Exercise and Type 1 Diabetes: part 2

A picture I found on the Interwebs that amused me

In part 1 I tried to set out the problem of exercising with Type 1 Diabetes (T1D) - in brief, keeping blood glucose levels within reasonable bounds while hormones stimulated by activity are doing their best to frustrate your efforts. Here is part 2, which contains a few things that might help to manage the situation.

Managing blood glucose and insulin

Let’s start with the basic theory. Usually, with low or moderate intensity exercise and some active insulin on board, blood glucose will fall steadily and relatively predictably, and insulin will work more effectively. In order to avoid a hypo then, you would need either to reduce your mealtime insulin at the meal beforehand, or consume carbohydrate during the activity, or both. It is estimated that between 30g and 60g of carbohydrate is needed per hour to fuel moderate exercise.

So you could measure your blood glucose level before and after your activity and see how much it drops – say, from 11 to 6 mmol/L over 30 minutes fast walking 2 hours after a meal containing 60g carbohydrate for which you took half your usual dose of rapid insulin. If on another occasion your blood glucose was only 8 mmol/L before the same activity in the same circumstances, you could predict that carbohydrate would probably be needed to prevent a hypo.

To be able to reduce your rapid insulin dose at the previous meal, the activity needs to be planned or anticipated. Often activity is not planned, in which case there is no option but to eat or drink carbohydrate, unless your blood glucose happens to be high anyway. You can see that this makes it much more difficult to lose weight by exercising than for someone without diabetes. So another tactic that was suggested to help weight loss was to do the activity when insulin levels are at their lowest, usually first thing in the morning, although clearly this also requires an element of planning. But I can’t see how that would work if blood glucose is also at its lowest, because that’s just asking for a hypo, so maybe you’d have to reduce your overnight background insulin so that fasting blood glucose levels are a bit higher than usual. I’m not a fan of messing with background insulin on a day-to-day basis, which I will outline later on in this huge essay.

Blood glucose doesn’t always drop with exercise. If the activity is anaerobic (sprint, weight lifting, resistance exercise at the gym) then blood glucose tends to rise because those other hormones (especially adrenaline) stimulate the release of glucose and increase insulin resistance. In this situation extra insulin may be needed to take blood glucose levels down rather than extra carbohydrate to prevent hypos. A stressful or competitive situation like a football match where adrenaline is a factor may have a different impact on blood glucose compared with regular football training, and may need a different insulin dosing strategy.

This effect can be used to your advantage. If blood glucose before an exercise session is between 4 and 7 mmol/L, then starting with anaerobic or high intensity/stressful exercise may raise blood glucose enough to allow you to carry out some aerobic exercise without the need for insulin or carbohydrate adjustment ahead of time.

So we can start to imagine types and duration of activity and the likelihood of blood glucose rising and falling so that insulin and carbohydrate can be managed before and during exercise. Then comes the aftermath.

There are two effects of exercise on blood glucose after the activity is completed. The first is that glycogen stores in muscles and the liver have been depleted and need to be restocked, which makes blood glucose drop in the hours following the exercise. The other is that activity makes muscles more sensitive to insulin (less resistant) particularly in the period between 7 and 11 hours after exercise – the stress hormones released during activity induce insulin resistance for about 7 hours afterwards. For exercise in the afternoon or evening, this period of greatest hypo potential occurs during the night. Exercising first thing in the morning means the period of maximum hypo risk occurs during the day rather than overnight, which may be helpful.

Ways to manage this hypo risk after exercise include taking carbs on board immediately after exercising, and/or reducing the amount of insulin given for subsequent meals and corrections by about 50%, and possibly also reducing overnight basal insulin (but see below). Another option uses adrenaline to raise blood glucose levels by incorporating a 10-second sprint at maximum exertion level at the end of the period of exercise.

Blood glucose monitoring is the key to managing the amount of carb/insulin to maintain good control after exercise. Some experimentation is likely to be needed, while bearing in mind the poor reproducibility mentioned earlier. Perfection is unlikely to be achieved.

Background insulin adjustment

So far, all the insulin adjustment has been with the rapid insulin that works with carbohydrates that are eaten or drunk. But it is possible to adjust the background (basal) insulin too, and it was at this point that our practice and the recommendations within the study day diverged.

Background insulin works over long periods – from 12 to 72 hours depending on the type. Reducing the long-acting insulin will reduce the hypo risk overnight, so the advice on the course included routinely reducing this insulin both before and particularly after exercise. Doing this will certainly reduce the hypo risk, but on the other hand calculations of rapid insulin will be thrown out of kilter if background insulin is being adjusted day to day, especially if you exercise some days but not others. We didn’t reach any consensus on this point, so I suppose I’d have to look in the research literature to see if there’s anything relevant there.

I can, however, see the point of a basal adjustment for a short continuous period of daily exercise like an activity holiday – skiing, watersports or walking holidays being the most common examples. And I had not considered the pros and cons of different background insulins before – the newer, very long lasting insulins being less flexible if background insulin is to be adjusted. It’s also true that adopting a more active lifestyle will probably reduce the need for total background (and rapid) insulin, but injecting different amounts of long-acting insulin on a daily basis might be problematic.

What about insulin pumps?

So far all the discussion has been based on multiple daily injections of rapid-acting and long-acting insulin. Pumps are a bit different, because they only use rapid-acting insulin, and basal rates can be adjusted hour by hour. So with a pump there’s no problem about reducing background insulin as well as rapid mealtime insulin to avoid the need for extra carbs or to reduce the risk of hypos. This raises the chances of better control as well as being an advantage if weight loss is one of the aims of doing the activity. Reducing insulin is usually preferable to increasing carbohydrate for the ‘ordinary’ person. Proper athletes will want the carbohydrate, though.

The reduction suggested on the course was to set a temporary basal rate (TBR) of 50% for an hour before and up to an hour after aerobic exercise. If extra insulin is needed for anaerobic exercise, the course recommended raising the basal rate by only 10% starting 30 minutes before and lasting until 60 minutes after the activity. The TBR might be reduced again by 10% in that crucial period 7 to 12 hours after the exercise. There are more complicated formulae for calculating TBRs but I will leave those to the serious competitors.

The main downside to a pump is that it needs to be attached to you, and most types are not waterproof. So the pump would need to be disconnected completely for contact sports or watersports, which is really only safe to do for an hour or so. Some pumps can’t be disconnected temporarily, like the tubeless pumps which are actually attached to the skin. This type is usually waterproof for bathing or swimming up to an hour or so, although it clearly wouldn’t be suitable for scuba diving, and might be dislodged in a rugby scrum or during martial arts.

For situations where the pump has to be disconnected for longer than an hour, competitive athletes sometimes connect up with the pump from time to time to give themselves a quick bolus, or revert to the use of basal and bolus injections from a pen to maintain insulin levels on those occasions. When the pump is reconnected then there may be a need for a correction, which could take one of several forms. You could increase the basal rate by 50% for up to an hour, or give 50% of a correction bolus, or even work out how much basal insulin was missed and bolus half this amount. Then, of course, be a bit more rigorous about monitoring and correcting blood glucose levels.

What else?

There are a whole lot more factors that affect management of T1D with exercise, some of which I haven’t mentioned up to now because they are routine, like the need for fluids. Dehydration not only affects athletic performance but can make the blood glucose level appear higher than it really is.

Heat and cold also affect the uptake of insulin from the injection site as they do at any time. The location of the injection site matters because if you’ve injected near a muscle that will be used for the exercise (usually leg or buttock/lower back) then the insulin will reach your bloodstream faster than if you injected in a non-exercising part of the body.

Keen exercisers may use Continuous Glucose Monitoring (CGM) either standalone or in conjunction with an insulin pump. The main point to highlight with CGM is that there is a delay between the readings they give for the glucose in interstitial fluid and the level of blood glucose, which may not matter if you’re in an office and it’s coming up to lunchtime, but may be critical if you’re just reaching the summit of a mountain.

Carb intake: it has been established that the requirement for carbohydrate during moderate intensity exercise is around 1g per kg body weight per hour, i.e. for a 70kg person that would be around 70g per hour. It has also been established that the gut can only absorb dietary carbohydrates at the rate of 60g per hour, so there is no point trying to increase intake beyond this as it will just cause gastro-intestinal discomfort. The difference is made up by the use of stored glucose and fat as fuel.

All foods are not equal, but the question of which carbs to have at what time was not covered in the course. Of course hypos associated with exercise have to be treated with fast-acting carbohydrate as at any other time, and it would make sense to have slow-acting carbohydrate to sustain any prolonged period of activity. Beyond that, I suppose it has to be trial and error with plenty of blood glucose monitoring to find out which foods before, during and after exercise have the best effect on blood glucose levels. Aside from diabetes, the prevailing view is that a mixture of protein and carbohydrate such as cereal+milk, yogurt or meat/cheese sandwich is a good idea post-exercise to replenish glycogen stores and supply material for muscle regeneration and repair.

The overall message I took away from the study day was that exercising with Type 1 Diabetes is very, very complicated if you want to do anything more exciting than up to an hour of moderate intensity exercise in a regular controlled environment like road cycling, a run around the park or an hour in the gym. Competitive athletes need much more insight into their own physiology, but it is possible to compete at the highest level, and one of the diabetes pharmaceutical companies sponsors competitive cycling with the Team Novo Nordisk.

I have had a couple of patients asking me questions about serious exercise, and we have very quickly reached the limits of my knowledge. I don't see that changing much as a result of this course, but perhaps over time I will absorb more on this subject alongside my greater experience in diabetes as a whole.

Exercise and Type 1 Diabetes: part 1

View from the conference centre, May 2016

The recent study day I attended was about exercise and Type 1 diabetes (T1D), which is a truly difficult topic to write about, and even more difficult to manage.

Many hormones are involved in keeping blood glucose levels stable with exercise, including insulin, glucagon, growth hormone, cortisol and adrenaline. For someone with T1D, insulin is delivered in a very non-physiological way via subcutaneous fat rather than into the hepatic bloodstream from the pancreas. It is also thought that glucagon production by the pancreas becomes less efficient over time following a diagnosis of T1D. Each of these hormones has multiple effects at different organs (brain, muscles, liver, pancreas etc.) and all interact with each other. This complex situation means that the tight regulation of blood glucose with exercise that happens automatically when the pancreas is working properly is almost impossible to achieve with a broken pancreas.

The study day

The course was a single day, but they packed a great deal into it. Speakers presented slides with graphs and evidence and whizzed through topics at such a pace that I could barely keep up let alone take comprehensible notes. The slides were supposed to be available after the event, but I don’t think they have appeared yet, a month later. My scribbled note “good slide explains this bit” will have to wait for interpretation later.

The first speaker talked about ‘normal’ exercise metabolism, the second introduced T1D into the metabolic picture, and the third session was presented by paediatric and adult Dietitians. After a break there was more detail about managing blood glucose before, during and after exercise. The workshops after lunch gave us the chance to think about case studies and individual scenarios.

Overall I think everything was included that needed to be included, but much too fast, and the main focus was on serious athletes and people who were going to be running or cycling or weight lifting or at least going to the gym regularly. There was very little about the unfit or overweight person who might be starting with walking up a flight of stairs rather than taking the lift, or trying to increase their level of activity for weight loss or fitness rather than competing for an Olympic medal. Gardening, DIY, housework and shopping are the more common types of activity that I encounter in my caseload.

I did a little brainstorm for this blog entry just listing all the issues that pertain to the subject – the list was 2 pages long. So what shall I include here? Of course, this particular blog post probably isn’t going to be of much interest to you unless you have Type 1 Diabetes and you want to know about managing your blood glucose while exercising, and I think I may have fewer than one reader in that particular category. No, this blog post is for me, to enable me to assemble my thoughts and produce a reference point for that future day when I might have to advise a patient on this subject.

Fuel for activity

So, first to recap the basics. Dietary carbohydrate is digested into glucose which moves into the blood to be transported around the body. Insulin allows blood glucose to be taken up by cells in the body where it is metabolised into energy or stored as glycogen in muscle and liver. Excess glucose is converted into fat in the form of triglycerides (a triplet of linked fatty acids) and stored in the liver, muscle and in fat cells. High levels of insulin promote this storage process and inhibit the release of glucose or fat into the blood from fat and liver cells.

When energy is needed for activity, the most accessible sources are muscle glycogen and blood glucose. The hormone glucagon prompts the liver to very quickly start converting its stored glycogen into glucose (glycolysis) and send it out into the blood. Triglycerides in the muscles are also easily accessible and are used as fuel (fat oxidation). It takes a bit longer for new glucose to be manufactured in the liver (gluconeogenesis) and for the liver to break down triglycerides into free fatty acids and send them out to be used as fuel (fat oxidation). Insulin levels need to be low for all these processes to work efficiently.

If exercise is more intense (anaerobic) there is more reliance on carbohydrate as fuel; if exercise is less intense but goes on for longer (aerobic) there is a shift towards fat as the main fuel. Obviously exercise drains glycogen stores in muscles and liver, and these are ‘topped up’ afterwards using dietary glucose (fat stores don’t need to be topped up!) Non-diabetic metabolism manages all the hormone levels so all this takes place with blood glucose maintained between 4 and 7 mmol/L at all times.

The main difference that makes things difficult for someone with T1D is that insulin cannot be regulated up and down in a physiological way. It is certainly possible to adjust insulin levels according to various ‘rules’, but adjustment is crude and doesn’t reflect the metabolic state minute by minute.

There are also a couple of scenarios when it is not advisable to exercise. If your blood glucose is high (over 14 mmol/L) then it is possible that you don’t have enough insulin on board, and the official advice is that you need to check for ketones. If blood glucose is high without ketones then a small correction dose of insulin might be all that is needed, but if ketones are present then the full correction dose should be given and exercise postponed until ketones have gone. The majority of people with T1D don't have a meter that will measure blood ketones, however, so this advice is moot.

The other situation when you might choose not to exercise is if you have had a hypo in the last 24 hours, because this makes a hypo with exercise even more likely. If it wasn’t a serious hypo needing third party assistance then you might go ahead bearing in mind the need to be extra vigilant. If the hypo was within an hour before planned activity you would be advised to wait for 45-60 minutes after your blood glucose level has stabilised before exercising.

Changes in blood glucose and insulin

The level of your blood glucose will fluctuate according to:

• the duration, intensity and type of activity
• the type and amount of food and snacks eaten or drunk before, during and after the exercise
• the level of stress and competitiveness
• your level of fitness or previous training
• hydration status
• the time of day

and probably more.

The level of your blood insulin will fluctuate according to:

• the timing of insulin injections/infusion
• the amount and type of insulin injected/infused
• the site of the injection or cannula
• the ambient and body temperature.

Poor ‘reproducibility’ was highlighted in the study day, meaning that the same exercise for different people or even for the same person on different days may have very different effects on blood glucose levels. With all these variables it’s not surprising that matching blood glucose levels and blood insulin levels in order to manage T1D and exercise is a minefield.

So this is the landscape we're working in, with different sources of fuel and the action of hormones all interacting, and we have to try to maintain blood glucose levels without going low or high using tools (carbohydrate and insulin) that are about as precise as trying to steer a car at full speed with just your elbows on the steering wheel. At some point you're probably going to crash.

So having set out the scale of the problem, how can it be managed? Look out for part 2 in the series, coming soon!

What I've been reading

Non-Stop
by Brian Aldiss

narrated by David Thorpe

"Curiosity was discouraged in the Greene tribe. Its members lived out their lives in cramped Quarters, hacking away at the encroaching ponics. As to where they were - that was forgotten. Roy Complain decides to find out."

The first book by Brian Aldiss, and it does a good job of describing the unfamiliar world where humans live among outsiders, giants and other tribes as well as intelligent rats, mind-reading moths and other creatures. Perhaps a few too many strands to the tale, and the rats are never fully explained, but the final chapter solves most of the conundrums. The story ends without letting on what finally happens, which in this case isn't frustrating but allowed me to think on about the different possibilities.

Invitation to the Waltz
by Rosamond Lehmann

narrated by Joanna Lumley

"Olivia Curtis wakes to her seventeenth birthday and her presents: a roll of flame-coloured silk for her first evening dress, a diary for her innermost thoughts, a china ornament, and a ten shilling note."

This is a calm, reflective and descriptive book that takes us from Olivia's birthday up to her attendance at her first ball, plus a tiny bit of the aftermath. It contained some memorable scenes: the dress had to be made, and it wasn't made all that well. The scene between Olivia and the itinerant lace saleswoman was excruciating in its reality. Olivia's older sister and younger brother were beautifully brought to life. The characters at the ball were all so different, and so nicely described. It wasn't a thrilling read, but I did enjoy living the early twentieth century life for a little while.

The Disappearing Spoon
by Sam Kean

"The fascinating tales in The Disappearing Spoon follow carbon, neon, silicon, gold and every single element on the table as they play out their parts in human history, finance, mythology, conflict, the arts, medicine and the lives of the (frequently) mad scientists who discovered them."

At last, back to the type of book I once used to read for pleasure. I discovered I had a lot of money tied up in book tokens so I treated myself to a trip to a real world high street bookshop. Such indulgence! And it's a good book, no doubt of that - I read it all and enjoyed it, but none of it was memorable. I only finished reading it yesterday but if you were to ask me for a nugget of information I wouldn't be able to remember anything worth telling.

The Return
by Victoria Hislop

narrated by Jane Wymark

"Beneath the majestic towers of the Alhambra, Granada's cobbled streets resonate with music and secrets. Sonia Cameron knows nothing of the city's shocking past; she is here to dance. But in a quiet café, a chance conversation and an intriguing collection of old photographs draw her into the extraordinary tale of Spain's devastating civil war."

I've read two others by this author, and I liked the first one best, and this one least. The use of a story within a story was clunky, but it did provide a flavour of the Spanish Civil War in the context of one family's experience. The resolution was obvious a mile off. The very worst thing about it was the narrator's Spanish accent, which was about as good as mine.

News of Paul Temple
by Francis Durbridge

"Leading lady Iris Archer pulls out shortly before the play is due to open and declares that she is heading for France. However, shortly after her disappearance Paul Temple receives a guest at his Scottish holiday home – none other than Iris Archer."

The last of the Paul Temple books I lifted from the 'free books' basket, and just as bad as the other two, except in this one absolutely all the bad guys are murdered or meet some other sticky end along with several innocent bystanders. The headcount is ridiculous for a 200-page book; there must have been at least ten deaths.

Difficult decisions

Art deco hotel, Borovetz, February 2016

I don't want to write much about last week because it's been dominated by family stuff that's not particularly suitable for public airing. I haven't felt like doing much in the evenings, which is unlike me. On Thursday I decided to go for a run anyway, but two thirds of the way round my usual route I decided to stop because I just wasn't enjoying it. I haven't even started sorting the stamps and envelope collection.

I have started to clear the loft and took a couple of boxes of books to Oxfam. There's a load of old papers from the loft in the downstairs hall that need to be sorted and shredded or recycled, which will leave quite a few ring binders and suspension files that I can't bring myself to throw out, so I'll have to find a good home for those. I also responded to a conversation on the local website Streetlife, offering the trampoline to a good home, so now I need to get that down from the loft too.

Getting the tenor sax serviced was on the list as a priority for this week. I was given contact details for a local chap who came highly recommended, and so far I have sent an email, left a voice message and sent a text without any form of response. I think this suggests either he isn't that interested in the work or is on holiday. There is an alternative but it's in the centre of Birmingham, so nowhere near as convenient.

At work there's been an interesting discussion about my job. I trained to deliver the 'DESMOND' education for people with Type 2 diabetes when there was a huge waiting list in the neighbouring city, and got some extra paid hours to help clear the backlog, and since then I've continued to deliver a course there about every two months. However, in the town where I actually work the course is delivered by two nurses once a month and a waiting list has now built up there, so we enquired about whether I could be paid to help them clear the backlog too.

This has opened a can of worms. It has exposed my ignorance of how the whole edifice of NHS funding operates. I find it very frustrating, but I had pretty much come to terms with the fact that there seems to be no way to find out, let alone understand, how our diabetes services are paid for, apart from the fact that ultimately the funding is allocated by the Clinical Commissioning Group. But are we paid per consultation? Do they give us a fixed amount for all we do in a year? How is my salary allocated between the Dietetic department, the Diabetes department, the hospital where I work and the Trust that employs me? Does the Diabetes service pay the Dietetic department for my support, and if so, what exactly am I supposed to be doing? What exactly are my responsibilities within the Diabetes service? Should I be delivering DESMOND at all, and if so, how often, and where?

This is further complicated by the fact that I am aware there are circumstances where I shouldn't see someone - if they are referred by their GP to a Dietitian but not to a Consultant then it ought to be a Dietitian from a different service, despite the fact that the Nurses in the same building can accept these referrals. And recently one of our Diabetes Consultants asked me to see someone for dietary input who doesn't actually have diabetes - should I accept that referral? Apparently I shouldn't, but what if I do? What difference will it make? Who will care?

Our Diabetes service is going to be reviewed, and I don't want it to appear as though I'm not fully occupied simply because I've been recording my activity wrongly. I'm not in the least bit interested in any of this but it looks as though I'm going to have to ask some more questions. The NHS is a wonderful institution, but it is mind-bogglingly complex.

Philharmonia and philately

Borough Market, May 2016

There has been a long weekend, which in my case extended to Tuesday due to my habitual day off, and it feels as though I have packed in several weekends' worth of excitement. Things that happened: I did not buy a tenor saxophone mouthpiece, I met a man who struck up a conversation (and this in London, mind) and who then offered to sell me a baritone saxophone, I bought said baritone saxophone, I met a lot of fans of the football club Sheffield Wednesday, I met two people I last worked with in 1988 (and one of whom I had not seen since then), people who weren't Lola II and Mr M came round to my house and stayed overnight and I think I managed to behave as a welcoming host rather than a reclusive hermit, two other people who still weren't Lola II and Mr M came round to my house and had a play with the baritone saxophone and were almost as excited as me, and I went to an organ recital. And this doesn't include regular ordinary things like cleaning, cooking, food shopping and running. And I went to my physiotherapy appointment about my painful shoulder.

The previous week-and-a-bit was also full of mysteries and wonders which did include Lola II and Mr M as well as the rest of my UK-based family and a little bit of non-UK-based family. Things that happened: I attended a Study Day about Type 1 diabetes and exercise (a blog post on that subject is a complex scholarly work and still in the pipeline), stayed with Lola II and Mr M, went to Borough Market and the Museum of London with Lola II, attended the UK-based family event, had lunch at a nice garden centre in Little Venice, didn't attend the non-UK-based family event (but neither did the non-UK-based family so that was all right), and spent a day with mum and a Postal Mechanisation Man sorting through dad's collection of philatelic material. I'm using the word 'philatelic' loosely to mean anything relating to the postal service.

I think I should stop complaining about being busy because this now seems to be my normal state. Since I bought the Fitbit there have only been two days when I haven't walked more than 10,000 steps without any extra effort - I thought I would have to try much harder.

I shall pick a few highlights from all the things that have been happening.

The non-UK-based family event involved a cousin who had been in touch to see if he could catch up with us on his way through London. We very nearly put mum and dad in a taxi for an hour and me in a car for even longer in order to meet at Lola II's house but in the end, for various reasons, we didn't. This was a good thing, because the meeting that the cousin was attending between flights took up all the intervening time and he didn't make it to Lola II's house either.

Dad's philatelic collection is big, very big. We have been trying to whittle it down now that he is not actively collecting it any more. One large chunk is all about Postal Mechanisation - in basic terms, the use of machines rather than people to sort mail. Just to prove that for any human interest there is an interest group, there exists a Postal Mechanisation Study Circle (PMSC), whose newsletter led me to contact its Secretary to see if they could provide any support in disposing of dad's collection in a more constructive way than through the medium of a bonfire.

Having spent four hours in his company, I can say that the Secretary of the PMSC is a lovely man. He extended a trip to London with a Tube journey out to mum and dad's house and went through the entire postal mechanisation collection with enthusiasm and excitement. He took a small proportion away with him for auction, and left the rest in piles representing valuable material, stuff that might sell on eBay, and a disappointingly small amount that could be thrown out. There is still much work to do - this collection is perhaps a quarter of the stuff that's still in boxes and cupboards - but I can't manage any more at the moment, especially with the LTRP and the new saxophone-related activity.

The new saxophone-related activity started with a proposal to meet up with people who were kibbutz volunteers at the same time as me back in 1987-88. The proposed venue was Baker Street, and there is a shop nearby that had been recommended as somewhere that would allow me to try out different saxophone mouthpieces, because I had been told that the difficulties I had with the low notes on my tenor sax might be resolved with a different mouthpiece. The tenor sax is extremely heavy, and usually when I go to London it is to the outer fringes where my family lives, so this was a perfect opportunity to get the sax to the shop without a great deal of messing about on the Tube.

So I arrived at the shop with my tenor saxophone and they duly provided me with different mouthpieces to try. It became very clear that the problem was between the mouthpiece and the chair - or possibly the saxophone itself. None of the different mouthpieces solved the problem, so I sat in front of the cafe next door (it was a lovely morning) with a cup of tea and pondered my options. This is when conversation started with the chap at the next table about saxophones and he offered me the baritone sax which was to be found in the basement of his shop across the road. A friend had recently managed to borrow one of these and told me it was worth more than his car, so the £100 price tag seemed like a bargain, especially as it played much better than my tenor sax.

This left me in London with two large saxophones and a meeting in the Baker Street pub - it is a large pub but none of us anticipated that it would be entirely full of football supporters due to an event known as a 'play-off' (I had to ask) which would allow either Sheffield Wednesday or Hull City to be promoted to the Premier League. This pub was restricted to the Sheffield supporters - Hull fans were refused entry and directed to a different pub to avoid any trouble. Unfortunately kick-off was not until 5pm so the pub would be full to bursting for several more hours. Which meant that I and my two large saxophones were not ideally suited to a quiet pint and a chat with ex-volunteers. We eventually decamped to an alternative location and had a lovely time.

There was a lot more activity to come within the long, long weekend, but I shall jump to the physio appointment I had on Tuesday to see if anything could be done about my painful shoulder. This was damaged during ski holiday #2 and has been giving me some trouble for two months but only in certain movements: applying the car handbrake, removing tight clothing over my head, carrying heavy luggage up steep stairs. I wasn't optimistic that physiotherapy would achieve anything, but in fact it achieved a diagnosis of inflammation in the joint between the top of the humerus and the acromion process of the shoulder blade causing some 'impingement'. Three treatments were suggested - a stretching exercise I should do a few times a day, anti-inflammatory gel and ice. It should get better slowly, but I have the option to contact the physio again within a month if I think I need to.