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The Influence of Training and Mental Skills Preparation on Injury Incidence and Performance in Marathon Runners

Hamstra-Wright, Karrie L.1; Coumbe-Lilley, John E.1; Kim, Hajwa2; McFarland, Jose A.1; Huxel Bliven, Kellie C.3

Journal of Strength and Conditioning Research: October 2013 - Volume 27 - Issue 10 - p 2828–2835
doi: 10.1519/JSC.0b013e31828a4733
Original Research
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Hamstra-Wright, KL, Coumbe-Lilley, JE, Kim, H, McFarland, JA, and Huxel Bliven, KC. The influence of training and mental skills preparation on injury incidence and performance in marathon runners. J Strength Cond Res 27(10): 2828–2835, 2013—There has been a considerable increase in the number of participants running marathons over the past several years. The 26.2-mile race requires physical and mental stamina to successfully complete it. However, studies have not investigated how running and mental skills preparation influence injury and performance. The purpose of our study was to describe the training and mental skills preparation of a typical group of runners as they began a marathon training program, assess the influence of training and mental skills preparation on injury incidence, and examine how training and mental skills preparation influence marathon performance. Healthy adults (N = 1,957) participating in an 18-week training program for a fall 2011 marathon were recruited for the study. One hundred twenty-five runners enrolled and received 4 surveys: pretraining, 6 weeks, 12 weeks, posttraining. The pretraining survey asked training and mental skills preparation questions. The 6- and 12-week surveys asked about injury incidence. The posttraining survey asked about injury incidence and marathon performance. Tempo runs during training preparation had a significant positive relationship to injury incidence in the 6-week survey (ρ[93] = 0.26, p = 0.01). The runners who reported incorporating tempo and interval runs, running more miles per week, and running more days per week in their training preparation ran significantly faster than did those reporting less tempo and interval runs, miles per week, and days per week (p ≤ 0.05). Mental skills preparation did not influence injury incidence or marathon performance. To prevent injury, and maximize performance, while marathon training, it is important that coaches and runners ensure that a solid foundation of running fitness and experience exists, followed by gradually building volume, and then strategically incorporating runs of various speeds and distances.

1Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois;

2Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago, Illinois; and

3Interdisciplinary Health Sciences, Arizona School of Health Sciences, A. T. Still University, Mesa, Arizona

Address correspondence to Karrie L. Hamstra-Wright, khamst1@uic.edu.

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Introduction

Marathon running has grown substantially in the past 12 years. In fact, 47% more runners finished a marathon in the USA in 2011 compared with those in 2000 (518,000 vs. 353,000 finishers, respectively) (26). With this increase in participation has come a simultaneous focus on the best way to train for the 26.2-mile race. In preparation for a marathon, runners typically participate in a training program that lasts approximately 16–25 weeks (4,16,25). For runners wanting to maximize their performance, their marathon training plan will include strategically placed runs of various distances and paces (e.g., easy, tempo, interval, long). One's performance goals, abilities, injury history, time available to devote to training, knowledge about training, and a host of other variables will influence a runner's weekly training structure. Training for a marathon involves building on each week by manipulating several variables, which may include but are not limited to the type of running (e.g., easy, speed, tempo, long), miles run per week, days run per week, and number of runs per day.

As training variables build upon the preceding week, overuse injuries often arise. For example, Maughan and Miller (21) reported that 287 of the 497 marathoners (58%) they surveyed experienced an injury while training for their marathon. More recently, Van Middelkoop et al. (33) found that 28% of the 694 marathoners in their study self-reported an injury in the month before or during the marathon. To prevent injury, it is wise to start marathon training with previous running experience and a strong foundation of running fitness (4). Inadequate running preparation (building speed and mileage too quickly, not enough months of running experience) is speculated as a contributing factor to injury incidence during marathon training (4), but mental preparation is also important.

Because of the intensity of training for and racing a marathon, mental preparation is a key variable for success and may have a direct influence on injury and performance. Numerous studies indicate a range of factors—including negative moods, unhelpful and unproductive thinking, expectancies, locus of control, life stress, poor coping skills, and daily hassles—are predictive of athletic injury in various populations in both men and women participating in endurance and contact sports (1,7,17,29,35). Mental skills are attributes whereby athletes “learn more about their individual mental life to allow a degree of control in coordinating effective movement through a range of psychological states of performance” (2). Mental skills differentiate between elite and subelite sport performers (20), and athletes have indicated that mental skills have a positive influence on their performance experiences and outcomes (8,11). Having a strong mental skills profile is important for marathon performance (24); however, to our knowledge, a specific investigation of how training and mental skills preparation at the outset of a marathon training program influence injury incidence and performance has not been conducted.

Research that surveys marathon runners allows for the investigation of the relationships among training, mental skills, injury, and performance. The outcomes of this research may provide relevant insight for coaches, runners, and clinicians on how the physical and mental aspects of running influence injury and performance. With the high rate of injury during marathon training (21,33), evaluating running and mental skills preparation for marathon training may provide unique practical suggestions about how to better avoid injury and maximize performance. Specifically, having a greater understanding of what type of running and mental skills preparation contributes to an injury-free training cycle and maximizes performance will allow coaches, runners, and clinicians to make more informed decisions on training schedules.

The goal of our study was to survey runners participating in an 18-week marathon training program for a fall 2011 marathon to determine how their training and mental skills preparation at the beginning of a training program influenced injury incidence and performance. Specifically, our purpose was to describe the training and mental skills preparation of a typical group of runners as they began a marathon training program, assess the influence of training and mental skills preparation on injury incidence, and examine how training and mental skills preparation influence marathon performance. We hypothesized that there would be a significant relationship between the type of training preparation and injury incidence and a difference in mental skills between injured and noninjured groups. We also hypothesized that there would be a positive relationship between mental skills preparation and performance and a difference in performance between the types of training preparation.

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Methods

Experimental Approach to the Problem

This prospective cohort survey research study (22) involved individuals who were enrolled in the Chicago Area Runners Association (CARA) 18-week marathon training program with the goal of completing a fall 2011 marathon. This population was selected because of the large number of Chicago area participants enrolled in the CARA standardized marathon training program, allowing us to describe the training and mental skills preparation of a typical marathon training cohort that is diverse in age, sex, and abilities. The runners in this program are given a beginning, intermediate, or advanced training schedule to follow with the goal of completing a fall marathon. They also have the opportunity to participate in midweek and weekend group runs at various training paces based on their program level. To evaluate the influence of training and mental skills preparation on injury incidence and performance in this group of runners, a survey (described below) was administered pretraining, 6 weeks into training, 12 weeks into training, and posttraining. The independent variables derived from these surveys were group (injured, noninjured), injury incidence (yes, no), and type of training preparation (type of runs per week: easy, tempo, interval, long; miles run per week: <20, 20–30, 31–40, 41–50, 51–60, 61–70, 71–80, 81–90, 91–100, >100; days run per week: 0–1, 1–2, 2–3, 3–4, 4–5, 5–6, 6–7; days run more than once a day: 0, 1, 2, ≥3). The dependent variables were a mental skills profile (composite score, described below) and performance (marathon finish time).

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Subjects

During the 4 weeks before the start of the training program (May 16–June 10, 2011), CARA invited all runners enrolled in their 18-week marathon training program to participate in this study by including an announcement in an electronic newsletter that was sent to the e-mail address of each runner. As a result, 1957 runners in CARA's marathon training program received the study announcement. The announcement included a web link where runners found further information, a consent form, and a field to submit their preferred e-mail address for survey administration. The runners were ineligible to participate if they indicated on the electronic consent form that they were <18 years of age or had current musculoskeletal pain in the lower extremity or back that had caused a restriction in exercise for at least 2 consecutive exercise sessions. The University of Illinois at Chicago's institutional review board approved this study, and all the subjects provided electronic informed consent before participating.

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Instrumentation

Electronic surveys (SurveyMonkey.com, LLC, Palo Alto, CA, USA) were developed to assess the training and mental skills preparation of the subjects participating in the 18-week CARA marathon program. Administering these surveys pretraining, 6 weeks into training, 12 weeks into training, and posttraining allowed us to investigate our purposes and practical question of how training preparation influenced injury incidence and marathon performance. The pretraining survey questions about training preparation were developed based on results from the current literature and clinical experience that indicate which training variables often contribute to injury incidence and performance (4,9). The pretraining survey also included the Nine Mental Skills of Successful Athletes (19) questions (coauthor, JCL, received permission from the developer of the Nine Mental Skills of Successful Athletes to use it in this research study). All the surveys were reviewed and revised by the research team for face validity and to ensure readability. Each of the 4 administered surveys had these distinct sections: (a) Pretraining survey: training preparation (4 questions), mental skills preparation (30 questions), and demographics (5 questions); (b) 6- and 12-week surveys: injury incidence (3 questions); (c) Posttraining survey: injury incidence (3 questions), marathon performance (2 questions).

Questions in the pretraining survey were written to characterize the training and mental skills preparation of runners beginning a marathon training program. Training preparation questions included: type of runs per week: easy, tempo, interval, long; miles run per week: <20, 20–30, 31–40, 41–50, 51–60, 61–70, 71–80, 81–90, 91–100, >100; days run per week: 0–1, 1–2, 2–3, 3–4, 4–5, 5–6, 6–7; days run more than once a day: 0, 1, 2, ≥3. For type of run per week, runners were asked to choose all responses that applied. For miles run per week, days run per week, and days run more than once a day, runners were asked to choose 1 answer. The mental skills preparation questions inquired about: attitude (6 questions), motivation (3 questions), goals and commitment (3 questions), people skills (3 questions), self-talk (3 questions), mental imagery (3 questions), dealing with anxiety (3 questions), dealing with emotions (2 questions), and concentration (4 questions). For each question, the runners were asked to select a number between 1 and 10 to rate how well the description fits themselves (the more the description fit, the higher the number). A mental skills profile score for each runner was determined by calculating the mean score from the 30 mental skills questions, giving us 1 composite score for each subject with the highest possible score being 10. Demographic questions asked for self-reported age, race, height, and weight were answered using a list of incremental values.

Questions in the 6- and 12-week surveys quantified injury incidence, which was the number of injuries that occurred during the previous 6 weeks of the runner's marathon training. An injury was defined as any musculoskeletal pain of the lower limb or back that occurred as a result of participating in running and caused a restriction from running for at least 2 consecutive training sessions.

Questions in the posttraining survey tracked the number of injuries that occurred during the previous 6 weeks of the runner's marathon training and requested the runner's marathon finish time.

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Procedures

The runners who gave their consent to participate received an electronic survey via e-mail, personalized by their first name, at these time points: pretraining (during the first week of their 18-week training program and before their first weekend long run), 6 weeks into training, 12 weeks into training, and posttraining (1–14 days postmarathon). Runners had 7 days to complete each survey. For each survey administration, runners received 1 e-mail notice that the survey was ready to be taken and 2 reminder e-mails 3 and 5 days after the initial e-mail notice.

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Statistical Analyses

Training and Mental Skills Preparation: Descriptive

Aggregate data from all responses were analyzed. Descriptive analyses (percentages, frequencies, means, and SDs) were conducted on training and mental skills preparation variables (pretraining survey).

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Training and Mental Skills Preparation: Injury

The χ2 analyses were used to assess the relationship between the type of training preparation (pretraining survey: type of run per week, miles run per week, days run per week, days run more than once a day) and injury incidence throughout the training program (6-week, 12-week, and posttraining surveys). For significant χ2 results, the magnitude and direction of the relationship was found using Spearman's rho (ρ) correlations and a logistic regression was used to determine the odds ratio.

One-way analyses of variance (ANOVAs) were used to examine differences in mental skills preparation (pretraining survey: mental skills profile score) between injured and noninjured groups (6-week, 12-week, and posttraining surveys).

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Training and Mental Skills Preparation: Performance

Pearson correlation coefficients were used to determine the relationship between mental skills preparation (pretraining survey: mental skills profile score) and marathon performance (posttraining survey: finish time).

One-way ANOVAs were used to evaluate differences in marathon performance (posttraining survey: finish time) between types of training preparation (pretraining survey: type of run per week, miles run per week, days run per week, days run more than once a day).

Significant ANOVA findings were followed up with Tukey's multiple comparison post hoc tests. Statistical significance was set a priori at p ≤ 0.05 for all tests. Data were analyzed with SAS (version 9.2; SAS Institute Inc., Cary, NC, USA).

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Results

Response Rate

One hundred twenty-five runners expressed interest in participating in the study and were eligible to do so. They completed the informed consent and provided an e-mail address to which the study surveys should be sent. Of these 125 runners, 115 started the first survey (pretraining survey) and 113 completed it. Figure 1 illustrates the number of respondents to each survey administered.

Figure 1

Figure 1

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Training and Mental Skills Preparation: Descriptive

One hundred fifteen runners participated in the pretraining survey (31 men, 84 women). Ages ranged from 20 to 70 years with the most frequently reported age range being 30–34 years. A description of the runners' training preparation is presented in Table 1. The average mental skills profile composite score of the runners was 7.69 ± 1.05 out of a possible 10.

Table 1

Table 1

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Training and Mental Skills Preparation: Injury

Ninety-three runners completed both the pretraining and 6-week surveys. Tempo runs during training preparation were significantly related to injury incidence in the 6-week survey (ρ[93] = 0.26, p = 0.01). Fifty-eight (62.4%) runners reported tempo running during training preparation as part of their weekly training and 35 (37.6%) did not. Of the 58, 23 (39.7%) reported experiencing ≥1 injury during the first 6 weeks of the marathon training program. The odds of experiencing an injury in the first 6 weeks of training was 3.96 times higher for runners who participated in tempo running compared with those who did not (95% confidence interval [CI] 1.35, 11.61). Although not statistically significant (p = 0.06), it may be clinically important to recognize that 43% of runners (16 of 37) who participated in interval runs in preparation for marathon training experienced an injury in the first 6 weeks of training.

A total of 28 runners reported injury during the first 6 weeks of marathon training and 96.4% (27 of 28) incorporated tempo or interval runs as part of their training preparation while running <40 miles·wk−1. Comparatively, a total of 65 runners reported no injury during the first 6 weeks of marathon training, but only 56.9% (37 of 65) incorporated tempo or interval runs in their training preparation with 96.9% running similar mileage as the injured group (63 of 65 ran <40 miles·wk−1).

Results from the 6-week survey showed no significant differences in mental skills preparation between injured and noninjured runners (n = 28 injury, 7.69 ± 0.93; n = 65 noninjured, 7.62 ± 1.08; p = 0.75). Results from the 12-week survey (n = 33 injury, 7.58 ± 0.87; n = 46 noninjured, 7.76 ± 1.01; p = 0.40) and posttraining survey (n = 35 injury, 7.73 ± 0.9; n = 41 noninjured, 7.80 ± 0.96; p = 0.76) were similar.

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Training and Mental Skills Preparation: Performance

The type of training preparation significantly influenced marathon performance. Runners who reported doing tempo runs before starting their 18-week marathon training program were 14% faster (n = 32, 282.12 ± 50.85 minutes, p = 0.002) in the marathon compared with those who did not (n = 18, 329.31 ± 44.02 minutes; mean difference: 47.18 minutes, 95% CI 18.43, 75.94; Figure 2A). Also, runners who reported doing interval runs as part of their training preparation were 18% faster (n = 20, 265.12 ± 47.02 minutes, p < 0.001) in the marathon compared with those who did not (n = 30, 321.77 ± 44.80 minutes; mean difference: 56.65 minutes, 95% CI 30.13, 83.18; Figure 2A).

Figure 2

Figure 2

Individuals who ran more miles per week and days per week in training preparation ran significantly faster in the marathon than did those who ran fewer days and fewer miles (p ≤ 0.05). Specifically, runners who reported running 41–50 miles·wk−1 pretraining were 32% faster (n = 2, 225.03 ± 47.75 minutes) than those who were running <20 miles·wk−1 (n = 19, 331.62 ± 39.30 minutes; mean difference: 106.59 minutes, 95% CI 19.23, 193.95) and 23% faster than those who were running 31–40 miles·wk−1 (n = 9, 254.33 ± 49.96 minutes; mean difference: 77.29 minutes, 95% CI 29.74, 124.85; Figure 2B). Runners who reported running 5–6 d·wk−1 pretraining were 36% faster (n = 5, 225.76 ± 24.14 minutes) than those who were running 2–3 d·wk−1 (n = 2, 351.00 ± 60.81 minutes; mean difference: 125.24 minutes, 95% CI 11.78, 238.70) and 29% faster than those who were running 3–4 d·wk−1 (n = 21, 319.03 ± 47.39 minutes; mean difference: 93.27 minutes, 95% CI 25.78, 160.75; Figure 2C).

No significant relationship existed between mental skills preparation (n = 114, 7.69 ± 1.05) and marathon finish time (n = 50, 299.12 ± 53.22 minutes, r = −0.10, p = 0.48).

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Discussion

The purpose of our study was to describe the training and mental skills preparation of a typical group of runners as they began a marathon training program and assess how training and mental skills preparation influenced injury incidence and marathon performance. Results from this study describe the training and mental skills preparation of a group of subelite runners participating in a marathon training program. We found that training preparation that included tempo runs was associated with an increased injury incidence during the first 6 weeks of the marathon training program. One's mental skill set as the runner entered marathon training did not appear to have an impact on injury incidence during training. Pretraining tempo and interval running, miles run per week, and days run per week were important in achieving a faster marathon finish time, but pretraining mental skills did not seem to influence performance.

A unique aspect of our study was evaluating training and mental skills preparation for a marathon. Our data characterized a typical cohort of subelite runners preparing to train for a marathon regarding sex, age, training, and mental skills preparation. The majority of runners who completed the pretraining survey were women. The higher response rate of women may suggest that a greater number of women were enrolled in the CARA marathon training program we recruited from or that more women responded to our survey invitation. From 2008 to 2011, 59% of marathon finishers were men, and 41% were women (26), suggesting the latter explanation may be more likely. The most frequently reported age range of the runners in our study was 30–34 years. The national average age of marathon finishers in 2011 was 38.1 years (26); thus, the majority of runners in our study were slightly younger than the reported average in 2011. However, the ages of our runners ranged from 20 to 70 years, providing a typical dispersion of ages and thus representing a standard cohort of marathon runners (26).

In a 2011, survey of >11,800 runners nationwide who finished a marathon in the previous 2 years, runners reported running approximately 4.4 d·wk−1 for an average of 29.4 miles (26). Similar to this nationwide survey, the majority of runners in our study reported running 3–4 d·wk−1 for an average of 20–30 miles·wk−1 leading up to their marathon. Unlike our study, however, the nationwide survey did not capture training preparation information. In regard to mental skills preparation, our study is the first to establish an average mental skills profile score for a group of subelite runners entering an 18-week marathon training program. As such, our data can provide a foundation for future work.

Given the increasing number of marathon participants, determining whether training preparation has a relationship to injury incidence is important. Our results indicate that approximately 40% of runners participating in tempo runs in preparation for marathon training experienced an injury within the first 6 weeks of marathon training. Almost all the runners who reported injury during the first 6 weeks of marathon training incorporated tempo or interval runs as part of their training preparation while running <40 miles·wk−1. Of the runners who reported no injury during the first 6 weeks of marathon training, just over half incorporated tempo or interval runs in their training preparation while running a similar mileage as the injured group. These findings indicate that the injured group did more fast-paced running leading into marathon training than the noninjured group did, probably without the appropriate base of training volume to do so.

The increased pace involved with tempo and interval training are important aspects of a well-designed marathon training program. In subelite runners, training pace, distance run per week, and distance run per day are all significant predictors of marathon performance (9,30). Although important for improved performance, faster running speeds generally result in increased force and stress on the musculoskeletal system (23,27). When running speed is increased too quickly, the rate of damage to tissues outweighs the rate of tissue repair (6) and may be a risk factor for running-related injuries (6,15). Gradual increases in running intensity may allow the musculoskeletal system to adapt to more stress, thus preventing injury incidence (13,14). Therefore, a strong running base of adequate mileage and uninterrupted weeks-months of injury-free running are necessary before incorporating the increased pace work of tempo and interval runs. Even then, the majority of marathon training occurs at a slower pace than at race pace as demonstrated by a 2004 United States Olympic marathon trials cohort. In the year leading up to the trials, the athletes ran 74.8% (men) and 68.4% (women) of their weekly distance at a pace slower than race pace (13). A group of 20 marathoners from Portugal and France preparing for their Olympic trials trained similarly (2). These findings suggest that approximately 25–30% of weekly running volume be devoted to increased pace work such as tempo and interval runs.

Although the type of running preparation influenced injury incidence in our population, mental skills preparation did not. No differences in mental skills preparation were found at 6 weeks, 12 weeks, or posttraining between injured and noninjured groups. This result may be attributed to our study design. Because we were interested in how mental skills preparation influenced injury incidence, as measured by a mental skills profile at the outset of marathon training, we did not investigate the use of mental skills training. Profiling alone, without athlete feedback and systematic programming that delivers a planned mental skills program aligned with physical and technical training akin to marathon training (12), does not allow the participant to be conscious on a regular basis about their mental skills profile and their use of mental skills. Also, we surmise that because we did not specifically investigate self-efficacy and coping relative to the Weise-Bjornstahl et al. (34) model of injury response, we were unable to see differences in the profiles of injured vs. noninjured runners. Future research should build on our study by completing regular profiling throughout marathon training while simultaneously conducting a mental skills training program. Regular profiling and a mental skills training program would allow for a better understanding of how mental skills relate to injury incidence in this population.

Training preparation had a significant influence on marathon performance. Runners who incorporated tempo and interval running into their pretraining schedule had finish times faster than those who did not. Runners who reported running 5–6 d·wk−1 finished faster than those who reported running 2–3 or 3–4 d·wk−1. Also, those who ran 41–50 miles·wk−1 finished faster than those running <20 or 31–40 miles·wk−1. These results suggest that increasing the number of days run per week, which simultaneously often increases the miles run per week, has a large influence on improving marathon finish time. Furthermore, the strategic incorporation of tempo and interval training after establishing a base of training seems beneficial for improving marathon performance. This finding is supported by the training schedules of elite and national class marathon runners (18). In the 12 months leading up to their marathon, their training schedule included a gradual increase in race-pace, tempo, and speed work as the race approached but low-intensity running and high volume were the staple of their training (18).

Similar to mental skills preparation and injury incidence, no relationship was found between pretraining mental skills preparation and marathon performance. As stated above, we believe this is primarily because of our lack of mental skills profiling and training during the marathon training program.

When interpreting our findings, the limitations of the study should be noted. First, information was collected via electronic survey; thus, variables were self-reported and no investigators were on site to answer questions during survey administration. Second, because the focus of this investigation was on training and mental skills preparation, we enrolled eligible runners based on these 2 criteria but did not track adherence to the marathon training program or other contributing factors such as nutrition, sleep patterns, and crosstraining incorporation.

One of the most practical findings of our study was that weekly tempo runs in preparation for an 18-week marathon training program contributed to injury incidence within the first 6 weeks of training and also resulted in faster marathon finish times. Notably, running 5–6 d·wk−1, 41–50 miles·wk−1, and incorporating tempo and interval running resulted in the fastest finish times, which suggests tempo and interval runs in conjunction with a strong foundation of running days and miles per week leads to an enhanced, injury-free performance. Strategically placed training runs at faster than marathon pace, such as tempo and interval training, do make runners faster (3), but to prevent injury incidence during marathon training, training runs that are faster than marathon pace should only be incorporated after runners have gradually increased their running volume.

Although mental skills have been found to enhance performance and help athletes gain control and consistency over their performance (10,28,31,32), our study did not support those findings. We believe this may be because we did not account for whether the runners used an explicit mental game plan or knew how to use their mental skills for their benefit. Incorporation of a mental skills training program and evaluation of its relationship with injury and performance is an important topic for future studies.

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Practical Applications

To prevent injury incidence while training for a marathon and to maximize marathon performance, coaches, runners, and clinicians should recognize the importance of entering marathon training with a solid foundation of running fitness and experience. Entering marathon training with a strong base of running fitness and experience will help runners prepare for the increases in running volume inherent in marathon training. Many coaches, runners, and clinicians contemplate how much and what type of running experience (months of preparation, type of run per week, miles run per week, days run per week) is optimal for the necessary balance between injury prevention and enhancing performance during marathon training. No research has established best practice guidelines for achieving this balance, but practical knowledge suggests that the answer is unique and specific to each runner based on the runner's health and running history. Anecdotally, many recommend that coaches and runners follow a “10% rule,” increasing mileage no more than 10% per week. However, this percentage may be too high and does not consider that some runners increase mileage and intensity concurrently, which puts them at further risk for injury (5). Thus, we recommend that before beginning marathon training, coaches and runners focus on establishing months of steady and gradual running progression, building volume first and then judiciously incorporating runs at various speeds such as tempo and interval runs. Adherence to these recommendations will allow for continued, gradual running progression during marathon training without the need to implement large increases in running volume or intensity that may predispose runners to injury. Additionally, by entering marathon training with an already strong base of running experience, coaches and runners can wisely build on tempo and interval runs, mileage, and days of running per week, which will improve marathon performance.

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Acknowledgments

The authors would like to express their gratitude to the CARA for their assistance in recruiting runners to participate in this research study, to all the runners for their enthusiasm and commitment to our study, and to the University of Illinois at Chicago's Center for Clinical and Translational Science for their statistical analysis assistance. The authors received no funding to conduct this research study. The authors have no disclosures to make.

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Keywords:

running; race; train; prevent; mind

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