Sunday, January 24, 2021

How To Increase Range Of Motion

All the kids posed for this picture

A typical comment from many of our patients is that they have been stretching all the time but their muscles still feel tight. 

Range of motion (ROM) is necessary as part of our health and important during sports performance. And static stretching is often prescribed to get better ROM gains. We know from previous research that static stretching is effective in improving our range of motion. 

However, the latest systematic review/ meta-analysis shows that strength training (ST) is just as effective as static stretching in getting improvements in ROM.

The researchers pooled data together and found eleven good quality studies comprising 452 participants to derive the following results.

Interventions lasted between 5 and 16 weeks while training frequency ranged from two to five times a week. Subjects included healthy sedentary subjects, subjects who already participate in ST subjects with fibromyalgia and subjects with chronic neck pain. There were also elderly adults who had difficulties in one of four tasks, transferring, bathing, walking and going to the toilet.

Both ST and static stretching groups showed significant improvement in ROM in seven of the studies. Differences between the groups were non significant. They did not find any significant differences in active and passive ROM for both ST and stretching. Dynamic stretching did not improve ROM in any of the groups.

You must be wondering how ST helps to improve ROM that is not statistically distinguishable from static stretching. The authors wrote that ST with an eccentric focus requires the muscles to produce forces in a lengthened position. This is what helps improve ROM. They also found that concentric strength training improves ROM when full range is required.

One study demonstrated significant reductions in pain associated with increases with strength, suggesting that decreased pain sensitivity may be another mechanism in which ST help increase ROM. Another mechanism may be an improved agonist-antagonist co-activation helping ROM gains.

The authors concluded that both ST and static stretching can improve ROM both in the short and long term suggesting that there are both neural and mechanical factors at work. Both ST and stretching can be prescribed to help improve ROM. If one does not respond or adhere well to a stretching program, they can switch to strength training instead.

What does that all mean you (if you did not understand the discussion above)? If you're looking to get an increase in your range of motion say in your knee joint, you can do eccentric strengthening exercises with some stairs at home. This previous article explains everything in a simple manner.

Just remember that static stretches are best done after exercise as just one bout of static stretching can slow you down as well as reduce your maximum strength.


Afonso J, Ramirez-Campillo R, Moscao J et al (2021). Strength Training Is As Effective As Stretching For Improving Range Of Motion: A Systematic Review And Meta-analysis. DOI:

Sunday, January 17, 2021

Is Good Posture Just A Myth?

If 295 physiotherapists (from four countries) cannot even agree on which is the best sitting posture, then how can the average person know what is? 

Other than having the physiotherapists do a back beliefs questionnaire (BBQ), the above mentioned study had a range of nine sitting options ranging from slumped to upright sitting. 85% of the physiotherapists surveyed selected one of two postures as 'best', with one posture being selected more significantly than the other. 

However, those two frequently selected postures were very different to say the least. The physiotherapists who selected the more upright posture had more negative low back pain beliefs in the BBQ. The main differences were what constitutes what a 'neutral' spine is and what is the best sitting posture is.

If you are slouching at your desk, almost everyone will tell you to sit up straight and watch your back. This is especially so when bending forward or while lifting. Back in 2019, I first suggested that slouching while sitting is not necessarily bad for you, challenging society beliefs about posture and back pain

So many companies have spent money on ergonomic programs to prevent back pain. This would usually involve a health professional/ physiotherapist (trained in ergonomics) checking your office chair/ desk height, screen height/ position with respect to your keyboard/ mouse to ensure everything is lined up in a straight line.

However, there is very little evidence linking back pain to poor posture. Oops, this basically means a huge profitable industry on work place/ home office ergonomics has very little sound evidence. 

All the published research to date has shown that there is no relationship between any postural factors causing back pain. This includes the shape and curves of the back, asymmetries and how we use our backs

Yes, if you already suffer from back pain, you may feel it more while sitting, especially for long periods. But sitting is not the cause of the back pain.

One of my patients told me that she just bought a two thousand dollar Herman Miller chair due to working from home 'causing' her back pain. It definitely helps with sitting up straight, however, it did not seem to help her back pain. That's why she still came to see me yesterday.

So, if you currently do not have neck/ back pain, you do not need to worry about your posture. If you do have pain, then your posture may affect it. Sitting for a sustained period is best avoided. The best ergonomic chair/ table will still give you pain. It is better to move more. Take breaks. Get advice and/or treatment to move with confidence and less pain.


O'Sullivan K, O'Sullivan P et al (2012). What Do Physiotherapists Consider To Be The Best Sitting Spinal Posture? Manual Therapy. 17(5): 432-437. DOI: 10.1016/jmanth.2012.04.007

Slater D, Korakakakis V et al (2019). "Sit Up Straight" : Time To Re-evaluate. JOSPT. 49(8): 562-564. DOI: 10.2519/jospt.2019.0610

Our spines have natural curves. It is not totally straight at all. You can see from the picture above that the neck is slightly concave, the chest area is convex while the lumbar (low back) region is again concave. In an ergonomic assessment, a 'good' posture usually refers to eliminating/ straightening out these curves.
Here are some common myths and facts about low back pain, slipped discs and your core muscles if you're interested in reading more.

Sunday, January 10, 2021

Which ACL Graft is Less Likely To Tear Again?

Post op -view from the front
In all my years of being a physiotherapist, I have treated many patients and athletes who tore their anterior cruciate ligament (ACL) and opted to have surgery to repair it. 

View from the back
In the earlier days, the bone patella tendon bone (BPTB) graft and the hamstring/ gracilis (HS) graft were the more popular choices. Allografts (cadaver graft) were not popular then, but they are definitely more accepted now.

I've had many patients (not just the athletes) who subsequently re-tore their HS graft. However, I have yet to encounter a patient who re-tore their BPTB graft.

If my observations were accurate, surely then the BPTB graft would be the 'better' and 'stronger' graft? Now it seems like there is evidence supporting my observations.

Researchers studied 770 patients (14-22 years) who were injured playing sports and had a six year follow up period. These patients had one normal un-injured knee and the injured ACL knee was reconstructed using the BPTB or HS graft. Average age of the subjects was 17 years, of which 48% were female.

There were 492 (64%) BPTB grafts and 278 (36%) HS grafts.

The chance of a subsequent  tear on the same reconstructed knee at six years was 9.2% compared to 11.2% in the uninjured normal knee. If it was either knee, the rate goes up to 19.7%.

The three most likely predictors of a subsequent re tearing of the operated knee were knee ligament laxity prior to knee operation, graft selection and age.

Those patients who had a HS graft were 2.1 times more likely to re-tear their ACL graft compared to those who had the BPTB graft.

Choosing your graft after tearing your ACL will definitely be influenced by discussions with your doctor, surgeon and physiotherapist etc. Moreover, besides the BPTB and HS grafts, you can also use an allograft (cadaver) now. 

Please bear this information in mind if you were to tear your ACL. Please come talk to us if you have any questions.


Spindler KP, Huston LJ, Zajichek A et al (2020). Anterior Cruciate Ligament Reconstruction In High School And College-age Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? 48(2): 298-309. DOI: 10.1177/0363546519892991.

R knee

Friday, January 1, 2021

Health Trends For 2021

Straits Times 1/1/21

Great suggestion in today's Straits Times article on the back page (B16, under Sports section) where the author suggested having more local running events for women.

I say not just more races for women only, but men and those under 21 too. In a year where most if not all running races were cancelled, runners are starved for social interaction and a chance to clock a personal best time for some or be quick enough for that elusive Boston qualifying (or BQ) time.

Perhaps with the rollout of the vaccines making exercising in enclosed spaces safe again, people may still want to go back to gyms, yoga studios and fitness centers etc.

I'm hope I'm wrong for the sake of those businesses, but I think gyms, yoga, Pilates studios may not be totally out of the woods yet. Bike shops, cheap dumbbells and other home exercise equipment will definitely continue to be in hot demand. Since March 2020, where most the world started lockdowns, too many people have learnt how simple, cheap and safe training at home is. 

I'm predicting that running, cycling, long walks and roller blading will continue to be popular in this new year. Let's all recognize the benefits of our local parks, bike lanes, park connectors and green spaces. All these spaces definitely impact our health.

A lot of us started baking, cooking and even growing our own food since the lockdown. All are healthy trends and may we continue to do that.

Let's continue to support our own local communities, the smaller shops and restaurants as they battle to carry on. We bought all our Christmas and birthday gifts from Everyday Vegan Grocer and Le Matin.

Here's wishing all of you a safe, healthy and wonderful year ahead.

Thursday, December 24, 2020

Not On The Surgeon's Birthday

Picture from Pinterest

It's Christmas Eve and I've just finished my day at the clinic when I happened to see this article.

The authors of this study analyzed 9,800,876 surgical procedures performed by 47,489 surgeons over four years. The surgeries were all emergency procedures to prevent selection bias (patients choosing their preferred surgeons and surgeons choosing patients based on illness severity).

Four common heart surgeries, hip, thigh fractures, lung resection, appendectomy, amputation of lower extremity were among the 17 surgeries performed by these surgeons.

0.2% (2064 surgeries) were performed by the surgeons on their birthdays. These surgeons who worked on their birthdays were on average older and more likely to be men. 

Here's the shocking news. Patients had a higher chance of dying (7%) within 30 days after surgery while operated by a surgeon on the surgeon's birthday compared to other days (5.6%).

This was after adjusting for patient characteristics and surgeon fixed effects (i.e. comparing outcomes of patients treated by the same surgeon on different days).

The authors suggest that surgeons may be distracted by other life events unrelated to work when they operated on their birthdays!

Perhaps from 2021 onwards we too should give our staff the day off on their birthdays so that they will not be distracted.

Here's hoping this post finds you resting and/ or enjoying time with your loved ones after one long, unprecedented year. Merry Christmas and happy holidays from all of us at Physio Solutions ad Sports Solutions.


Kato H, Gena AB et al (2020). Patient Mortality After Surgery On The Surgeon's Birthday. BMJ: 371: m4381. DOI : 10.1136/bmj.m4381.

Friday, December 18, 2020

Patient Waited 5 Hours For Appointment

Has this happened to you before? The patient above, mentioned that there was a waiting time of about three and five hours respectively during the last two visits to see the eye doctor.

I've had many of my friends and family tell me about the same thing happening to them. Attending a medical appointment would often take up a whole day. 

On a personal note, I remember having to accompany my mother for a doctor's visit and we had to wait for over two hours as well. Such a waste of time.

At our clinics, we promise you will never have to wait more than five minutes. We will try our utmost to see you on time. We never ever book two patients or more for the same slot. 

You will not be attended by a therapy assistant if you're seeing the physiotherapist. We do not employ any therapy assistants in our clinics. If you're seeing us for an hour, you will have our undivided attention. We will not put you on a machine and attend to another patient. 

The first session with us is longer as we take the time to ask questions and assess you thoroughly to find the cause of your problem. We treat the cause of the problem and not just treat your pain. If you get better after one session, we will not ask you to come for another session.  

Rest assured, you would never have to put aside a day to see us for physiotherapy. We respect your time.

Sunday, December 13, 2020

Be Patient So You Don't Become A Patient

Maybe the best thing to do now is nothing. To not change anything. My friend, whom I shall not name is always drawn to bright, new and shiny things. He is always after the latest fads. Especially when it comes to health and fitness.

Consider his diet. He is always following the latest 'flavour of the month'. Whether it's low carb, high fat, Atkins, South Beach, intermittent fasting etc, he's tried them all. I often tell him that his quickness in switching diets (due to not seeing results quickly enough) is probably detrimental to him losing weight.

I quoted him a study done by researchers comparing low fat and low carb diets. Participants were randomly tracked for a year. Those who lost the most weight were those who adhered to that diet. Being on either diet didn't matter as much. Slow and steady wins all the time in the long haul.

I would say this is exactly the same for fitness too. A paper published in the British Journal of Sports Medicine found that the best way to avoid getting injured is to slowly increase your training volume over time. Excessive and rapid increases in training loads are responsible for a large proportion of non-contact soft tissue injuries.

I travelled extensively with our Singapore badminton players and went to two Olympic Games with Team Singapore. The players had training camps and competitions all over the world and I've had the privilege of seeing world class badminton players like Lin Dan, Lee Chong Wei, Taufik Hidayat, Peter Gade and Singapore's own Ronald Susilo  train. (Below is a picture of him beating Lin Dan at the Athens Olympics).

I'm more excited than Ronald!
They all employ different strategies to build fitness and hone their court skills. Different coaches have different coaching styles. But all lead to the same objective, to be able on put the shuttlecock where they want to on court, be it with a smash or drop shot to win the point. To win the badminton match.

Sitting on court in Beijing 2008
And the key to success is that the players stick to the plan. There are many roads leading to Rome, and they get there only if they stick to their path.

If the training you did this week was twice as much as what you average over the past four weeks, you're 5 to 10 times more prone to getting injured compared to 10 percent increases in training volume and intensity.

This is especially true when my patients are returning from injury. I always tell them to err on the side of caution. Doing too much too soon may get them injured again. Our bodies need time to adapt to training loads after injury.

So as this strange, unprecedented year draws to a close, hang in there if your diet or fitness routine hasn't gone exactly to plan. Be patient, keep at it, remember it's slow and steady that always wins in the end. Patience is really a virtue.


Gabbett TJ (2016). The Training - Injury Prevention Paradox: Should Athletes Be Training Smarter And Harder? BJSM. 50(5): 273-280. DOI: 10.1136/bjsports-2015-095788.

Gardner CD, Trepanowski JF et al (2018). Effect Of Low-fat Vs Low-carbohydrate Diet On 12-month Weight Loss In Overweight Adults And the Association With Genotype Pattern Or Insulin Secretion. JAMA. 319(7): 667-679. DOI: 10.1001/jama.2018.0245.