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EPISODE BEGINS 

���ϳԹ��� Podcast Theme: From ���ϳԹ��� Magazine and PRX, this is Sweat Science, stories of human endurance.

Vittoria Bussi: Pain everywhere because the position is not comfortable. You need to be [inaudible].

Peter Frick-Wright (host): This is the ���ϳԹ��� Podcast. I'm Peter Frick-Wright, and on today's episode we're asking some really basic questions about pain.

Bussi: And the saddle is the most painful thing.

Frick-Wright:What is it? Why is it?

Bussi: ...and the muscle of the legs...

Frick-Wright: How do we ignore it? Should we ignore it?

Bussi: Your mind that tells your body stop, because it's something that hurts.

Frick-Wright: This is Italian pro cyclist, Vittoria Bussi, who a few months ago went through something that required her to change her relationship with pain, to stop treating it as an enemy. Started thinking of it as a friend.

In fact, when it comes to endurance sports, the difference between winning and losing, fame and obscurity, is often just how friendly you can get with your pain. This story starts in Vittoria's childhood.

Bussi: Yeah, I'm proud to say that I was born in Rome. Rome is one of the most beautiful city in the world.

Frick-Wright: As a kid in Rome, Vittoria played sports and ran track and field, and she was good at it, but she also had an incredible brain. So when it came time for grad school, she moved to England to get her PhD in mathematics at Oxford. She was going to pursue a life of the mind. But while she was there, in 2011, her father had a stroke.

Bussi: He was in the hospital, like fighting between life and death for one year. And that period I was traveling between Rome and London, like once a week I was back in Rome to visit him.

Frick-Wright: Her father's stroke reorganized her life. Things that were once permanent felt temporary; priorities changed, goals were abandoned. She saw just how quickly your mind can be taken away from you.

By that point Vittoria had begun to casually race bicycles and her talent was obvious, but math has always been our priority. But then, after the stroke, math just didn't seem all that important anymore. It wasn't the profession she wanted to look back on from her deathbed. So she traded a life of the mind for seeing what exactly her body was actually capable of.

Bussi: My father passed away in 2012 and that year of suffering for my family was one of the main reasons to start to make something big in my life. If you have a dream, like start to do it now. So in my mind that was the intention to do something like live, not 100% but 200% every day of my life. Like live for me and my father.

Frick-Wright: In the span of a single year, she went from trying out amateur races to competing in the tour of Flanders, one of the most prestigious and difficult one day races in cycling. And just to be clear, this is not normal. She clearly already had a lot of the skills needed to be a pro cyclist, although it turns out not the bike handling skills.

Bussi: [inaudible]... was so scared and my technical ability and the way I handled the bike in the middle of 200 bikes were really bad.

Frick-Wright: So Vittoria turned her attention to time trials, the race of truth, as they're known. Just you against the clock. And in the world of cycling, there's no more prestigious, no more punishing time trial than the hour; just you by yourself on a track, trying to see how far you can ride in 60 minutes. It's a punishing event. At the time, the women's record was held by American Evelyn Stevens, who in 2016 finished at 47.98 kilometers. Vittoria and her coaches believed she had both the physical and mental prowess to beat that record and she decided she wanted it. Robbie Carver takes the story from here.

Robbie Carver: The hour is one of the most rarefied records in cycling. Very few professionals ever attempt it and even fewer succeed. It was a mortalized by cycling legend Eddy Merckx in 1972, who, after setting a new record, called it the longest hour of his career and refused to ever do it again. When journalist Simon Usburne attempted it, he invokes the most catchy description that “it was like death without dying,” and said it left him feeling like he had aged by 30 years. So when talking about how pain affects him and endurance, there are few better places to look.

But it was about this point in the story that we realized we didn’t have a great understanding of what pain even is.

Alex Hutchinson: People have been arguing about that for about 400 years.

Carver: This is ���ϳԹ��� columnist Alex Hutchinson, who writes about the hour in his book Endure.

Hutchinson: Our intuitive understanding of pain is that you poke yourself in the leg and sensors register that and send a signal to your brain and there you go, you feel pain. And the harder you poke yourself, the more pain you feel.

Carver: For certain kinds of pain, Alex says, that intuitive understanding isn't wrong. Let's say you start to sprint and a searing pain immediately erupts in your hamstring. You have to stop running; in fact you have to stop because your hamstring is no longer attached to your leg, not necessarily because it hurts. That's a lot different than stopping because your legs and lungs feel like they're on fire.

Hutchinson: But what most of us experience in quote unquote normal situations is pain that doesn't force you to stop, it just makes you really want to stop.

Carver: For Alex's money, there's no greater test of your ability to endure this kind of pain than the Hour.

Hutchinson: The Hour is uniquely suited to maximize your pain. And if you think about like a marathon, if you're running a marathon, people always say, Oh, the race really starts after 20 miles. And that's because with a race that long, you have to start out in a pace that feels easy. If you don't feel like, Hey, this is a lark after five miles of a marathon, you're in big trouble because it has to feel easy at the beginning.

In comparison, if you race a mile, then there's no point at which it's going to feel easy. It's going to be painful right from the get go, but it's going to be over in let's say four or five minutes. So it's very painful, but very time limited.

Carver: Between those two types of effort is a boundary. Cyclist’s call it functional threshold power. You may know it as your lactate threshold, but basically. stay across that invisible line for more than a few minutes, and if you can't see the finish line you're done for. You're about to implode. But stay too far below that threshold and you're falling short of your potential. Most endurance sports are about negotiating the percentages between those two types of efforts, but not the Hour, because it turns out that the amount of time you can physiologically stay right on top of that boundary, right at the edge of collapsing, is just about an hour. If, that is, you can handle the pain.

Hutchinson: Physiology aside, what it essentially means is that the Hour is the longest possible race you can compete in that will hurt the whole time.

Carver: On October 6, 2017, Vittoria made her first attempt at the Hour.

Bussi: You start to suffer from the second lap, maybe. because you need to be on pace from the beginning, otherwise you are too far away.

Carver: For the first 40 minutes she was on pace to break Evelyn Stephen's world record of 47.98 kilometers. Her legs hurt, but she was in control. Then a piercing pain began to stab her rips. It wasn't her legs that were screaming for her to stop. It was her lungs.

Bussi: It's the worst pain ever in the hour, it’s the ‘die from’ pain.

Carver: Vittoria’s position on the bike was extremely aerodynamic, but that also meant she was bent over in an awkward scrunched posture.

Bussi: Because all the body’s contracted, there is not room for the diaphragm to let you breathe in a normal way. So when you cannot breathe anymore, you cannot like push.

Carver: She tried to ignore the pain, tried to push through. and she refused to give up, but fighting her lungs sapped her energy. And at 48 minutes, her pace dropped. She only slowed down by a second per lap, but it was enough. After 60 minutes in the most brutal pain cave she'd ever experienced, she came up 404 meters short, less than two laps around the village room. She had failed.

But Vittoria had promised herself and the memory of her father that she wouldn't feel so. She caught her breath and started training again.

Vittoria had the fitness to break the record, but it was the pain that got in her way. And that raises the question, one scientists have only recently begun to take seriously. When it comes to endurance, what is pain for?

If you remember from our first episode, when your muscles contract, they release metabolites and nerve endings and your muscles are paying very close attention to when those metabolites increase. In a very rudimentary sense, you can think of these nerves as the CO2 monitor in your house. As long as levels stay below a certain amount, everything is fine, but as those levels start building, the nerves send an alarm to the brain; ‘Ow!’ basically. And just as that CO2 alarm goes off, well before you're dead, your muscles are nowhere near failure when your brain starts getting pain signals. But what if you could turn those sensors off completely? If you felt no pain, you'd never slowed down, right?

Hutchinson: Yeah. I mean that's the dream, isn't it? Wouldn't it be nice to be able to cycle without feeling any pain and just sort of see what your body can actually do? And there have been a series of studies that try and investigate basically this picture using fentanyl injected into the spine to block the nerve signals from your legs back to your brain.

Carver: This study that Alex is talking about was done by Dr. Markus Amann at the University of Utah.

Markus Amann: We’ve done studies in the lab where we have...

Carver: We've talked to him before in this series. Anyway, Dr. Amanm had fit amateur cyclists do a 5k time trial as hard as they could and what he found is that over those five kilometers, cyclist power output would start out relatively high, then come down in the middle, then go back up at the end up.

Amann: It's kind of like the final sprint, if you will.

Carver: What Dr. Amann found was that this pattern, and the time it took each subject to complete the time trial, was remarkably consistent. What he wanted to know was why that slump in the middle? Clearly they had more to give at the end, so why couldn't they push just a little bit more and go a little bit faster?

Amann: We didn't know that. What regulates it? Why don't they push hard at this point?

Carver: So to find out, Dr. Amann injected the drug fentanyl into the subject's spine. If you think of your nerves as a phone line, fentanyl basically puts the muscle side of the conversation on mute. And this is fascinating, because what that means is that the brain never gets the information that those metabolites are building up, never hears those alarms, but it can still give the command to the muscles to go as hard as possible. All of a sudden there's no Scotty in the engine room warning that you can't take much more of this, captain.

Amann: What we saw was just amazing. So people started out flying,  the power up went through the roof right at the beginning and they were just cruising along at a gear they never thought they would be able to push. Until about to the halfway point. At this point, all of a sudden the very high power output there dropped and the power output in the second half of the race was actually much lower compared to the control trial where they did it with an intact neural feedback system.

Carver: He's saying that without the sensation of pain, they started out writing riding than they'd ever ridden before, but in the end produced times almost identical to their previous effort.

Amann: The reason why the second half is slower is because despite this high drive from the brain to the muscle, the muscle is simply so tired that it cannot respond anymore, or to a much  lesser degree. They still pushed very, very hard, much harder than they do under control conditions, but the muscle just could not respond anymore.

Carver: No gain in performance, and yet they basically blew their muscles off their legs.

Amann: The interesting thing in this case was at the end, many of them were so tired they could not get out of their click pals. And once we got them off the bike and put them on the ground, I want to say, more than half just like fell down. We had to catch them to prevent it.

Carver: It turns out when you block pain, it's not just that your brain can't hear your leg say ouch, it also can't hear them say what they need to keep going. So you're driving them past their limit while also not sending the oxygen and fuel they need to work. So without pain to guide us, we don't know where the line is between a blowout performance and a blow up.

Hutchinson: So you know what's happening here -- one interpretation of that is that you need pain to pace yourself properly. Otherwise you actually slam into the real limits of your muscles. You reach the point where your muscles really aren't working properly. And so pain isn't just a sort of negative thing that slows you down. It's also what tells you when you're getting too close to the flame and exactly how to just cook it at the right heat that you can maintain all the way to the finish.

Carver: So pain isn't a hard stop; it's a warning light and it can tell you just how much more you have to give. But in order to push yourself right to the edge and stay there, you have to learn to embrace the pain. You have to learn how to suffer. And as Vittoria trained for her second attempt at the hour, learning how to suffer was terrifying.

Bussi: Every day I woke up in the morning like really scared going to the truck, the first lap. You try to convince yourself you're ready, but actually you are never ready enough because your body, your mind, tell you like to protect yourself. Don't do that because it's suffering. So just quit as soon as possible. But if you really believe that at the end of the day you can do that, then you're able to push lap by lap and the time go on. When you finish you’re happy, you're tired, but you're happy. And then you go to bed, you rest and the day after you wake up and then you have again the same, you're scared, you don't feel ready. So I remember this process like every day for all these years.

Carver: she suffered for a year in training and worked with a physical therapist to learn how to breathe without pain in her aerodynamic position. By the next summer, she was ready. Her form on the bike was good and she was in perfect condition. So she packed her bags and traveled with her team to a velodrome in Aguascalientes, México.

A number of velodrome records have been set at this track in Mexico. At 6,100 feet, it has the perfect combination of temperature and elevation to reduce aerodynamic drag. This is because the higher you are the thinner the air, so the easier it is to push through. Providing your body can adapt to less oxygen. Hot air is also less dense than cold air, but you don't want to overheat. So you want a warm day, but not a scorcher; the kind of perfectly warm day common this time of year in Aguascalientes. Unfortunately, September 12th, 2018, Vitoria second attempt at the hour record wasn't warm at all.

Bussi: So I was really unlucky that day because the night before there was a storm in Aguascalientes. The temperature were really low, like 10 degree lower than expected.

Carver: Vittoria decided to save her effort for the next day. So when she headed to the track, it was just to train. But then all of a sudden the sun came out, temperatures rose. And at the last minute she and her coach decided to go for the record.

Bussi: I have to say, my mind was completely out of focus, you know, not really focused anymore because I was there just for training and then had to prepare suddenly because of the temperature. For the hour, you cannot prepare like that. But anyway, I decided to go, and my legs were strong that day, I was really like strong. I felt strong, but I wasn't never in the right pace.

Carver: As strong as her legs felt, Vittoria couldn't focus. Her mind couldn't reach that place where she was embracing the pain, feeding off of it, which meant she couldn't reach the pace necessary to break the record. She was falling behind.

Bussi: My legs couldn't receive what I was telling to my mind to push more. So I was kind of lazy. I don't know how to say, but I was like not prepared to suffer enough. So I was there, but not enough. And then up at the end of the 45 minutes, I decided to quit. Let me say that honestly, I was crying so much that night because when I decided to stop, the adrenaline was really high and I really didn't realize what was my decision.

Carver: She'd reserved the track for two days. She just wasted the first day with 45 minutes at near world record pace. So her legs were trashed and her mind was devastated.

Bussi: I felt like stupid, I have to say. And I started to cry and I felt weak.

Carver: Despite feeling weak, Vittoria is obviously tough. Like all professional athletes, she knows how to suffer, but that does beg a kind of chicken vers egg question. Are top athletes so good because they're better at suffering? Or do they learn to suffer because they're top athletes? Or, put another way, can you learn to suffer?

We were not the first people to ponder this there.

Hutchinson: There's a sort of famous pioneering study that was back in the early 1980s with a bunch of Scottish national team swimmers where they tested their pain tolerance by basically putting a blood pressure cuff around their arm to cut off all blood circulation and then making them clench and unclench their fist.

Frick-Wright: All right, so I'm going to start counting one, two, three...

Hutchinson: Until they couldn't handle it, which is very painful.

Carver: Obviously when we heard this, Pete and I had to try it, so we got a blood pressure cuff and recreated the experiment, clenching and unclenching our fist without any blood circulation in our arms.

(to Frick-Wright) Okay. I'm first now feeling a tinge of pain…

(voiceover) The researchers also had amateur swimmers and non-athletes do the test. And the first thing they found in this situation was that everybody's pain threshold, meaning the point at which we started noticing that something hurts, is about the same.

(Carver and Frick-Wright doing pain experiment in the background)

Hutchinson: After about 50 times when they were clenching and unclenching their fists, all three groups, the elite swimmers, the good swimmers, and the non athletes were like, yeah, that hurts. But there was a huge difference in how much they were willing to tolerate. The non athletes gave up after 70. So not long after it started to hurt. They're like, I don't want to do this anymore. The good swimmers lasted about 90 contractions. So they were better at tolerating pain. And the national team swimmers had like 138 contractions. A huge difference after it started to feel painful in how much they were willing to suffer.

Carver: So good athletes aren't wired differently than the rest of us. They don't feel less pain. It's just that they're willing to sit there and be in pain for longer. And it turns out this tolerance is trainable. Further studies have shown that the amount of pain you're willing to tolerate changes based on what phase of training you're in. Those swimmers from the study, they gave up earliest when tested during their off season, and held out the longest when tested during their period of heaviest competition. Another study showed that how you train matters too. When two different groups were trained to the same level of fitness using different methods, the group that trained with high intensity intervals scored higher on pain tests and performed better in time trials than the group that was trained with low intensity. The only way to learn to withstand the pain then is to be in pain over and over.

Bussi: You think, Oh I did everything in the right way and it didn't go at all like I was hoping.

Carver: The night after her failed attempt, Vittoria wasn't sure she would be able to try again. With tired legs, she wondered, did she even have a chance of breaking the record? But she got a massage and did some stretching. Went out to dinner with her boyfriend.

Bussi: And I'm not proud of that, but I ate a pizza for dinner. I was like so bored of rice, chicken, proper like healthy food, and pizza in Mexico is not a nice experience for an Italian. (laughs)

Carver: When Vittoria was training, she had met with Graham Aubrey, who in 1993 broke the men's hour record after failing the day before. Vittoria thought about this encounter when she woke up the next day. After being introduced, Graham had asked her flat out, are you ready to die for the record? He was speaking metaphorically, but he wasn't joking.

Bussi: So I focused on -- that day was my last day to do something big in my life. I focus on all the motivation I had at the beginning,  of the death of my father,  all the sacrifice I did. And that day was really like the last day of my life.

Carver: Her legs were heavy with fatigue, but her mind was back where it needed to be. This was her last chance to pull off a world record. So at 3:30 in the afternoon, she got on her bike, stomped on her pants and set off for an hour of pain. (time trial biking noises in the background)

Bussi: I can tell you I was scared. At the start, I was really feeling the fatigue of the day before.

Carver: And then right on schedule it started to hurt.

Kevin Alschuler:I'm quite interested in this question of pain.

Carver: This is Dr. Kevin Alschuler, a psychologist at the University of Washington who specializes in pain. Dr. Alschuler's main work is with chronic pain, but recently he became interested in the pain athletes feel during their long endurance efforts. He wanted to know why, despite being an obvious pain, do people keep going? And why do others decide to stop?

Alschuler: What kind of factors can both get in the way of performance as well as what factors can enhance performance?

Carver:And so he and his team traveled to the Sahara, Gobi, and Atacama deserts to interview ultra runners competing in the 4 Deserts ultramarathon. It's a race that over a period of three days per desert covers 155 miles in each.

Alschuler: Each day after their stage, they filled out the questionnaire about  how much pain they felt, how much they felt the pain got in the way, and how they coped with that pain.

Carver: Dr. Alschuler was interested in the psychology of pain, how athletes think about it. And part of what he found makes intuitive sense: the more defeating your thoughts are about the pain, what Dr. Alschuler would call maladaptive language, the more likely that pain was to inhibit your performance. Thoughts like, ‘this hurts too much,’ ‘this pain will never end,’ or ‘I can't keep going if it stays like this’ -- those are maladaptive thoughts. What's more, based on how much of these thoughts runners used, Dr. Alschuler was able to predict how likely they were to drop out of the race.

Alschuler: And so what we found is kind of this parallel to the perceived impact in that those maladaptive responses not only harm how we feel we're doing in our management of the pain, but they actually have an objective impact on the ability to meet the primary goal of the event for most people, which is to complete the race.

Carver: But perhaps even more fascinating was what they found out about the role of adaptive thoughts, which is when you speak directly to the pain in a positive way, saying things like, ‘you can't stop me,’ or ‘pain is just weakness leaving the body.’ While those kinds of thoughts don't impair you, it turns out they don't do a darn thing for you either.

Alschuler: It didn't matter how much they're helpful strategies were varying. So there's kind of this idea of you can make it worse by getting in your own way. You can make it better by getting out of your way, but we otherwise didn't really see a need to focus on the pain through using helpful strategies.

Carver: Dr. Alschuler says, imagine a smoke alarm is going off in the office building where you work. Your work, that's your athletic performance; that alarm, that's your pain. You know there's no fire, but you also can't turn off the alarm. A maladaptive approach would be to run out of the building right away, just to get away from the noise. But an adaptive approach isn't much better. It's the equivalent of standing under the alarm and yelling at it to stop. Sure, you're still in the building, but you're not getting any work done. What Dr. Alschuler's studies shows, is that the best thing to do is stay at your desk, except that the alarm is blaring, put in some headphones and get back to work.

Alschuler: It can just be there and it can just be a thing. Just like breathing heart as a thing or muscle fatigue is a thing, or I'm running in the rain as a thing, right? It's just one part of the experience. And so it becomes an observation, right? What I'm doing hurts.

Carver: You acknowledge the feeling and then move on to something else. But when you're attempting the Hour, there's nothing to move on to. The rules of the Hour record are designed to deny you distractions. There's no cycling computers or heart rate monitors to gauge your effort and no lap counters to keep track of how far you've gone.

Hutchinson: And the whole construct of the Hour record, it's organized so that there is nothing to do except focus on how incredibly bad you feel and how incredibly painful it is. You're just riding round and round this tiny little track and you have to rely -- you have to just kind of live in your own head for an hour and it's going to be excruciating.

Carver: For the first 20 minutes, the fatigue from the day before was so much that Vittoria could only talk directly to it, using what Dr. alschuler called adaptive language.

Bussi: The first 20 minutes, I was like just focusing on don’t feel the pain of the legs because they were painful from the day before.

Carver: But as Vittoria circled the track, she began to pull on stronger mental strategies, ones that didn't try to fight the pain, but instead ignore it by filling her mind with distractions. She sang along to the music blaring on the speakers.

Bussi: It’s really not good music, it’s like disco music.

Carver: She counted laps.

Bussi: I counted around the 64 laps. It's weird, but you have to think about everything except that you are riding. If you think you are riding and you realize that you have to ride for the hour, it's just stressful. So you think about everything like, but not riding.

Carver: She compared how she was feeling to her training, remembering days that felt far worse.

Bussi: So I just said to myself, let's go through this bad day. I said,  I’m used to that.

Carver: And she focused on why she was here at all suffering so intensely. She wanted to do something big, in honor of her father.

Bussi: Sometimes I shouted his name during the ride, just to ask for help, for motivation, for everything that we were riding into on the bike, not just me.

Carver: Because of this and because of her failure of the previous day, the pain itself felt different this time. In her first attempt in 2017, pain had told her to stop, to give up. She ignored it and then fought it as best she could, but ultimately succumbed to it. And the day before, she hadn't even been able to convince her legs to go to that super painful place. But this time pain meant speed. Pain meant a world record and having done something big with her life/

Bussi: This fatigue is good because we are trying to break a world record. So if you feel the fatigue, it’s not something you have to be scared, it's not something that suggests you to quit, but it's something that you have to love.

Carver: Most of the time, the last 20 minutes are the hardest part of the hour. But this time as the clock wound down, Vittoria sped up. She flew around the track, finishing the hour at 48 kilometers, seven meters, a new world record.

Bussi: I was like pushing harder and harder. I didn't feel anymore the pain. Actually it's weird to say, but we are enjoying that last 20 minutes.

Carver: So pain is not just metabolites in your muscles or your brain interpreting nerve signals, it's also your relationship to those feelings. Focus on them and it overwhelms your experience, but accept them, incorporate them into the larger context of your effort in your life, and the pain doesn't just get farther away. It can actually become sort of beautiful.

Bussi: It’s not masochism. It's that you are in the mental attitude that you don't feel that pain. You just feel that you are going to reach your dream. So you're like leaving that 20 minutes and you won’t remember those 20 minutes for the rest of your life.

Frick-Wright: That's Robbie Carver. He wrote, produced and composed the music in this piece. It was edited by me, Peter Frick-Wright.  Thanks to Patty Torchira for setting up an interview in Italy. It was brought to you by Saris . Find out more about their Ride On for World Bicycle Relief at worldbicyclerelief.org. The ���ϳԹ��� Podcast is a production of ���ϳԹ��� Magazine and PRX. We're taking a break through the rest of the year. We'll be back in 2019 with more Sweat Science.