Monday, August 10, 2020

Thera/ Massage And Vibration Guns. Do They Work?

Picture taken by iPhone 11 Pro from Shopee
Earlier in the week, I read an article on the same topic written by CNA Lifestyle. Actually, I already wrote half of the article on that exact same topic last week but decided to publish the article on bicycle lanes in Sigapore since bicycles are much closer to my heart.

The author did a good introduction on what massage or thera guns are and what they do in that article. She also interviewed other health professionals for their thoughts. So my article will be different. It will explain the science behind why thera or massage guns feel so good when you use them. And of course the evidence available.

Thera or massage guns are being advertised with all kinds of benefits like helping with aches, pain and stimulating "muscle recovery". They can certainly vibrate your muscles/ tissues but almost all the medical claims are not totally true.

Vibration therapy definitely is relaxing for most people especially if it's not too strong or sudden or in an uncomfortable location. Sitting in a warm pool with bubble jets (like a jacuzzi) come to mind and I'm sure all of you who tried will agree that it's a pleasant sensation.

And vibration, waves and frequencies are what some physiotherapists already use for treatment. These include ultrasound, electrical (TENs) and magnetic stimulation, infrared radiation and even lasers. The above are mainly microscopic vibrations aimed at cells at the cellular level and a wider range of frequencies and smaller amplitudes.

Even ESWT (or shock wave) uses high intensity waves to smash kidney stones, (used by doctors) and/ or stimulate bone healing. Many other physiotherapists also uses ESWT to treat plantar fasciitis.

An article published in the British Journal of Sports Medicine showed that runners who receive daily sessions of vibration therapy on the legs were less sore  and had fewer blood markers associated with soreness compared to runners who did not (Broadbent et al, 2010).

Coarse vibrations have interesting neurological effects too. Vibrations added to really flexible gymnasts appears to increase their flexibility further (Kinser et al, 2008).

One reason why vibrations help is a change in our proprioceptive state. Proprioception is how we sense or judge our position. When the body is being vibrated or shaken, plenty of input goes to our cerebellum in the brain. When there is no danger perceived by the cerebellum, the nervous system send signals for the body to relax. That's why the body calms down and you feel good.

Another reason is the strong and distinctive vibratory sensations are quite the opposite of feeling stiff and tight. Just like splashing cold water on your face when you're hot, vibration feels like a natural remedy to your stiffness.

So patients with conditions like muscle strains, neck pain and especially low back pain with fear being a big part of it may feel better after using massage guns or other vibration therapy.

However, if you have shin splints (will hurt more actually), plantar fasciitis and nerve entrapment issues then they probably will not help.

So, still thinking about splashing your your earned cash on this? Save your money. Or better still come see us in our clinic to treat the cause of your problem.


Broadbent S, Rousseau JJ et al (2010). Vibration Therapy reduces Plasma IL6 And Muscle Soreness After Downhill Running. BJSM. 44(12): 888-894. DOI: 10.1136/bjsm.2008.052100

Kinser AM, Ramsey MW et al (2008). Vibration And Stretching Effects On Flexibility And Explosive Strength In Young Gmynasts. Med Sci Sp Exer. 40(1): 133-140. DOI: 10.1249/mss.0b013e3181586b13.

Saturday, August 1, 2020

Bike Lanes In Singapore?

Singapore's only bike lane@ Coastal road
I last wrote about having bicycle lanes on the road way back in 2010 and 2011. No one really paid attention then. Then earlier this week, British Prime Minister Boris Johnson came out promising to build thousands of miles of new bike lanes to get the Brits moving and healthy after months of coronavirus lockdown.

His pledge came after plans to force restaurants to display calories on menus as part of a bigger battle to help the British lose weight. This is after an analysis by the Organization for Economic Development released in 2019 found that Britain was the second fattest nation in Europe, with almost a third of the population classified as overweight.
ST 1/8/2020 on page A23
Being obese makes one more vulnerable to many diseases including the coronavirus.This is especially true for Johnson himself after his own experience with Covid-19. His life was in danger and he had to be treated in intensive care largely because he was overweight. He had previously dismissed the idea of government intervention over what the public should eat, but changed his mind after being hospitalized.

When Minister Mentor Lee Kuan Yew was still alive, he did consider special bike lanes for cyclists in Singapore. He had in his younger days cycled to university in Cambridge and had to also cycle about five miles uphill to visit his girlfriend and later wife as she lived in a different hostel.

From -Hard truths to keep Singapore going
"It's better for everybody's health, it's better for the environment and it's certainly better than having the place or having the roads overcrowded with cars, taxis, buses."
From -Hard truths to keep Singapore going
During the circuit breaker/ lockdown in Singapore, it was a dream come true for cyclists, as there was so much less traffic on the roads. My sons and I went cycling almost daily as we did not have to worry about sharing the roads with the cars and buses. Throughout the world, bicycles were selling like hotcakesincluding Singapore, as many people rode bikes for both transport and exercise.

Some of you reading this may say that it's too hot to ride bicycles to the office or to run errands. Yes, in our climate you will will definitely need a shower after riding to work. But it will also not to be too cold when it rains. So we will need to have toilets and parking spaces for bicycles. A small price to pay for a cleaner and greener environment.

Many drivers will not like this idea (there are many drivers who hate cyclists if you look at the online forums) of bike lanes on our roads. Well, you can't please everyone.

Newly appointed transport minister Ong Ye Kung, are you reading this?

*A big thank you to Jeffrey Keng. The very first picture right at the top and the one just above was taken from a video by Jeffrey Keng on 22/9/18 while we were cycling along Coastal road.

Sunday, July 26, 2020

Do You Need To Treat Your Trigger Points?

A common comment I get from patients is that they have "trigger points" in their muscles. Either they have been told by someone else treating them or they have read somewhere that "trigger points" are sore, painful areas in their muscles.

Trigger points are often assumed to be specific areas of tenderness in a muscle which can cause generalized musculoskeletal pain when over stimulated. It is believed that most of this occurs because of muscle overuse, muscle trauma (or injury) or even psychological stress.

Trigger points are also thought to arise from sustained repetitive activities like working on a computer/ phone all day or lifting heavy objects at home or work.

Trigger points feel like a lump or knots just under the skin. When pressing on trigger points, most people don't feel any pain or discomfort although there are others may feel pain.

If you google "trigger point therapy" the following shows up (see picture above). Many physiotherapy clinics and other healthcare professionals advertise and make money by claiming to be able to treat your trigger points.

I have also had some of my patients that me that some health practitioners they see say that trigger points are distinct areas of localized inflammation. However published evidence suggest otherwise.

Patients with chronic tension-typed headaches were matched with a healthy control group that had no such trigger points in the trapezius muscle.

Samples after needles were inserted into the patients at rest, 15 and 30 minutes after static exercise (10% of maximal force). All samples were coded and analyzed blindly.

The researchers found no difference in resting concentration of inflammatory mediators or metabolites between patients with tender trigger points and non tender controls. There was also no change after exercise.

The researchers suggest that the trigger points are not sites on ongoing inflammation.

Now you know. Trigger points are not sites of inflammation. You do not have to treat it. Getting rid of trigger points may not solve the problem.


Ashina M, Stallknecht B et al (2003). Tender Points Are Not Sites Of Ongoing Inflammation- In Vivo Evidence In Patients With Chronic Tension-type Headache. Cephalalgia. 23(2): 109-116. DOI: 10.1046/j.1468-2982.2003.00520.x

Sunday, July 19, 2020

Lots Of Recreational Runners Take Drugs To Run

Not the kind of drugs that that elite athletes use like growth hormone or erythropoietin, but common off the counter ones like Ibuprofen. 

Don't believe what I'm writing? Consider the following patients I treated recently. I had a runner who runs ultras and another newbie runner who just started running during the circuit breaker/ lockdown because he couldn't go to the gym. Both had a combination of mild injuries and muscle soreness and instead of taking a break they both gulped down a couple of Ibuprofen tablets and occasionally stronger non steroidal anti-inflammatory drugs (NSAIDs) so they can keep running and training.

Here's what I read. 46% of runners recruited (total 109 runners) recruited during the 2016 London Marathon registration planned to take an NSAID during the race.  Of those 109 runners returning for data collection, 34% had already taken an NSAID on the morning of the race while more than half the runners completing the study (16 out of 28 runners) had taken an NSAID.

Only 13 of the 28 runners (13) correctly stated the risks of taking NSAIDs while only 10 runners (35%) knew the correct safe dose.

NSAIDs while helpful with masking your pain while exercising can cause stomach ulcers, acute kidney injuries and also a risk of strokes and heart attacks (depending on dosage  and how long they are taken).

Under duress of a long distance endurance event, risks may increase. Reduce blood flow and motility in the stomach make tummy problems common even without NSAID use. Muscle damage from racing may increase protein in the blood which can lead to acute kidney damage. This may be worsened by NSAID use. Hyponatremia can also be heightened by use of NSAIDs.

Researchers in UK, surveyed 806 runners in the Parkrun there to find out about usage in a diverse group of runners. A third of  these runners raced marathon distances or higher. Almost 90% of the runners surveyed used NSAIDs (most used Ibuprofen, which does not require prescription by a doctor).

More than half the Parkrun runners took NSAIDs before a run or a race.The longer the run, the more likely they were to take NSAIDs before or during the run. One in ten runners took them during a run and more than 65% took them after a run.

33% of the ultra runners compared to 17.5% of marathon runners took NSAIDs during the event. This is of concern a the longer events already put extra stress on their stomach and kidneys as it is.

Those who do not log longer distances used NSAIDS so that they can keep exercising with pre-existing pain, ongoing medical issues or current injuries. Those who ran further (>40km a week) were more interested in reducing inflammation, soreness, pain and performance enhancement/ improvement.

Almost half the surveyed runners used NSAIDs without any advice from a healthcare professional thought almost all said they would read the advice if it was provided to them.

I, too have taken NSAIDs on the night before and the day of a race. Tried it twice, although I thought they didn't make much of a difference to my performance. Hence, I didn't take them after.

If you're using NSAIDs to run through pain and injury to meet your training/ racing targets, it is counterproductive to the long term health benefits of running especially since NSAIDS can affect healing and recovery. Using NSAIDS occasionally before or after your weekly run is definitely less risky compared to frequent, regular usage during demanding training. Needless to say, they should be avoided while your body is under sustained physiological stress during races.


Rosenbloom CJ, Morley FL et al (2020). Oral Non-steroidal Anti-inflammatory Drug Use In Recreational Runners Participating In Parkrun UK: Prevalence Of Use And Awareness Of Risk. Int J Pharm Pract. DOI: 10.1111/ijpp.12646

Whatmough S, Mears S et al (2017). The Use Of Non-steroidal Anti-inflammatories (NSAIDs) At The 2016 London Marathon. BJSM. 51:409. DOI: 10.1136/bjsports-2016-097372.317

Sunday, July 12, 2020

Do Heavy School Bags Cause Back Pain In Children?

I had a nine year old girl come to our clinic to see me this week complaining of neck pain. Her grandmother who brought her thought it may be related to her very heavy school bag that caused it. That along with the extra time on screens during home based learning recently during the circuit breaker.

After examining the little girl, I explained to her grandmother that what she thought may not be true.

You would have seen plenty of advertisements on the internet suggesting you buy your child an ergonomic bag pack for your child to avoid back and neck pain. However, when I searched the literature, there were no convincing proof in the last 20 years between heavy school bags and posture/ back pain among the young.

Many of you would have seen a young child with a big school bag on their shoulders. You would have read about it in the papers. There are many articles available online regarding this topic too. Many of the articles quoted above suggest that your child should not carry more than 20 percent of their body weight. After searching, I found out that this figure is taken from an article by Dockrell et al in 2013).

The most recent evidence published was from a systematic review in 2018 conducted by a team of Australian Physiotherapy researchers. They examined 69 eligible studies with a total of more than 72,600 children.

Many of the articles were rated as either having a moderate to high risk of bias due to high attrition rates, mixed testing methods, confounding factors and poor prognosis. As a result, most of the articles did not find an association between school bag characteristics and low back pain even though there were mixed sample sizes, different school bag weight and different definitions of back pain.

The authors suggested that due to variables in school bags, measuring instruments and timing of data collection, there were no straight "yes" or "no" answers. Hence, no strong conclusions can be formed.

An older systematic review in 2008 examined 10 qualified trials with more than 17,000 children/ teens on neck, upper back and shoulder pain. The authors found that static postures, depression, stress, psychosomatic symptoms, age and gender (girls had higher reports of pain than boys, especially those who were depressed (Prins et al, 2008).

If I may digress here, even among adult research there was insufficient evidence for association between spinal curves (e.g. scoliosis) and all other health related outcomes. This includes low back pain, disc herniation, neck pain, fractures, headaches, symptomatic degenerative lumbar disc disease and thoracic pain (Christensen et al, 2008).

Perhaps many of us (including all the online articles you read) after seeing a child hunched forward with a heavy school bag while walking home assume that heavy back packs causes neck and/or low back pain.

This may have fueled further beliefs among doctors, physiotherapists, other clinicians and the general public that heavy back packs can cause neck/ back pain.

Personally, I do get concerned whenever I see a young child carrying a heavy back pack even if the evidence does not suggest that it will hurt them permanently.

As my wife says (quoting Tom Myers), children have very elastic connective tissue and they are very resilient. Unless your child is perpetually carrying a super heavy school bag, it probably will not affect their necks and backs permanently.


Dockrell S, Simms C et al (2013). Schoolbag Weight Limit: Can It Be Defined? J Sch Health 83: 368-377.

Prins Y, Crous L et al (2008). A Systematic Review Of Posture And Psychosocial Factors As Contributors To Upper Quadrant Musculoskeletal Pain In Children And Adolescents. Phy Theory Pract. 24: 221-242. DOI: 10/1080/09593980701704089

Yamato TP, Maher CG et al (2018). Do Schoolbags Cause Back Pain In Children And Adolescents? A Systematic Review. BJSM. 52: 1241-1245. DOI: 10.1136/bjsports-2017-09827.

Sunday, July 5, 2020

Iliotibial Band Pain In Runners

The ITB originates from the TFL
I had a patient this week that was suffering from Iliotibial band (ITB) pain and he was so fed up with the pain that he was considering getting a steroidcortisone injection to get rid of the pain. He sent me an article he'd found for me to ask for my opinion.

Having previously suffered from Iliotibial band or ITB syndrome myself before, I'll naturally read any article I'd come across about the ITB.
The ITB over the Vastus Lateralis muscle
The article itself wasn't so interesting even though the authors got a good result after their intervention. The authors concluded that a steroidcortisone injection was effective in reducing ITB pain in runners in the first two weeks of treatment.

I'm not a fan at all when it comes to injecting steroid (or cortisone) to treat any sporting injuries. I written previously that often the cause of the problem is from the hip. For best results, you treat the cause of the problem.

As I've written previously, if you're an athlete or exercising regularly, you definitely do not want a steroidcortisone injection since there is a very high chance of degenerative changes in the surrounding area of the steroid injection. You can read about how my patient tore his forearm flexor tendon after repeated steroid injections.

Anyway, what intrigued me about this article was the small sample size and how long it took to recruit the runners (it took two whole years). The authors managed to recruit 45 runners but only 18 fulfilled the criteria and finished the study.

There was an attempt to have a longer follow up period, but there was too much variability in the second phase treatment of the condition. Their return to running, distance ran, rehabilitation program, change in footwear and use of orthotics etc.

Most of the eligible runners did not want to stop running during the 2-week intervention period. Exactly what I said about athletes (not wanting to rest) in my interview which you can see here. This shows the challenge of recruiting runners for research.

How about you? If you were recruited for a running research and asked to stop running for 2 weeks for the sake of research, would you comply? I'd like to hear your views.


Gunther P and Schwellung MP (2004). Local Corticosteroid Injection In Iliotibial Band Friction Syndrome In Runners: A Randomised Controlled Trial. BJSM. 38(3): 269-272. DOI: 10.1136/bjsm.2003.000283.

Sunday, June 28, 2020

My Patient Had Myositis Ossificans

I had a patient who came in recently with Myositis Ossificans. Myositis Ossificans is a condition where there is formation of bone inside a muscle, other soft tissue or around a joint after an injury. It is more common in younger patients and athletes after a traumatic injury such as receiving a hard kick while playing football.

It can also happen where there is a repetitive injury to the same area, such as my left elbow joint area (more on this later).

Regardless of what caused it, Myositis Ossificans happens when there is an 'error' in the body's healing process. This occurs after fibroblasts (or muscle cells) are accidentally replaced by immature bone cells at the injury site.

This causes a hard lump to develop within the muscle. It starts off as a gradual process and begins shortly after the initial injury.

Unlike other common muscle strains or injuries, patients with Myositis Ossificans will find that their pain worsens as time goes by instead of getting better. The muscle /injured area feels warm, often has a decrease in range of motion, swelling and a obvious lump or bump.

This patient received a big knock on the thigh after an accidental collision while cycling. It was initially thought of as a deep muscle bruise. But when the pain and swelling did not subside, the patient's parents consulted me and I immediately suspected Myositis Ossificans after hearing the history and feeling the 'lump' in the patient's thigh. This was later confirmed by an ultrasound scan by a doctor.
Carrying angle on the left is altered
I, too had Myositis Ossificans in my left elbow. This occurred back in 1994 after I fell repeatedly on my left elbow while cycling.

I had exactly the same signs and symptoms described above. If you look at my left elbow now, it's still looks mildly swollen and a little 'deformed' compared to the right. My left elbow's carrying angle has also been altered.

I can't straighten my left elbow fully (lacking the last 2-3 degrees) compared to my right. Other than that it does not really bother me at all.

It's not difficult to treat once you know what it is and especially if you seek treatment early. Otherwise you may end up with a slightly 'deformed' elbow like mine. Just purely cosmetic, no real deficits.


Rossetini G, Ristori D et al (2018). Myositis Ossificans: Delayed Complicatio Of Severe Muscle Contusion. JOSPT. 48(5): 348-427. DOI: 10.2519/jospt.2018.7567

See the 'lump' near top of picture