9 September 2012 IAU 24-h WC/EC Katowice (POL) 249.809 km 24 h X 19–20 October 2013 Polish Championships in 24-h run (POL) 251.113 km 24 h I 26 April 2014 International Rudzki run 12-h (POL) 145.572 km 12 h I 26–27 September 2014 Spartathlon (GRE) 245.3 km 25:49:05 h III 30–31 May 2015 Ultrabalaton 221 km (HUN) 221 km 18:58:32 h II 30 September–1 October 2016 Spartathlon (GRE) 246 km 23:02:23 h I 8–9 April 2017 Polish Championships in 24-h run odz (POL) 256.246 km 24 h I 26–27 May 2018 IAU 24-h EC Timisoara (ROU) 265.419 km 24 h I 18 January 2019 48-h Athens Int. Ultramarathon Festival (GRE) 362.000 km 48 h I At 2 weeks before the start of the 24-h UM, the athlete gradually reduced his training activities until the competition. The competition referred to in this study started at 12:00 h on 8 April 2017. All participants ran on a 2-km loop (exact distance 1.984 km) in a clockwise direction. On one of the straight sections was a tent where an athlete could stop for a meal, a short rest, or basic hygiene. After 12 h, our subject stopped for 12–15 min for a warm meal and to rehydrate, changed his shoes, and used the toilet three times (2–3 min each). The primary goal of the study was the cardiovascular assessment (separate article) [17]. For the rst time at the nish line, our subject experienced pain in the right knee starting after approximately 12 h of running (approximately 130 km) and intensi ed up to the end, thus affecting his performance. Magnetic resonance imaging on the right knee one day after the run showed a general overload and degenerative as well as speci c features associated with “turning to the right” on the run loop (separate article) [18]. These competitions comprised the of cial Polish championships of the 24-h UM. 2.2. Study Protocol Transthoracic

to the end, thus affecting his performance. Magnetic resonance imaging on the right knee one day after the run showed a general overload and degenerative as well as speci c features associated with “turning to the right” on the run loop (separate article) [18]. These competitions comprised the of cial Polish championships of the 24-h UM. 2.2. Study Protocol Transthoracic echocardiography (TTE) and blood tests were performed three times and other tests once (Table).

Analysis of factors contributing to success in 24-h ultramarathon races.