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Development Team Member
Posts: 65
I have an endurance triathlete (we'll call him "Jeff") that has been training with Moxy for a number of months now and we have determined that his mostly well rested normal Moxy SmO2 is in the mid 70's.  His limiter is respiratory, weak diaphragm.  He works with the Spirotiger (not often enough) but does work with the diaphragmatic breathing during each workout and finds the 30 second interval intensity workout very effective in targeting and fatiguing his diaphragm.  

Wed Feb 18 he did an intensity workout, stopping when he could not recover to highest SmO2.  (note time 1:15 to 1:32) is him walking around prepping his bike etc.) Intensity Feb 18 2015.PNG   
His diaphragm was completely exhausted by the end and he felt it through the evening.
The following day he attempted an easy 45 min run but SmO2 would not go above 60 so he brought it to a walk where it went to the high 60's and then he aborted at 30 minutes.

Friday scheduled day off.

Saturday he did a scheduled long (2 hour) Computrainer ride with highest SmO2 achievable. 

Long Bike Ride Feb 21 2015.PNG  He was able to ride with increasing watts as the ride progressed.

Followed by a long run on Sunday of 90 minutes.  Outside, very poor footing.
Long Run Feb 22 2015.PNG 
Monday he did a recovery ride of 60 minutes, highest SmO2 achievable. (note dips in his SmO2 are from him getting out of the tribars and sitting up).
Recovery ride Monday Feb 23.PNG 
My question is: during this recovery ride he was able to see SmO2 values mid 80's to 90 which is very high for him.  Is this the result of plasma expansion?

Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
Sandy  woww  great  information  and a great help  for sure  for many to look at closer in  integration  of  moxy into endurance sport. No  the feed backs  are again no critic   but just  another  view on what   we can try  when using MOXY  as great as  Sandy is doing it.

1. To understand  more on the total involvement of the  athletes physiology  it is nice  to have  some additional bio markers handy.
- That is HR  as it  could give a  certain answer  to your question.
 HR  as in resting HR in the morning   and HR as in resting HR  in standing  and   HR  as in resting HR  before the workout. Easy  to do  as most have anyway a HR monitor.
 Some coaches  may like to have as well HRV
Note: HRV  can be used  to  have some feedback on the cardiac  recovery  as it is mostly used,
  but it has as well some  feedback on respiratory  recovery. ( More later if people are interested. )

 Now    resting back position HR  and  standing resting HR  can give a simple , easy feedback on the question of  plasma  volume expansion. We  used this short on Evans  interesting middle distance  runner. In very simple  words.
 Plasma  volume loss can create a  higher  resting  HR  in back position and a  very  much bigger    orthostatic  reaction and therefor  a very high  standing resting HR. So much harder  for the  cardiac system  to work with a  lower    preload  and a   lower SV therefor.

 Plasma  volume expansion   results in a   clear lower  resting back position HR and  as well in a lower  standing resting  HR. Much  nicer  preload  and  therefor much  higher  or bigger SV

 We have than one more  simple  direction  low  resting back position HR  due to plasma  expansion but than  still a  very high  standing resting HR . ??? what is that  for  a potential reason. ?

 -Now  second  easy but not always accurate  bio feedback  can be respiration frequency.
 How   to assess,  Simply count  and use  RPM  or steps  as a  guide line. 
- Last on the bike :  use  wattage  as performance  and if you do not have  on an indoor  bike trainer with wattage you can use speed or   levels like on an  elliptical trainer  as long you are pretty sure the same level is  the same performance.
 We need wattage  and performance  to understand better the potential reasons of the change in tHb  and SmO2  as well.
 Yes we can guide  with SmO2  and tHB   for workouts ,  but  we  as well  can use wattage  to see, why  my  SmO2  may be higher or lower  and this together with tHb.
Example .
 200 watt  your  SmO2  based on a TIP is  just in the  STEI. So you have  a  stable  SmO2 level ,but slightly lower than the highest SmO2  you   had   at the end  of the ARI.
 Now  you    warm up and you see by 200 watt a  dropping SmO2 level . ????? So 200 watt today is not STEI intensity
 Now  scenario  that  by 20o watt  you actually  have a  higher  SmO2  than usual   but you feel it is hard  to work    and HR is higher than usual  and your RF is much  faster  than usual. Your limitation is ???
 Now  MOXY  and plasma  volume  ??
 A  high SmO2     does  not  give you a feedback  on   plasma volume expansion.
 In fact that is the weak part of  NIRS . We  do NOT have  really a  volume  feedback directly  . ( yes some will tell we  can  calculate   ( metric ) this but   not very practical applicable.
  BUT  yes  we  can use MOXY   with some  small  habits  to see, whether  volume expansion worked.
 We  can use tHb    and performance  and HR  as a feedback. I  have some intriguing workouts from some athletes and I will see, whether they allow  me to share it , otherwise  I have  many more but not that clear  as in this cases , where we  actually  planned  plasma volume  expansion..
. Here in words.
Lets' take our  200 watt example.
- tHb  by  100 watt low  due to low  CO  and  initial overrule  of  muscle contraction tension.
 125 watt   increase in tHb  due to higher CO  and minimal higher contraction fore ( better  coordination now  and   better  recruitment pattern.
 150 watt  again increase in tHb  same reason and  better CO.
 175 watt  highest tHb  for the moment. 200 watt    slightly drop of tHb  due to  higher  muscle contraction force  and  CO is overruled   as well due to  reaching vascularisation limitation.
 Now  after a plasma  volume expansion we  see that by 200 watt  tHB  is the highest compared  to    before  due to  a higher  CO  and now CO  can  overrule the muscle  contraction tension.
 - HR :   how would HR look in this  example. ?

 - RF  why  would  RF  react  like it   will do.
 But  - Smo2 can react very different. Think  what   RF may create     if 200 watt  is now  easier to push  due to the plasma  expansion. Do not think numbers  think trends.
 I am not confident that  we can  see plasma  expansion  by just looking  at SmO2  values. A higher SmO2  value    just tells us  that we have a high %  of  Hb loaded and hope fully because  we  deliver  a lot more  ( could be due  to a great CO.   and we do not use it yet. (  better performance by the same  load.  but  it as well could be not optimal  as  we may  not be able to release O2 or utilize  O2.
 When you combine  performance  and HR  , RF  and MOXY  and  last but  not least the  clients  feeling you will have the feedback  on good feeling great performance.
 The rest is assumption  due to plasma  expansion. again  HR  as explained  can give you some better  feedback  so less assumption more  reality and if you  use tHb  as a trend  as  explained you know  for sure.
 Than you repeat  and see, whether it is repeatable .
Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
Nice feedback on this  one  and it  shows me that more and more  readers  start looking  at  physiological reactions besides  actual performance. Here in short  the feedback:
 The tHb  reactions  as explained  above  could as well mean a  improvement of  CO  over SV.
 Absolutely  true  and  in fact  plasma  expansion is a  kind of  an improvement of SV  but only short term.
  So here  the interesting part on that feedback.
 It is a  greta example  of   functional reaction versus  structural adaptation.
  SV increase over plasma  volume expansion is a functional  reaction. It is  an ability of the   body to react on a stress full event  with  a fats   and  efficient increase on   plasma  volume  to support  and compensate    for  or with the cardiac system.
  A  SV increase over  a structural change  will show up with the same result  but will be repeatable  over a  longer  time . A  functional plasma  volume  reaction is  a  short time     help  and   will be gone  after a  few days  for sure. Where as  a SV  as a structural change will stay  and will be repeatable over the next  few  weeks  with each  workout  or tip. it IS SUPPORTED  WITH A RESTING hr  WHICH DROPS  SLOW  BUT STEAYD OVER WEEKS  VERSUSU  A  SURPRISINGE   5  +  DROP OF RESTING hr OVER NIGHT.
 here  The  CIRCLE  OF  FUNCTIONAL  AND Structural    Reactions  From A PRESENTATION   I DID MANY Years back in Spain.

F  and S.jpg


Development Team Member
Posts: 264
I would like to add a personal experience quite similar to what has been reported here.
The graph below is a comparison of two TIPs performed, one mid January (light green SmO2 and orange HR), last one few days ago (dark green SmO2 and red HR) after a week with few high intensity workouts and one rest day before the TIP.
The trend is  similar to what has been reported for the tri-athlete.
In this case, the wattage was the same on the 2 TIPs, SmO2 was much higher despite a lower HR.
RPE was also better (less perceived exertion).
I would go as well for a short term adaptation (plasma volume increase). tip_comparison.png 

Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
Woow  great feedback  and    as well great   observation  and yes it is something we see in both cases    functional and structural  and I will try  to set some  feedback up on  how  we  can  nicely   follow this trend s and see, when we  change  from a  functional  reaction to an actual  structural adaptation. This than  is  from us considered a  physiological periodization.
When I  was reviewing my answer  to Sandy  I was not really happy lot's of  talk  little substance.
 So I was searching in my   mess  for some    studies  I  could recall on  SmO2    reactions in connection with the opposite of   plasma  expansion   but rather  a fast drop in plasma  volume  due to some  action. So this  would    gives  us some connection to what we see in SmO2  trends  and SV  as when SmO2   would drop  and SV  would drop  due to hypovolamia  we  could expect the opposite. So here  much better  feedback.

Noninvasively determined muscle oxygen saturation is an early indicator of central hypovolemia in humans

Babs R. Soller,1 Ye Yang,1 Olusola O. Soyemi,1 Kathy L. Ryan,2 Caroline A. Rickards,2 J. Matthias Walz,1 Stephen O. Heard,1 and Victor A. Convertino2

1Department of Anesthesiology, University of Massachusetts Medical School, Worcester, Massachusetts; and 2U. S. Army Institute of Surgical Research, Fort Sam Houston, Texas

Submitted 5 June 2007 ; accepted in final form 13 November 2007


Ten healthy human volunteers were subjected to progressive lower body negative pressure (LBNP) to the onset of cardiovascular collapse to compare the response of noninvasively determined skin and fat corrected deep muscle oxygen saturation (SmO2) and pH to standard hemodynamic parameters for early detection of imminent hemodynamic instability. Muscle SmO2 and pH were determined with a novel near infrared spectroscopic (NIRS) technique. Heart rate (HR) was measured continuously via ECG, and arterial blood pressure (BP) and stroke volume (SV) were obtained noninvasively via Finometer and impedance cardiography on a beat-to-beat basis. SmO2 and SV were significantly decreased during the first LBNP level (–15 mmHg), whereas HR and BP were late indicators of impending cardiovascular collapse. SmO2 declined in parallel with SV and inversely with total peripheral resistance, suggesting, in this model, that SmO2 is an early indicator of a reduction in oxygen delivery through vasoconstriction. Muscle pH decreased later, suggesting an imbalance between delivery and demand. Spectroscopic determination of SmO2 is noninvasive and continuous, providing an early indication of impending cardiovascular collapse resulting from progressive reduction in central blood volume.


Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
Daniele  do you have the csv  and  it would be fun to see the tHb  reactions in timing when t it  starts  dropping. In  many cases, when we have a  higher SV  than the drop   is  some steps later  as the CO  can longer overrule the   muscle contraction. ?

Development Team Member
Posts: 279
Hi guys. Just a question. Why are you thinking about plasma expansion and not enhancements on the mitochondrial side or any other adaptations that might exist? What are the key things in this instance which drive you to the direction of plasma expansion? Is there like something if you see this and this and this and this than it might be this.

Development Team Member
Posts: 264
@Juerg, I've attached the xls of the last tip.

@Ruud: the reasons why I am thinking to a plasma expansion phenomenon:
SmO2 is much higher than last time so Delivery is more than Utilization. If it was a mithocondrial enhancement I would have expected a lower SmO2. 
Lower resting HR (approx 5 bpm)
Since the "training intervention" was quite limited on time, it is difficult to have structural adaptation which instead I hope to see in the medium term.

Attached Files
xlsx tip515_20150219.xlsx (199.98 KB, 18 views)

Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
Ruud  good points    and yes   there are  always this additional questions  and   it is  fun to see, what  we  have   on  answers    which leads  us  more likely to one , than the other  possible options.

 Increase in mitochondria  density  would most likely increase   O2   storage  ability as we may have a higher  Mb    level. So  if we have a regular  SmO2  resting values  we  collect over  a few month we   may see a change in this  direction , like we  may see a change in resting HR over time.
 As  Daniele  points  out. Plasma volume  expansion is  a   functional reaction  and as  such we  would have  functional   reaction response. Most likely the  easiest  one  we all can assess is resting HR.
 If  we  do an artificial plasma expansion ,we have a very fast  Resting HR respond   and as well a  very fast  SV  respond.
 So  when you collect RH  regular over a certain  time  and you have  55 +- 2  beats on a    big number of data collections   and you now suddenly have 50 _  you know that there was a change. Again  at rest  we  can somewhat use  statistical numbers.
Let's take 5 L  as   " average "  CO ( cardiac out put. . So  5 L  and  55 HR    would end  up with a  +- SV  of 90 ml

 Now we suddenly  over night have a  50  RH  so we end up with a  100 ml  SV.
 If this  situation is  gone  after  1 - 3 days    and we are back  to 55+-  we have  a   feedback after the fact of a  plasma  volume  expansion.  Now  to the  potential  mitochondria  density change.
 This is a very interesting ongoing discussion  and every about 15 years it  flairs  up.
 The question  of  LSD  ( long slow  endurance  workouts  or base training  versus HIT High intensity intervals.
 I like to use  a great summary  from the following   website.( see below) about  two  famous  coaches  of  rats
 What both show  that they are both right in their  own   area. and  what we have here is a great example  of a functional reaction   ( meaning survival  idea  so I have to react   as fast as possible with what I have and  can change fast )  and a  structural adaptation  where I have  to survive and   adjust as the ongoing  stress  will stay there  for   a long time  and I can't afford  to push  always   at my max  so I have to increase structure  so that by the same given performance I may drop back to 80 %  of  may   all out   stress level.  Plasma  volume is a   functional  reaction.  
Yes we could have  short term a  functional  mitochondria  reaction  which would end up with a better  utilization  and lower SmO2  values.
 In both cases the functional reaction will disappear in a short  time.  Structural reaction  for  a plasma  expansion would be  an actual increase in SV  , Structural reaction on mitochondria   density   take much longer  as you first have to    build   a better vasuclarisation  before you  start   increasing mitochondrial  density. This than creates a very nice picture  when using MOXY / NIRS in   endurance sport.
 There are  some fascinating fundamental studies  done    and I will try to dig them out , where they show, that before we  actual  see mitochondria density improvement  we  first need a  vascular bed  to actually deliver  what the mitochondria need   -  O2.

Mitochondria Adaptations

As a solution to the problem of inadequate aerobic metabolism, Hadd provides a training prescription supported by two research studies – a 1960s study by John Holloszy and a 1982 study by Gary Dudley. Using these studies, especially the study by Dudley, Hadd promotes the idea that training at very specific intensity levels will cause an increase in mitochondria density and an increase in aerobic metabolism.

“Way back in the late 1960s a professor called John Holloszy got some rats to run on a treadmill for various lengths of time up to 2hrs per day at around 50-75% of the rats’ VO2peak (easy running, therefore). After 12 weeks, he found that the rats had increased the mitochondria (vital for aerobic energy production) in their running muscles (compared to control rats that did no training). This was a seminal piece of work, because it explained why runners get better with training.”

“The next question was logical. How long should people run for to optimally cause this effect?

Back to Holloszy and his fellow researchers who formed 4 groups of rats to train: one group running 10mins/day, a second running 30mins/day, a third running 60mins and a fourth running 2hrs/day. All at the same easy 50-60% VO2peak, and for 5 days/week for 13 weeks.

Perhaps logically, the 2hr-group had the greatest increase in mitochondria at the end of the training period.”

“But what about intensity? Were mitochondria only created while running long and slow?

In 1982, a guy called Gary Dudley decided to explore this question. He had several groups of rats training five days/week (but only for 8 weeks). Like Holloszy, he also used a range of different training durations, from 5-90 mins per day. However UNLIKE Holloszy (whose rats all trained at the same pace) he also used a range of training intensities. Dudley’s rats trained at either 100%, 85%, 70%, 50% or 40% VO2peak. He also examined how different intensities and different durations affected different muscle types (fast twitch white, fast twitch red or “intermediate”, and slow twitch).”

“…the best way to cause improvements in slow-twitch fibers was to run long and slow at 70% VO2peak (adaptation began from as low as 50% VO2peak pace). Faster was not better. Although Dudley found that 90 mins was not better than 60 mins, Holloszy had shown that 2hrs was definitely better than one…”
  And  teh discussion will go on. BUT now  you can make a TIP  and assess   for yourself  what  your training idea  may have changed in limiter  and compenator.

Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
Well I expected it  and  yes  I got some  feedback question  to  explain  how we looked   some years back on plasma  expansion.
 One of the goals was to  find  an easy way  for us  to see, whether  certain tHb reactions  would   give some  trends  , whether a plasma  expansion workout was successful and  more important the timing , when  it is most effective  and how long  the  functional effect would  be available.

 Let's  make a  small summary  as it would fill up  along forum  and we talk here about  use of NIRS in different sports  and for different activities.

 For  coaches  looking  for a feedback on the  trends  we see   with MOXY  you again have to have some baseline  assessment information's. We  suggest a  set of  at least 10 - 15  TIP's like assessment  and we    collect this data  in each workout  as it is a part of a  " warm up " or better formulated   preparation for the upcoming  workout. I will in our  story telling section  show   from a  specific  sport how we do this  and like to leave  cycling out  for the moment in this section  as it is   discussed   often  in this  sport.
 1. Plasma  volume  for a  base  coach  with minimal access to  lab   technology  . You can use a Hct  point of  care   equipment. It is a very common equipment in many sports  and many top athletes  actually have their own  one. One of the more popular  once  is the hemocue but there  are cheaper once out there. As  usual the discussion is  on validation  and accuracy. For plasma  volume  expansion trends  it  does not has  to be accurate   as per actual  values  but it has to be accurate  in the way of repeatable. So you  are interested in the trend. It has  to be accurate  for  top athletes  who like to    avoid  certain reactions.  Now the interested partb9n plasma  expansion as a functional  reaction is the fats  and effective performance improvement   under certain situations.
   Who benefits  the most.
 The athletes  , where we  have a delivery limitation so  cardiac out put limitation  and or even  respiratory limitation. The limitation  has to be due to an extremely well  and overdeveloped   vascularisation  and  mitochondria density  system.
 So  any further  performance improvement  can only come over cardiac  or respiratory    system improvement.
 As  based on the classical ideas we all learned   the respiratory  system is NEVER  a limitation the idea    and how we train the respiratory system was never really closer looked  at.
 The idea, that we  actually can stimulate  the cardiac  system  and there even  make a difference between right an left ventricle   sounds  futuristic  for many  and therefor it b=never got  looked  upon this one either.
 So the focus  was  on increasing  hours  and intensity  and as  such we  either added LSD  or  we  added HIT  workouts.
 Both in their own   idea  will improve  vascularisation and mitochondria density including function  mitochondria   ability.
 What we  created  is the  nice  word  by Marshall , a sleeping giant. meaning   the situation, where we created a  incredible trained  muscular system , which could use  an incredible amount  of O2  if  it  could be delivered.
 So bu y adding  O2  to it we  easy can show that , when the limiter is  one of the vital systems  as we can avoid a  reflex  protection over  reduction in motor unit recruitment as well as  we  can  to a certain extend   limiter  reflex  vasoconstriction as a BP  protection  as well as a  metaboreflex reaction.

 Here  a picture   of a  world class athlete  who  was  trained into this  situation  and than  to improve    he had  no  other choices  as to  try to avoid this situation by boosting  functionally the delivery system in one or  another way. Unfortunately he  got  caught as  the medical team    missed  the opportunity  to  work on a physiological solution rather than  on a pharmacological    help.

d thb smo2 leg.jpg 
here is an easy way to see, whether the drop in tHb is a  mechanical reason or  a reflex reason.

 Now  back to plasma  expansion. It is  super  effective  if  we have  top athletes  with a  cardiac  limitation ( CO )  as we  immediately can improve delivery due to increase in SV  by a  perfect timed  plasma expansion.
 There are some very   well documented   cases like the finish  national team in cross country skiing  some years  back  , where there was a    perfect ( nearly perfect )  controlled  system  on hand  with plasma  ex pander.
There  are actually  much  worse  cases out there, where  the  coaches  and athletes  not even had  to hide  and from the plasma expansion in the stadium in front of the competition and got  away  with it  due to the fact, that " classical '   exercise physiology  does not accept the idea of limiter and compensator  and the  idea, that in this athletes  the  muscle is always the limitation. Decathletes  have  for the amount of  muscles  they have a completely underdeveloped  cardiac  system. The CO  never ever is able to  supply enough  BP  and   enough O2  in any  event , where O2  is the   absolutely needed main sources  to be delivered. They are  very effective in  aerobic  ability as long the O2  has  to  come from the  storage    area  in the muscle  , so they are aerobically  well trained  and have a well trained  aerobic ,  ability  to recover for  duration of   30 +- sec. which allows  them a  decent but ugly looking  last 100 m in a 400 m run. but  makes them looking pretty heavy in a  1500 m  run.
 So the best short term  solution is a plasma ex-pander.  hidden in a glucose  infusion.
 Here  what the end result is :

Olympic decathlon champion Roman Sebrle will not be...

August 14, 2005|By Tribune news services.


Olympic decathlon champion Roman Sebrle will not be punished for receiving a glucose infusion during competition and will be able to hold on to his world championship silver medal if his blood sample confirms a negative urine doping test, the International Association of Athletics Federation said. Sebrle and former three-time world champion Tomas Dvorak received the infusion before the final event--the 1,500-meter race at the World Track and Field Championships in Helinski, Finland. Glucose is not an illegal substance.

 The end result is  a functional  fast and easy  improvement of the  1500 m time  not  by minutes  but by   a decent amount of seconds  and that is  all what is needed to  win  or to loose.
 This  is another example of the fundamental difference in  being a chef  versus  being a franchisee  and just follow the orders  so the  food  is  decently digestible.
. Give them a cook book  and they will cook no matter  what  the outcome is. ????

 Give  them a  calculator  and they go  or  Give them a MOXY  and create some honest questions  but as well some interesting individual solutions.

Juerg Feldmann

Fortiori Design LLC
Posts: 1,530
We  got  as so often slightly  side tracked  as some people  would argue. I  on the other side  think this back ground   knowledge  will show you , why we  are  so keen to show the options  with have  with NIRS  for the grass root coach  and the average fitness center who  are  not ready  nor  do they see the point  in investing large amount of  money in VO2  max testing or lactate testing.
 In an " average  fitness and coaching center the risk that  we have some contamination when taking blood  or   a not optimal disinfection  with VO2  masks   out weights  the benefit of a  test where w e simply  get one  end point  or better one point  as a  magical 100 %  value  and than  start to calculate. Fro this  facility a  simple estimation of VO2  max  or  any current   "magic"  maximal HR  formula  will do it as statistically    many people  will fall into a decent    " zoning"  now  WITH moxy  THEY HAVE A  REALLY NICE  OPTIONS 2 moxy'S  AND YOU CAN OFFER  YOUR CLIENT A  SIMPLE   EASY  INDIVIDUAL 'zoning" IF  YOU JUST USE sMo2  . you CAN MAKE A STEP FURTHER  AND LOOK  AT ThB  AND YOU CAN MAKE  A  NEXT LEVEL WHERE YOU LOOK AT LIMITER AND COMPENSATOR . so OVER A   period  of  3  years you can grow  and learn with your client  and  have a lot  of  fun  developing  some very interesting  and new ideas in  coaching  and   as well motivation.
 For the  many  great  advanced coaches  with a  huge  amount of experience  MOXY offers  a new  tool to be added to their  current ideas  and testing options  and  as  such offers  them an option to critically look  what   is going on, what   never  made sense in the past  in " science"  and  experience  took over  versus  live feedback now  where  your experience  may  be proven to be  pretty darn  great.
 KEY. Allow yourself  to  think out  side the BOX  and you open  a whole new  way of   very  motivational  hours    for you  and your  client  no matter on age  performance  and goal settings.
Now  here what created this  section. An email asking me about the Finish  story  and where  we  can find it. Here   on the MOXY  forum ? 




News & Comment / Sports Medicine


Doping Disaster for Finnish Ski Team: a Turning Point for Drug Testing?

Stephen Seiler

Institute of Sport, Agder University College, Kristiansand, Norway. Email:

Sportscience 5(1),, 2001 (1750 words)

Reviewed by Carl Foster, Department of Exercise and Sport Science, University of Wisconsin-LaCrosse, LaCrosse, Wi 54601, USA


A recent doping scandal at the world cross-country skiing championships may mark a turning point in the war on illegal drug use in sport. Six Finnish skiers tested positive for hydroxy-ethyl starch (HES), a plasma volume expander and masking agent against EPO use. The athletes knew the drug was on the banned substance list, but neither they nor the doctors and coaches who assisted them knew that the World Anti-Doping Agency had developed a urine test for HES.Reprint pdf · Reprint doc · Help


KEYWORDS: banned substance, blood doping, cross-country skiing, EPO, ergogenic, HES, hydroxy-ethyl starch



In late February, the World Nordic skiing championships in Lahti, Finland, became the latest battleground in the war on doping in sport. For once, it was the drug testers who had the bigger guns. Actually, they had a hidden gun.

In endurance sport, we are all aware that the central target of this battle has become use of erythropoetin (EPO). Hemoglobin boosting has been rampant in cross-country skiing for years, both via natural (altitude training), semi-natural (altitude houses), and illegal methods (EPO use now, blood transfusions previously). Blood testing initiated in 1997 (see various articles at this site) has had some impact, but with an upper limit of 18.5 g/dl, and still no accepted method in place to directly detect EPO administration, eradication of EPO use has remained a pipe dream.

This year, the International Ski Federation (FIS) reduced the acceptable "safe" hemoglobin limit to 17.5 mg/dl for men, thereby raising the chance of a positive test. In fact, some athletes reach this limit after altitude exposure. Some athletes, via their doctors, quickly learned that by combining EPO administration with the use of plasma volume expanders such as Dextran 70 and the newer HES (hydroxy-ethyl starch, a chemically modified form of corn starch), they could achieve performance enhancing combination of elevated total blood volume and high hemoglobin, all while holding hemoglobin below the legal limit. HES is a very large molecule (450,000 Daltons)--five times larger than the more familiar Dextran, which exercise physiologists use in studies of plasma volume. The molecules of HES and other plasma volume expanders are so large that the stay in the blood. As osmotic agents, they hold extra fluid in the blood, thereby elevating plasma volume and total blood volume. These agents are unique on the banned substance list, in that they enhance performance and mask the presence of another banned substance.

HES must be delivered intravenously via a drip bag and a large-gauge cannula. In other words, HES infusions aren’t something that athletes are likely to pull off alone. The disadvantage of this product is that the starch is only partly broken down by the body. The large molecule is slowly cleaved into smaller sections by the liver. A part is excreted via the urine, another part via the bile, but a last part remains in the circulation for weeks and is slowly deposited in the tissues, particularly the skin.

HES was officially placed on the banned substances list 1 year ago. Often, substances are banned before they can be detected, and HES was no exception. The Finns were informed, apparently by international sources, that HES could not yet be detected in urine samples. Their head coach, two national team doctors, and 6 team athletes therefore chose to systematically use HES in the two weeks prior to the world championships. Meanwhile, the new World Anti-Doping Agency (WADA) and its certified drug-testing labs had purposefully not announced that they had a detection method for HES in place prior to the world championships. This method was the hidden gun. For once it was the drug testers who had a secret.

The first Finnish skier to test positive was medallist Jari Isometsaa. This unexpected positive created panic in the Finnish team, some of whom responded desperately by faking accidents and illness. For example, Jani Immonen had the incredible "bad luck" to ruin a ski binding in one race and break a ski pole in another. Meanwhile, Finnish spokesmen claimed that the one positive test was an isolated incident. Jari Isometsa tried to protect his team by claiming that his actions were in cooperation with a foreign doctor unknown to the Finnish support crew. When "accident prone" Janne Immonen tested positive two days later, systematic doping was suspected. Yet, even after they knew that HES was being detected, they chose to start the men’s 4 x 10-km relay with HES-injected athletes.

To make bad things worse for the Finns, a physician’s bag containing used needles and drip bags was found at a gas station near the Helsinki airport. The bag turned out to belong to the Finnish cross-country team. In this story, we might call this bag "the smoking gun".

When two more male skiers from Finland’s gold medal relay team and two female skiers subsequently tested positive, Finnish skiing was finished. National heroes Mykka Myllala and the ageless wonder 42-year old Harvi Kirvesniemi, who earned a bronze medal in the Lake Placid Olympics of 1980, tested positive and ended their careers in the worst possible way.

I was visiting the German Sport University (GSU) in Cologne when the first positive test was announced. Besides being perhaps the world’s largest sports science and sports education program (6000 students), GSU is the location of one of the world’s 24 WADA-certified drug testing laboratories. The man I talked to had just returned from the WADA laboratory in Helsinki. Hidden away on the seventh floor of an 11-story academic building, high performance gas chromatography and mass spectrometry are the big guns in an impressive arsenal of detection methods. Eleven combination HPCG/mass-spec machines sat in one room! The chemicals in the urine are transferred and concentrated into organic solvents. Under high temperature 2-microliter liquid samples become gaseous and are pushed through 17 to 60 meters of super-fine separation tubing to detect banned substances. With eleven HPGC units running, each with their own heating units designed to raise solvent temperatures to 300°C, even the special cooling system in the room is not enough to stop it becoming a sauna. The lab technicians work in T shirts, but the serious looks on their faces tell you that they know what is at stake. By virtue of its structure, each chemical compound moves through the tubing at a different, highly reproducible speed, making separation possible. Separation by HPGC and exact identification by mass spectrometry comprise a "finger-printing" system that can detect the majority of banned substances. A few others are revealed using other methods such as liquid chromatography (HPLC). In the Cologne lab alone, 10,000 human urine samples and 4,000 horse urine samples are tested annually.

The Cologne lab boasts the largest collection of reference samples of banned substances in the world. These samples are the key to the mass spectrometry identification system and are protected by an impressive system of security measures. All of the WADA labs are subject to unannounced double-blind sample testing and regular inspection for any irregularities in laboratory procedures, chain of evidence, and so on. Had I been a competing athlete with an urge to take a chemical short-cut, this lab tour would have scared me straight. Any athlete who claims that their positive test is a mistake should keep this in mind that the Cologne lab has never produced a single false-positive test in all the double-blind control tests performed over the last 10 years. Not one. So much for the B samples.

Although hardly noticed outside of northern Europe, the demise of Finnish skiing may well represent a breakthrough in the war on doping. The Ben Johnson episode in Seoul in 1988 kick-started a build-up in drug testing technology that has continued for more then a decade. In 2001 the technology and organizational structure for year-round testing in and out of competition is at last beginning to accomplish its mission.

The Finnish scandal also gives hard evidence to strengthen or refute several suspicions that have been whispered for years. First, while the former East German and Soviet sports machines have been disassembled, we have suspected that systematic drug use by isolated national sports organizations is still happening. By "systematic", I mean one or more athletes, doctors, and perhaps coaches working together. In the case of the Finnish incident, it appears that only a small group within the national team was cheating. So, we should not persecute those Finnish skiers who were and are clean. But, Finnish endurance athletes have been suspected since the days of Lasse Viren and old-fashioned blood replacement techniques in the 1970s. In international cross-country skiing, the Finns have displayed an uncanny capacity to be best when it counted. At times their performances in major championships have born little resemblance to performances during the season. We training theorists and exercise physiologists could not understand how an athlete training 25 hours a week and competing 20 times in three months could suddenly raise his capacity 5% in one week. Our suspicions are now strengthened. There was no training magic. On the other hand, the fact that a Finnish laboratory reported the positive tests on the home team helps refute the claim that the entire drug-testing program is corrupted by sports organizations in an effort to hide positive tests that would cast a bad light on the sport.

Finally, this drug scandal reminds us again that, without doctors and physiologists, much of the drug problem in sport would not exist. Two Finnish doctors gave their blessing and their assistance to the offenders. The guilty athletes are now banned from their sport for cheating. National team sport physicians and top athletes private doctors are in a powerful position to influence athletes regarding all things pharmaceutical. When they directly aid an athlete by providing a banned substance, they are "an accessory to doping." War history buffs know that one key to winning a war is cutting off supply lines. Drug testing is beginning to win battles. When national governments criminalize a doctor’s assistance of an athlete using a banned substance, and take away their medical licenses, we could move a big step closer to winning the entire war.

Edited and webmastered by Will Hopkins.
Published April 2001.



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