Monday, November 20, 2017

Strength Training Just As Important (If Not More) Than Aerobic Exercises

Lifting before running
After our two beautiful boys came along, my wife used to just run as there was not much time for any other exercise. She found big benefits from minimal running. It improved her mood and energy levels while also lowering her risk of heart disease and stroke.

After a few years of just running, she felt that her fitness level was stagnating and that she was losing strength. So earlier this year, (along with two friends), my wife has been doing twice weekly strength training sessions at the Holland Village F45  gym.

A recent study found strength training just as important (if not more than aerobic training) and can add years to your life. This is the largest study so far (over 80,000 adults) to compare mortality outcomes of different types of exercise people did.

Researchers found that strength training (both gym machines and body weight) decreased the risk of early death (23 percent) and cancer-related death (31 percent).

Earlier I wrote about how weight training can also help solve Singapore's diabetes problem as highlighted by our prime minister during the 2017 National Day Rally. This study lends more weight to my suggestions to help Singaporeans get healthier.

Moreover, the World Health Organization's (WHO) physical activity guidelines suggest 150 minutes of physical activities and two days of strength training every week.

Seems like my wife's twice weekly strength training sessions at the Holland Village F45 is spot on with WHO's guidelines.

For those intimidated by gyms, (be it costs or images of heavy weights), the researchers suggested that body weight exercises like sit-ups, push-ups, lunges and triceps dips done in your own home or local park can be just as beneficial.


Reference

Stamatakis E, Lee I, Bennie J et al (2017). Does Strength Promoting Exercise Confer Unique Health Benefits? A Pooled Analysis Of Eleven Population Cohorts With All-cause, Cancer, and Cardiovascular Mortality Endpoints. Am J Epidemiology. kwx345. https://doi.org/10.1093/aje/kwx345.

Ting Jun having a go with Rachel's help

Friday, November 10, 2017

Like Father Like Daughter

With Mona
Earlier you've read about how I've treated 2 of Singapore's fastest men in our clinics previously. Well, today Mr C Kunalan's daughter Mona came to see me.

I've known Mona since our school days. She used to dominate all the sprints in the National Schools Track and Field events held at the old National Stadium.

I remember when she was running in the "B" division (17 years old and under) as a 15 year old, she clocked 12.2 seconds to break the previous record and be the fastest school girl outright. Much faster even than the all the girls running in the "A" division (20 years and under).

It wasn't a surprise when she went on to don national colors and even won medals at the SEA Games.

As you can see from the picture, Mona is still in very good shape. Other than running, she still does strength training regularly to maintain her speed. Like father, like daughter.

See the resemblance?



Wednesday, November 1, 2017

Arches And Legs

Gotta be in slippers for "Arches and Legs" right?
It has been a big learning week for us. Aized and Rachel went for their Anatomy Trains course last Friday to Sunday. And Ting Jun, Reggie and I went for the next part on the "Arches and Legs" for the past three days.

Some of it has been revision of earlier concepts, while incorporating more in depth details as well.

Here are some pictures from our past 3 days at the course.

Feet and arches
Let me have a look too
Ting Jun deep in thought

When it comes to learning and making ourselves better physios, we make sure we do not cut any corners. As a team, we've spent lots of time going for courses, discussing difficult cases and sharing what we've learnt with each other to improve ourselves.

Majority of our patients are by "word of mouth" referrals. A patient comes and sees us in our clinic, they get better really quickly and they then refer their families and friends to our clinic.

So please come and see us in our clinics and we'll do our best to help you.

Looking forward to using what we've learnt at work tomorrow. Yes, back to work tomorrow.

Wednesday, October 25, 2017

Older Men And Calf/ Hamstring Injuries

Both the calf and hamstrings
After last week's post, I was just talking to Rachel and she mentioned to me this past week she's seen a few cases of patients tearing the calf muscles too. All happened to be male patients on the older side of 40 years old.

I thought of my own patients with calf muscle strains/ tears and realized that they too tended to be the older male patients too.

I was pleasantly surprised that Rachel's and my observation was spot on. A recently published article in the British Journal of Sports Medicine investigated over a thousand articles on the risk factors of calf muscle strains. Ten articles satisfied their inclusion criteria of which more than 5000 athletes in football, rugby union, Australian rules football, basketball and triathlon were involved.

As you get older, your aging athletic body has a few things going against you. You have a higher incidence of disc degeneration and the potential of L5 nerve root compression as mentioned in last week's post.

Older athletes lose some muscle power output and rate of force production. (Trust me on this, I have definitely experienced this).

Moreover, as the athlete gets older, your testosterone levels and production start to decline and this may limit your muscles' rate of recovery, which can lead to accumulative fatigue.

The most predictive risk factors were down to age and previous injury of calf strain. Having previous hamstring or groin strain was also a contributing factor. A possible proposed mechanism for this is a change in the change in the muscle architecture following a muscle strain.

When your muscle heals after a previous injury, the damaged muscle is usually replaced by a fibrotic scar tissue. It is often common to get future damage in the areas adjacent to this scarring.

Another factor that may play a role is due to a change in the length and shape of your damaged calf muscle. Shorter muscle fascicle length has been noted as a risk factor for repeat hamstring strains too.

We can't help you when it comes to your age and previous injuries to the calf and/ or hamstrings. But what we can do along with treating you is to ensure you have a sound rehabilitation process with some definite focus on eccentric exercises.

Here's a tip for those who you who haven't seen us in our clinics. Do your eccentric training at the end of the day when you have no training scheduled or only light training the next day. This minimizes the risk of DOMs or delayed onset of muscle soreness.


Reference

Green B and Pizzari T (2017). Calf Muscle Strain Injuries In Sport: A Systematic Review Of Risk Factors For Injury. BJSM. 51: 1189-1194.

Sunday, October 22, 2017

SS Turns 8!


Our clinic celebrated our 8th anniversary yesterday. A big thank you to all our families, staff, friends and patients for all your support all this while. We wouldn't have done it without all of you.

Our goal has remained the same all this while. To make our patients better quicker. "As long as we're happy and enjoy treating our patients, it's not really work."

Here's to many more years to come!

Monday, October 16, 2017

Hamstring/ Calf Pain? Treat Your Back

Now here's a nasty hamstring injury
I was looking through some of our past articles in our Physio Solutions blog and came across this article on how treating the lower back helps with hamstring injuries.

Here's a good reason why this is so. This article written way back in 2004 addressed the issue of hamstring and calf strains in older footballers in particular (but can also be in runners, triathletes etc).

I came across many of Dr John Orchard's articles back when I was doing my post graduate physiotherapy studies in 2003. This particular article suggested that a possible mechanism of higher occurrences of hamstring/ calf strains in older athletes may be due to your lumbar spine (or lower back) issues.
See where L5 nerve root is, (disc is next to it in white)
He suggested that the L5/ S1 neve root segment may be more prone to irritation and compression under the lumbosacral ligament due to disc degenerative changes. Dr Orchard notes that the L5 nerve root has the "most tortured path through the lumbosacral canal" before going over the sacrum to join the sacral plexus (or nerve roots).
The lumbosacral ligament further lessens the L5 space 

He suggested that it is likely that the location of a larger lumbosacral ligament is clinically more significant in older athletes due to degenerative disc changes (or slipped discs).

Due to possible L5 nerve root entrapment, some older athletes may have regular hamstring/ calf  and nerve muscle and tendon injuries. This happens when the L5/ S1 segment loses disc height (due to a slipped disc).

Space for the L5 nerve root is thus reduced (under the lumbosacral ligament) and may cause back pain and/ or hamstring and calf muscle/ tendon injuries.

So now you know why we treat your lower back when you have a hamstring or calf injury, especially when treating just the hamstring or calf doesn't improve your condition.

This is especially so when you saw from last week's post on how the hamstrings are closely related to the thoracolumbar fascia.


Reference

Orchard JW, Farhart P et al (2004). Lumbar Spine Region Pathology And Hamstring And Calf Injuries In Athletes: Is There A Connection? BJSM. 38(4): 502-504.


Sunday, October 8, 2017

How Your Hips Are Connected To Your Shoulders


Yes, our shoulders are connected to our hips! Definitely if you refer to work done by Tom Myers in his Anatomy Trains book.

If you look at the picture above, you can see that the right hamstrings through its fascial attachments are linked to the buttocks then through the thoracolumbar fascia across to the opposite (left) rib cage, shoulder and arm.

If I say it simply, it means your hamstrings actually attach to your arms! Or if I put it in a different way, your arms don't end at your arms. They end at your legs.

Another look at the connection
So supposing you have a rotated/ and or unstable pelvis (or hip), this can affect your shoulder and change the biomechanics in your shoulders and cause pain.

So in order to treat your shoulder pain, I'm not really crazy if I assess your hips before I look at your shoulder.

Just ask Bertrand, without really assessing his shoulder pain, I made his shoulder better just by taping his hip. 

Now when you come and see us in our clinics, you know why we look at your hips first if you have shoulder pain.

Saturday, September 30, 2017

How To Prevent Fading In Your Next Marathon

Rachel showing her exaggerated "float" phase of the run
You were running really well in your key marathon. You've trained very well, started conservatively despite feeling great hoping to have a strong negative split. You've hit all your target times at each 5 km split that you've written down on your hand.

To your greatest horror, you start to tire in the final miles of the race. Your dreams of a personal best begin to fade too.

What was the fade due to? Was it dehydration? High core temperature or low blood sugar? Apparently, none of the usual suspects according to a paper that studied 40 marathon runners immediately before a race and within three minutes of them finishing the race.

The best predictor of the runners fading was in fact muscle damage.

With each stride you run, your quadriceps and calf muscles contract "eccentrically" (lengthen instead of shorten). The muscles shorten when you push off, but they lengthen whilst you are in mid air in the double swing (or floating phase). See picture below.


This causes an accumulation of microscopic damage to your muscles. It's this eccentric contraction that causes delayed onset of muscle soreness (or DOMs).

The above mentioned study of the marathon runners showed that the eccentric contractions can literally hobble you during the race. Runners whose pace dropped more than 15 percent from the beginning to the end of the race had levels of creatine kinase and myoglobin (both are by products of muscle damage measured in blood tests) 53 and 112 percent higher than the runners who managed to maintain a steadier pace.

When I read the paper, my first thoughts was that the runners who faded did not train enough as those who didn't. However, the researchers suggested that age, running experience and training were not significant enough to explain the differences.

The authors suggested three ways to prevent fading in your next marathon.

Doing your long run close to your target marathon pace is crucial to get your muscles stronger. A 30 km run at or close to your target race pace three to four weeks before to simulate the effort will lessen the chance of muscle damage in the race.

Due to the "repeated bout effect", it will be harder to trigger as much muscle damage once they have recovered. You will need to run harder or faster to trigger similar damage.

The second way to increase your ability to withstand eccentric muscle damage is with weight (or resistance) training. Eccentric lunges and squats of at least 80 percent of the heaviest weight you can lift will help prevent damage to your muscles. Do the weight training twice a week during your training cycle and cut back to once a week when you are tapering for the race.

Be sure to practice downhill running if your race has downhill sections. Running downhill causes lots of eccentric contractions, a sure fire way of triggering muscle damage. Experiment with your stride to find the best way of descending as lightly as possible to minimize the muscle damage.


Reference

Del Coso J, Fernandez De Velasco D et al (2013). Running Pace Decrease During A Marathon Is Positively Related To Blood Markers Of Muscle Damage. PLoS One. 8(2): e57602. DOI: 10/1371/journal.pone.0057602.

Saturday, September 23, 2017

FFTT - Floss Band, Foam Roller, Trigger Ball And Taping

Underwrap? To explain fascia?
It's been a few months since we had our last floss band course. i was told by Jane we had eight previous courses so far.

After the last course Jane mentioned to me that many people have asked about the benefits and especially differences between using the Floss band, foam roller, trigger ball and taping.

She told me my new task was to effectively address how FFTT - floss band, foam roller, trigger ball and taping can be effective (or not depending on how you use them) in treating myofascial pain, addressing adhesion/ knots in fascia and improving range of motion.

Talking about fascia
We spent lots of time on the anatomy of fascia. After explaining how to effectively move fascia, we went on to the practical part of the course. Demonstrations using the floss band, foam roller, trigger ball were shown.
Marc helping with the foam roller demo
For the taping bit, I just showed the class pictures. You've got to come to our Kinesio Taping course if you want to learn the taping techniques.

Let me also mentioned that other than Kinesio TapingFunctional Fascial Taping (or FFT) using rigid sports tape too can influence fascia.

Functional fascial taping for the knee
Ron Alexander who used to treat the Australian Ballet dancers developed the technique while working with the ballet dancers.  If you've attended the course, you will know how much you need to "gather" or pull the tape. In Kinesio Taping, the ability of the Kinesio tape to recoil does the work for you.

Once again, chapeau to Jane, Danny and Ekina for coming to get the place ready and for helping me to pack up too. I wouldn't have gotten ready in time to teach without their help. Please contact them at Sanctband Singapore if you are keen to find out more.

Thank you also all the physiotherapy students, physiotherapists, Terrance Yap from Atlas Chiropractic, the teachers from Nanyang Junior College and the rest who attended the course today. Hope you found it useful.
Getting Tang from NYJC to march
The physiotherapy students and their discussion
Gek Han deep in thought
Gurmit comfy on the floor

Friday, September 22, 2017

Kinesio Taping For F45 Trainers

Demonstrating how it's done
By special request, our clinic organized a special "Introduction to Kinesio Taping" session for F45 trainers from Holland Village and Novena.

The trainers from both F45 have had their fair share of injuries and have some basic knowledge of taping. They were very keen on the session and thought it would be great to get some pointers.
Explaining "recoil"
Of course the session touched on understanding concepts rather than just dishing out recipes on how to tape. That's always how we organize these sessions and the actual Kinesio Taping Level 1-2 courses.

Please contact us if you're interested to learn more.

Saturday, September 16, 2017

Today's Straits Times Article On Hydration

Straits Times article 160917 page C13 under Sport section
Every morning when I pick up the newspapers, I'll usually turn to the sports section first. Today, I happened to look at the article on the training plan for those planning to run the Singapore marathon at the end of the year. "Right hydration integral to a successful race". I thought the article was well written. Fairly straight forward and simple to understand. Also mentioned that over drinking water can lead to hyponatremia.

Wrote about about sports drinks. Though you need to know that sports drinks cannot replace or even maintain your sodium levels during exercise or racing.

Just wanted to point out that the two percent loss of body weight (through sweating) during endurance exercise/ racing affecting your performance may not be totally accurate.

I wrote about it before earlier in the year that latest published research suggest that current hydration guidelines may well be wrong.

Two published studies on cyclists and elite male marathoners (including Haile Gabreselassie during 13 major city marathons) showed that weight loss up to three percent did not slow the runners down nor decreased the cyclist's power output.

In fact Gabreselassie lost 9.8 percent of his body weight during the 2009 Dubai marathon and still won the race in 2:05:29 hours! All drinking by the elite runners were ad libitm (or at their own time and pleasure).

Yes I do agree that the quoted study was done on elite runners. How does that apply to us in super humid and sunny Singapore?

My own thoughts are that the sports drink companies definitely recommend us to drink to much. I wrote before that I definitely drink less than my fellow team mates and competitors. From the time I started running cross country as a twelve year old kid to when I was racing triathlons. Even now during my weekly group bike ride. Most of the other cyclists carry two or more water bottles while I survive the three hour ride on one.

In fact I often had a side stitch after drinking while running cross country as a kid. That also deterred me from drinking too much then.

Of course this does not mean you try not to drink at all in your next long run/ ride and especially your next race. What I'm suggesting is that you at least give it a try in your next few long bike or run sessions.  Everyone is different. Try to get through those long sessions drinking as little as you can. You might be pleasantly surprised that you may not need as much fluid as you think.



References

Beis LY, Wright-Whyte M, et al (2012). Drinking Behaviours Of Elite Male Runners During Marathon Competition. Clin J Sport Med. 22(3): 254-261. DOI: 10.1097/JSM.0b013e31824a55d7.

Wall BA, Watson G et al (2015). Current Hydration Guidelines Are Erroneus: Dehydration Does Not Impair Performance In The Heat. BJSM. 49(16): 1077-1083. http://dx.doi.org/10.1136bjsports-2013-092417.

Friday, September 8, 2017

Lumbar Spondylolisthesis But No Real Deficits So Far


Have a look at the MRI and you can see a very obvious spondylolisthesis in my 38 year old patient's lumbar spine at the L5-S1 area. The last time I saw one so obvious was when I was working at the Singapore Sports Institute in a young gymnast in 2001.

Spondylolisthelis is a condition in which one vertebra slides forward over the vertebra below it. In simple terms, it means that there is a forward slip of one vertebra relative to another.

From what my patient says, there wasn't any traumatic incidents. He complains of lumbar area aches in the past year.  Often there is discomfort over his L buttock and tightness down his L outer thigh at the end of the day. He is still able to exercise including running and playing football. Other than that he hardly has any other symptoms.

His surgeon has suggested surgical intervention to stabilize his spine at the end of next month. Looks like lots of rehab after surgery.


Saturday, September 2, 2017

How Singapore Can Solve Our Diabetes Problem


In our National Day Rally, Prime Minister Lee Hsien Loong highlighted that 1 in 9 Singaporeans has diabetes. And of these, an average of 1200 undergo amputations every year!

I was quite shocked at the sobering figures that he cited. Three in 10 Singaporeans above the age of 60 have diabetes. If you break in down by race, 2.5 in 10 Chinese over 60 have diabetes, half of Malays over 60 years old and six in 10 Indians over 60 are affected.

PM Lee then urged Singaporeans to get regular medical check ups to know if they are diabetic or are at risk and suggested solutions to counter it. He then recommended that Singaporeans exercise more, suggesting that the easiest way to do so is "just walk  a little bit more every day".

If possible, I would definitely suggest including weight training (also known as strength training or resistance training).

In case you think weight training is only for bodybuilders pumping iron for beefy biceps and bulging pecs, current evidence shows that weight training - whether with a light dumbbell or your own body weight may be the best exercise for lifelong overall function and fitness.

Here's what most important. Research has shown that weight training helps with improved insulin sensitivity among people with diabetes and pre diabetes. Twice weekly weight training sessions helped control insulin swings (and body weight) among older men with type-2 diabetes.

During weight training, our muscles are rapidly using glucose (or blood sugar). This energy consumption continues even after you finish your strength training session. This is especially beneficial for anyone at risk for metabolic conditions like Type-2 diabetes, high blood pressure, and unhealthy cholesterol levels making weight training the most effective remedy.

In addition, weight training can strengthen our bones and improve our posture through bone remodeling. Weight training stimulates the osteoblasts (bone building cells) to build more bone. Weight training is also superior to aerobic exercise for enhancing and maintaining total body bone strength. And that's probably another post.

That's why I bought a Olympic bar, squat rack and got some free weights earlier this year as I realize I was losing muscle mass. Here you see Ting Jun trying out the Olympic bar with Rachel's help.




Reference

Ibanez J, Izquierdo M et al (2005). Twice-Weekly Progressive Resistance Training Decreases Abdominal Fat And Improves Insulin Sensitivity In Older Men With Type 2 Diabetes. Diabetes Care. 28(3): 662-667. DOI: 10.2337/diacare.28.3.662.

Thursday, August 24, 2017

Kinesio Taping At Raffles Institution


A few weeks ago I received a call from the Physical Education Head at Raffles Junior College (or known as Raffles Institution now) to teach their PE teachers Kinesio Taping. They had seen an increase of self taping by their students in school especially during PE classes and/ or training sessions. They needed to know if the students were doing it correctly as most were just following instructions looking at youtube.

Just so you know, participants who have attended the Kinesio Level 1-2 courses must sign a disclaimer that they cannot post any videos of what they've learnt online. Hence, whatever videos you can find online are not the real Kinesio Taping techniques but are from other copycat or imitation tapes.

So there I was showing the PE teachers there from year 1 to 6 some pointers on how to tape. The emphasis was on understanding concepts rather then simply giving them "recipes" on how to tape.

We've had lots of people asking when Sports Solutions will be hosting the next Level 1-2 Kinesio Taping course where they even learn about what the homunculus has to do with Kinesio Taping.

Well, I was informed by Kinesio Taping International that they were tweaking the Level 1-2 course from June 2017 onward. They were making some changes to the course world wide. As of now, the Kinesio Taping Instructors recertification courses are slated to take place between October 2017 to January 2018 in USA, South America, Europe and Asia.

I need to clarify some of the content changes at the next Kinesio Taping Instructor Recertification course that I will only attend in early January 2018. I want to ensure that I'm not shortchanging the future participants that I teach. Hence, I've decided I'll only teach the next Level 1-2 course after I've attended the next Instructors Re-certification early next year.

Yes, Kinesio Taping Instructors have to re-certify themselves every three years to be able to keep teaching.

We will definitely inform those who keen to attend the next Kinesio Level 1-2 taping course on our website and Facebook page when dates are finalized.

Saturday, August 19, 2017

Can Sports Injuries Lead to Osteoarthritis In Your Joints?


Picture by Liji Jinaraj from Flickr
The first question I get always get asked when an injured athlete sees me in our clinic is "How quickly can I get back to training?"

Actually it's not just the athletes, every single weekend warrior or physically active patient that I see will ask when they can get back to their usual activity or exercise.

I'm guilty of doing the same. That's exactly what I asked my doctor after my bicycle accident.

There is now evidence to show that if you rush to get back to playing, whether as part of a team or elite sport or simply just your usual weekly recreational tennis game or jogging you may not allow the injured joint to heal fully.

Adequate recovery includes strengthening the structures the support the injured joint. This will allow joint stability to reduce risk of re-injury and stave off irreparable joint damage. If you're not careful, irreparable joint damage can eventually lead to post traumatic osteoarthritis (OA).

OA is a degenerative joint disease. It happens when the protective articular cartilage lining the surfaces of bones wear out. This causes pain, stiffness, swelling and often disability that diminishes one's quality of life.

Post traumatic OA don't just happen to older patients. It can affect adolescents or young adults too.

Researchers suggest that acute joint damage can lead to a deterioration of the surface of the bone itself and structures that cushion and stabilize bones of a joint like the knee (Anderson et al, 2012).

That same study found that OA can develop in more than 40 percent of people who seriously injure their ligaments, the meniscus in the knee or articular surface of a joint.

They also found that people with a history of knee trauma are three to six times more likely to develop knee OA.

In order to better manage post traumatic OA, a group of Athletic Trainers (ATC) has suggested a more aggressive approach to both preventing and managing post traumatic OA. Especially in younger patients who get injured playing sports.

They suggested that having less deficits (between both legs) in muscle strength, endurance, balance movement quality and stability will reduce a person's risk of getting injured. After the initial injury, it should be properly managed to prevent additional injuries to the same joint or other joints to minimize OA developing. Ideally a structured rehab program should be maintained for six to nine months.

So don't be too impatient to return to your usual physical activity especially after a joint injury. You may have to modify the activities you do in order not to place unnecessary repetitive stress on the injured joint. Remember our articular cartilage likes and needs weight bearing forces for nutrition. Inactivity will cause the articular cartilage to deteriorate.


References

Anderson DD, Chubinskaya S, Guilak F et al (2012). Post-traumatic Osteoarthritis: Improved Understanding And Opportunities For Early Intervention. J Ortho Res. 29(6): 802-809. DOI: 10.1002/jor.21359

Palmeri-Smith RM, Cameron KL, DiStefano LJ et al (2017). The Role Of Athletic Trainers In Preventing And Managing Post Traumatic Osteoarthritis In Physically Active Populations: A Consensus Statement Of The Athletic Trainers' Osteoarthritis Consortium. J Athl Train. 52(6): 610-623. DOI: 10.4085/1062-6050-52.2.04.

Friday, August 11, 2017

Don't Drink The Pool Water!


During the last couple of days over National Day, we took a family staycation at the Goodwoodpark Hotel. I ended up spending lots of time in the pool with my two boys as you can see in the picture above. Probably ended up drinking some too.

Not the greatest thing to do if you read what Canadian researchers found when they tracked two public pools for three weeks. Olympic swimmers have admitted doing it and now evidence shows that the rest of the general public are doing it too.

Doing what? Peeing in the swimming pool that's what!

The researchers tracked the concentration of an artificial sweetener, acesulfame potassium (ACE), which is found commonly in processed food and passes through our bodies unaltered. Great for the researchers if you happen to eat processed food and pee in public pools.

By tracking ACE levels, the researchers calculated that swimmers released 75 litres of urine (enough to fill a medium sized dustbin) in the first public pool (830,000 litres, about one-third the size of an Olympic pool).

There was 30 litres of urine in the second public pool, which was around half the size of the first pool over this two week period.

The research team sampled a total 31 different swimming pools and eight hotel jacuzzi hot tubs in two Canadian cities. ACE was present in 100% of the pools and hot tubs!

Number of pool visitors were not monitored, but the results also suggested that urine content in the pool was added several times each day.

If you thought that the pool readings were bad, measurement in the eight jacuzzi hot tubs were much higher. One particular hotel jacuzzi had more than three times ACE levels than the worst swimming pool.

Just so you know, urine is sterile, but the compounds in urine (urea, ammonia and creatinine) can react with pool disinfectants cause eye and respiratory irritation. Long term exposure to these compounds has been linked to asthma.

The results were not surprising as another anonymous survey showed that 19% of adults polled admitted to having urinated in a swimming pool at least once. Professional swimmers have confessed to being among the worst offenders.

Have you ever peed in a swimming pool? Hmmm, let me ask Jo Schooling when he next comes and sees me in the clinic.


References

Blackstock LKJ, Wang W et al (2017). Sweetened Swimming Pools And Hot Tubs. Environ Sci Technol. 4(4): 149-153. DOI: 10.1021/acs.estlett.7b0043.

Wiant C (2012). New Public Survey Reveals Swimmer Hygiene Attitudes And Practices. Int J Aquatic Research Edu. 6(3): Article 4. http://scholarworks.bgsu.edu/ijare/vol6/iss3/4.

Researchers Lindsay Blackstock and Xing Fang Li testing for ACE

Saturday, August 5, 2017

Joseph Schooling At Sports Solutions

Jo at Sports Solutions
For the past few days, our staff were already talking about taking pictures with him when they saw his name booked in for an appointment in our clinic today.

I was treating another patient when Jo arrived, so Jo went to see Aized for his appointment. My next patient was running late so I went to say hello to Jo. Aized said the first question he asked was "Where's Uncle Gino?"

Yes "Uncle Gino" is what Jo still calls me. We used to swim together from 2004 until early 2008 when we were both swimming at the Center of Excellence (COE) under coaches John Dempsey,  Au Yong Kim Moon and Herbert Yu. I used to treat all the swimmers there including Jo.

That was my agreement with head coach John Dempsey. He would allow me to swim with the COE swimmers (while I was still training for triathlons) on the condition that I treat all the swimmers who needed help.

In fact I first treated him at a swim meet in Kuala Lumpur, Malaysia in 2004. Jo used to kick my behind in the pool even when he was nine years young!

Great seeing you today Jo! As Aized said, our pleasure and honor to be treating you when you're home.

Saturday, July 29, 2017

Rhabdomyolysis - The Scary Side Effects Of Exercise


My patient just attended her first spin class with her colleagues. Prior to this, she's been running and wakeboarding for exercise.

The doors to the studio were shut, while the air conditioning was turned off. Other than that, she didn't find pedaling fast on the stationary bike to rhythms of popular music while an instructor shouted motivation too difficult. Neither did she feel she pushed herself too hard. Her legs at the end of the hour long class weren't too sore or wobbly afterwards.

Over the next two days, her legs started throbbing and she came into the clinic to see me. I noticed bruises on her thighs and asked if she knocked them against the stationary bike. She said she didn't recall that happening.

The next day she noticed blood in her urine and checked herself into a hospital where she was warded and after blood and urine tests and was told her she had rhabdomyolysis.

Rhabdomyolysis is rare but can be a life threatening condition often caused by extreme exercise. It occurs when muscles that have been overworked dies and leak their contents into the bloodstream. This strains the kidneys and can cause severe pain.

My patient ended up staying in hospital for a few days before being discharged and has since recovered.

Subsequently I saw an article that documented three unusual cases of rhabdomyolysis, each occurring after a first spin class all treated by the same doctors (Brogan et al, 2017).

The article also described 46 other cases of people developing rhabdomyolysis after a spin class (42 of them in people taking their first spin class). The authors wrote that the condition was rare and not a reason to avoid high intensity exercise.

Another published study found 29 cases admitted to the emergency department between 2010-2014 for exercise induced rhabdomyolysis. Weight lifting, running, cross fit were some of the causes, but the most common cause was spinning classes!

The patients were not unfit, they were in fact being pushed too hard. Since they were not used to the new exercise, they ended up getting really bad muscle trauma.

Remember this next time you try a new exercise. Rhabdomyolysis occurs when you do not give your muscles time to adjust to a new aggressive exercise. When you stress your muscles too much, they tend to break down, releasing contents like myoglobin into your bloodstream which causes brown or tea colored urine, a classic symptom of rhabdomyolysis.

While any intense activity can cause rhabdomyolysis, it almost always strikes the person doing something new. So when you try a new exercise, start moderately first.

Know your limits, don't be pressured by the instructor. You can stop the exercise if you're struggling. Exercise can be dangerous when your body is not prepared for really intense levels.


References

Brogan M, Ledesma R et al (2017). Freebie Rhabdomyolysis: A Public Health Concern, Spin Class-Induced Rhabdomyolysis. AJM. 130(4): 484-487. DOI: 10.106/j.amjmed.2016.11.004.

Cutler TS, DeFilippis EM et al  (2016). Increasing Incidence And Unique Clinical Characteristics Of Spinning-induced Rhabdomyolysis. Clin J Sp Med. 26(5): 429-431. DOI: 10.1097/JSM.0000000000000281.

Here's a picture of a spin class.

Picture from Soulcycle.com

Friday, July 21, 2017

Will The Real Athletes Please Stand Up?

Written by Rachel Wong.

Bella Hadid's picture from Nike 
Just last month, Nike announced that fashion model Bella Hadid would be the face of its previously popular Cortez sneaker, designed in 1972 for runners. If you're an older runner you will remember the Cortez, after all even Forrest Gump used it for his runs.

Picture from Sneaker news
The Cortez is being re-released as a fashion/ lifestyle sneaker. This follows a series fashion models being chosen to front the campaigns of other sportswear brands - Kylie Jenner (Puma), Karlie Kloss (Adidas) and Gisele Bundchen (Under Armour) just to name a few.

Naturally, some professional athletes have picked up on this and commented against this trend.


As a female football player myself, I think it is completely fair that people are upset that the big sporting companies are choosing to hire fashion models (instead of female athletes) to front the advertising campaigns.

It highlights the differences the way marketing is done in female sports. Emphasis is often placed on how good the women look rather than how well they perform, and women's sports are viewed as less prestigious.

Female athletes definitely do not get the same recognition and endorsement opportunities compared to their male counterparts. Not featuring female athletes in major advertising campaigns also perpetuates this problem as the wider population miss out on seeing more female athletes.

After all, most if not all sports brands instantly opt for professional male athletes in their advertising campaigns. Nike previously used Michael Jordan and now Lebron James for its basketball ads while Puma uses Usain Bolt. Why not the same for females?

However, it is not surprising that Nike (and other sporting brands) choose to use these fashion models with their massive social media presence guaranteeing a broader reach. The target audience is also different today - more people are wearing their sneakers as part of a fashion statement and not for exercise. I suppose from a business/ profit making point of view, this is justified.

Occasionally, these companies do get it right. Misty Copeland (ABT ballet dance), Simone Biles (Olympic gymnast), Ronda Rousey (UFC fighter), Annie Thorisdottir (crossfit) and even the USA women's soccer team have broken into the male-dominated world of sports endorsement deals.

Hopefully these big sporting brand names start to understand the value of real-life athletes to their consumers. I feel that the authentic stories of female athletes, rising above the pressures of their circumstances and beating the odds, are so much more powerful than looking good in whatever apparel they are marketing.

Seeing this will definitely attract my attention, and I might end up buying more clothes and shoes I don't need? :) Nike are you listening?


Friday, July 14, 2017

How Healthy Are Elite Athletes?

Taken with my iPhone off my computer from Cyclingnews.com
Compared to most people in the general population yes, elite athletes are very healthy if you read the article by Lemez et al (2015). However, this is a controversial topic that has been debated for years by athletes themselves, coaches and researchers.

I'm sure you've watched the riders at the Tour De France or the athletes competing at the Olympics. At these competitions, they usually rested and focused, look lean, powerful, slick and bursting with energy.

Can you guess how much it took for them to get there? All the grueling training and obsessive dedication required to reach those levels. Is at good for them? Will that pursuit of sustained excellence damage their health?

The answer depends on how you define health and who you compare elite athletes to.The findings from the comprehensive review on mortality and longevity in elite athletes is very clear. Elite athletes fare better than everyone else when it comes to longevity and disease if you define health as "the absence of disease and the capacity to enjoy life and withstand challenges."

That article by Lemaz et al (2015) examined more than 450, 000 athletes and found that elite athletes live four to eight years longer when compared to an equally matched control group in the general population.

Athletes who competed in running, cycling, soccer and swimming (sports with high aerobic demands) had the greatest benefits. Those athletes have lower rates of heart disease, stroke and smoke related cancers. The Tour de France cyclists for example have a 40 percent lower mortality rate than non athletes.

See how skinny he is (taken from Cyclingnews.com)
The other element of health is psychological, the question of enjoyment in life. That is difficult to quantify and answer.

Some studies show that elite athletes have better mental health after their retirement from elite sports. This may be due to the resilience they developed while competing or that exercise itself (trumps medication when treating depression).

However, other studies show comparable rates or even potentially increased risk for mental health issues. This is actually also dependent on the support the elite athletes received during their athletic career and early retirement (Rice et al, 2016).

Similar to an overworked doctor in the emergency department, corporate lawyer or investment banker, elite athletes often put into situations that require them to sacrifice a lot for their mind and body.

The best endurance athletes will push their bodies and their minds as far as humanly possible and this may not be good for them. If not controlled, that very same drive and determination that propels the elite athlete can eventually become harmful.


References

Lemez S, Baker J et al (2015). DO Elite Athletes Live Longer? A Systematic Review Of Mortality And Longevity In Elite Athletes. Sports Med Open. DOI: 10.1186/s40798-015-0024-x.

Rice SM, Purcell R et al (2016). The Mental Health Of Elite Athletes: A Narrative Systematic Review. Sports Med. 46(9): 1333-1353. DOI: 10.1007/s40279-016-0492-2.

Monday, July 10, 2017

Rise In Singapore Teenagers' Use Of Steroids?

"Muscular kids" gym bound at Holland V MRT today
I was a little annoyed with myself when I saw the Channel NewsAsia (CNA) headline on their website this morning.

I actually read about a similar report in the Journal of the American Medical Association (JAMA) just two weeks ago and was going to write about it but I got sick last week and didn't write it yet. So CNA beat me to it. 

Well, my wife told me the journalist (from CNA) does this for a living, whereas I am just a Physiotherapist. So it's already good I have the ideas (but not the time to write it). Grrrrrrr, guess I have to blame it on the fact that our whole family fell sick recently. 

Next time .....

So what does an American journal finding got to do with our local youths?

Well, ever since Holland village has sprouted three gyms, I've noticed a lot more "muscular kids" walking around. Yes, we do have three gyms right here in Holland Village. First F45 set up shop, followed by Ritual gym  and then Virgin Active opened it's doors recently.

Similar to the American article, it may be a widespread misconception that anabolic steroids is only an issue in elite sports. Both the American article and the Channel NewsAsia article suggest that there may be more anabolic steroid users among our teenagers. The Jama article suggest that "most young men using these drugs are doing it to improve their appearance."

Personally, I don't think it's a new problem. I've definitely had cases of teenage bodybuilders and young adults see me in our clinics for sports injuries (and telling me in strict confidence of course) that they've been injecting themselves with anabolic steroids. And that's all I'm gonna say.


Reference

Pope HG Jr, Khalsa JH et al (2017). Body Image Disorders And Abuse Of Anabolic-Andrrogenic Steroids Among Men. JAMA. 317(1): 23-24. DOI: 10.1001/jama.2016.17441

Friday, July 7, 2017

Finding Our Way Back To Fitness

My wife resting and still not feeling quite right after 11 days
It definitely happens to us runners at some point. We get sick, busy or injured. Well, it just happened to my family.

First my wife fell sick last Tuesday. She had a really bad sore throat, viral fever and was feeling really terrible. She thought she could self medicate and had to take two Panadol tablets thrice a day "just to barely function" in her words. I brought her to see the doctor on Thursday and she got better with the stronger medication given by the doctor.

 On Friday, my two and half year old boy woke up with a fever. Oh dear, my wife groaned, she had passed it to him. We had very little sleep that night as his temperature kept spiking during the night. Our helper had to help us throughout the night too. I ended up not going to my usual Saturday morning long bike ride.

Despite not sleeping well, I managed to see patients the whole Saturday. When I got home, my older seven year old boy was running a temperature.

We spend the whole Sunday resting and trying to keep everyone comfortable at home. Thanks to my helper who decided to forgo her off day to help us. Thanks Ami!

I was the last one standing, the "last of the Mohicans" or so I thought. I woke up with a fever at 3 am on Monday morning! Grrrrrrr. I thought I was strong/ healthy enough not to catch the bug but in the end I succumbed.

I ended up not working for the past few days. My wife still hasn't gone in to the clinic. Though she's feeling better, she just doesn't seem quite right. The older boy hasn't gone to school this whole week while the younger boy still gets a fever on and off. Now that was really strong bug that got us down.

A body at rest can and tends to remain at rest. My wife is just lamenting that her fitness is gone, poof just like that! How do we start running or exercising again?

If you've been away from running more than a week, the pool  is great for doing deep water running. If you prefer something land based, you should just try walking first. The goal is to be able feel strong going on a 30 minute walk. If that's too much try 10-15 minutes walking and build from there.

Next, add in some running. Throw in a 10-15 second run after walking  five minutes. If you feel good, you can continue with 10 seconds run / 40 seconds walk for 5-10 mins. Every other day add 3-5 minutes and you'll back on your way.

Your body will definitely tell you if you've done too much during your comeback- you just need to listen to it.

Hmmm, should I go for my long bike ride tomorrow?

Actually, my helper, Ami, is the last one standing, "the last of the Mohicans". Good on you Ami!

Friday, June 30, 2017

How Is Running Good For Your Back?


Many of us runners have heard that running is bad for your knees (although I've put that beyond reasonable doubt here).

Many more of us have been told that running "overloads" our intervertebral discs (IVD) and causes jarring on our spine. And that in turn leads to low back pain.

 I've written about how my own back feels better after running after my accident.

Well, here's more proof that people who regularly run or walk briskly tend to have healthier discs in their spines than people who do not exercise.

This findings refute the myth that running overloads your spine. In fact it shows that running makes the spine sturdier.

The IVD's are located between the vertebrae, acting as cushions to dissipate shock. They contain a thick, sticky fluid that compresses and absorbs pressure during movement to keep your spine in good shape.

Aging, disease and/ or injury can cause the IVD's to degenerate and bulge causing back pain which sometimes can be debilitating.

Check out the evidence provided in the following study. 79 adult men and women were recruited for the study, of which two-thirds of the group were runners for at least five years. The "long distance" group ran more than 30 miles (48 km) a week while the others ran between 12-25 miles a week (19-40 km). The last group rarely exercised at all.

In order to get more information out of the study, the subjects wore accelerometers. Accelerometers measure movement in terms of acceleration forces, or how much power your body is generating when you move.

All the subjects' spines were scanned using MRI, measuring size and liquidity of each disc. In general, the runners' discs were larger and contained more fluid than those who didn't exercise!

Mileage did not matter. The IVD's of the runners who ran less than 30 miles per week were almost identical to the "long distance" group. The authors suggested that compared to moderate mileage, heavy training does not increase disc health nor does it contribute to deterioration.

Here's what's more surprising. The accelerometers showed that walking briskly at about four miles (or 6.4 km) per hour generated enough physical force to bring movement into the range associated with the healthiest IVD's.

Slower walks and standing in place were outside this range. (Now you know why your backs hurt when you stand and not move). Running faster than 5.5 miles (or 8.8 km) per hour were outside the range as well.

The "sweet spot" for IVD's health seem to be between fast walks and gentle jogs.

Things to note. This is a one-time snapshot of the subject's backs. This study cannot prove that running (or exercise) caused the subjects' IVD's to become healthier. Not yet anyway. It shows that people who ran had healthier IVD's.

It also does not tell us whether running (or exercise) can help treat existing disc problems.

My thoughts? The available evidence strongly indicates that IVD's like movement. If you've always been walking and running don't listen to the naysayers. If you have never ran before and want to, perhaps it will help if you start walking briskly first, this will strengthen your IVD's. Progress to run walks (run a little, walk a little) before running to gradually ease your back into it.


Reference

Belavy DL, Quittner MJ, Ridgers N et al (2017). Running Exercise Strengthens The Intervertebral Disc. Scientific Reports. Article No: 45975. DOI: 10.1038/sreo45975.

Friday, June 23, 2017

Please Help My Swollen Knee


My patient sent me the above picture recently asking for help. Her knee became swollen after a recent run. After icing her knee, she decided to use some "imitation/ copy cat" Kinesio Tapes but that didn't resolve the swelling and worse still gave her an allergic reaction.

Knee joint effusions (or swelling) are usually caused by the knee joint producing more synovial fluid due to aggravating factors causing damage to the joint.

As little as 5 ml of fluid can increase pressure within the knee joint. This can be a source of discomfort and concern for the person affected.

It takes a very small volume of fluid in the knee (20-30 mls) to result in biomechanical changes. The quadriceps will be inhibited as a result (meaning you are less willing to use that muscle) and strength decreases rapidly.

It has also been found that swelling in the knee affects joint mechanics particularly during landing tasks. If someone has effusions in the knee, they tend to land with greater ground reaction forces (or impact) and in greater knee extension (or straightening). This results in more forces transmitted to the knee joint and its ligaments. So you can't run and jump quite as well.

When we see knee joint swelling in our clinics, we try to remove the swelling pronto. Flossing the knee joint, using correct Kinesio taping techniques with genuine Kinesio tapes definitely helps.

My favorite is of course aqua based rehabilitation/ deep water running to take advantage of hydrostatic pressure to help with the swelling. This also allows for quadriceps/ hamstrings strengthening early on without additional loading.

If the patient has more severe effusions, we may suggest altering their gait temporarily (we call this pain free walking), using non-steroidal anti inflammatory medication (NSAIDs) or even suggest they get the joint aspirated (I've tried it, it hurts like crazy).

Once the swelling settles, it will quickly and significantly reduce internal pressure in the knee as well as improve quadriceps strength.

We will quickly select rehabilitation exercises to allow specific quadriceps muscle recruitment without increasing intra articular pressure with knee extension. This is usually done in positions of partial knee flexion (20-30 degrees).

Now you know. Come see us in our clinics if your knees are swollen.


References

Hart JM, Pietrosimone B et al (2010). Quadriceps Activation Following Knee Injuries: A Systematic Review. J Athl Trg. 45(1): 87-97. DOI: 10.4085/1062-6050-45.1.87.

Palmieri-Smith RM, Kreinbrink J et al (2007). Quadriceps Inhibition By An Experimental Knee Joint Effusion Affects Knee Joint Mechanics During A Single-Legged Drop Landing. AJSM. 35(8): 1269-1275. DOI://doi.org/0.1177/0363546506296417.

Friday, June 16, 2017

Both Men And Women Equally Unhappy With Their Bodies

Picture by suez92 from Flickr
I do happen to see quite a lot of men and women who are unhappy with their bodies. And lately, some boys and girls too. Previously, I used to treat a lot more women who were unhappy about how their bodies looked so they'll exercise more and get injured in the process. They'll come and see me hoping that I'll make them pain free so they can exercise again.

Their injuries were easy to treat, their mindset much more difficult.

Well, it seems that men are just as likely to be insecure about their looks. I think we're in a cultural shift in terms of the ideal body image. In movies, advertisements and magazines etc, the ideal man is often portrayed and shown to be more muscular than men in the real world.

Don't get me started on the ideal female physique. The fantasy female has a slim hourglass figure with big boobs and a BMI which was in the normal range but close to the underweight category.

A recently published study of 12,716 respondents found that only 28% of men said that they were "extremely satisfied" with their appearance compared to 26% of women.

It is not surprising to note that weight was closely to people's body image. Only 24% of men were extremely satisfied with their weight while 20% women felt extremely satisfied with theirs.

These findings are consistent with the emphasis placed on the importance for being slender for women and appearing athletic and/ or lean for men.

Take note that the subjects had to opt in to take part in the study so this sample size may not be representative of the general population.

And it gets worse for kids. Adolescent boys who were dissatisfied with their body shape were found to be more likely than girls to self criticize and feel distress (Mitchison et al, 2016).

Don't let others tell you how you look affect you. You're stronger than that.


References

Federicks DA,Sandhu G et al (2016). Correlates Of Appearance And Weight Satisfaction In A U.S. National Sample: Personality, Attachment Style, Television Viewing, Self-esteem And Life Satisfaction. Body Image. 17:191-203. DOI: 10.1016/j.bodyim.2016.04.001.

Mitchison D, Hay P et al (2016). Disentangling Body Image: The Relative Associations of Overvaluation, Dissatisfaction, And Preoccupation With Psychological distress And Eating Disorders In Male And Female Adolescents. Int J Eating Disorders. 50(2): 118-126. DOI: 10.1002.eat.22592.