Friday, July 14, 2017

How Healthy Are Elite Athletes?

Taken with my iPhone off my computer from
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
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.


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.


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.


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.


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://

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.


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:

Sunday, June 11, 2017

Is Running On A Treadmill More Difficult Than Running Outside?

I've had patients travelling this past couple of weeks during their kid's school holidays. The only time they could run was on a treadmill in the hotel. A few of them have asked me why they found running on a treadmill more tiring than on the road or track. 

I thought this was strange as running on a treadmill should not be more difficult than running outside and looked it up. 

And true enough, I found an article in which runners were asked to run on a track and then asked to rate how difficult the exercise felt. They then went on a treadmill without a display unit of the speed they were running and told to set the treadmill at the same pace they thought they had just ran. Almost all the runners chose a speed that was much slower. 

Researchers have found that for most people, running biomechanics are similar whether running on a treadmill or outside (Riley et al 2008).

In fact, running on a treadmill is less jarring than running on the ground outside. A 2014 study (Kaplan et al, 2014) showed that we strike the ground with about 200 percent of our body weight while running on an outside track. This was reduced to 175 percent of our body weight when running on a treadmill. 

Evidence suggest that the hard work associated with treadmill running is psychological. Many studies show that people experience less fatigue, more vitality and greater pleasure waling outside compared to walking on a treadmill. 

Personally I feel it is definitely nicer to exercise outdoors. I don't like running on the treadmill too much. I'd much prefer running outdoors any time. I feel like a caged hamster going on and on in a wheel when I'm running on a treadmill. 

Picture from giphy
However, after my accident, I'm very happy just being able to do any exercise. A run is a run, whether outdoors or on a treadmill.


Kaplan Y, Barak Y et al (2014). Referent Body Weight Values In Over Ground Walking, Over Ground Jogging, Treadmill Jogging, And Ellipticall Exercise. Gait Posture. 39(1): 558-562. DOI: 10.1016./j.gaitpost.2013.09.004.

Kong PW, Koh TM et al (2012). Unmatched Perception Of Speed When Running Overground And On A Treadmill. Gait Posture. 36(1): 46-48. DOI: 10.1016./j.gaitpost.2012.01.001.

Riley PO, Dicharry J et al (2008). A Kinematics And Kinetic Comparison Of Overground And Treadmill Running. Med Sci Sports Ex. 40(6): 1093-1100. DOI: 10.1249/ MSS.0b013e3181677530.

Thompson CJ, Boddy K (2009). Does Participating In Physical Activity In Outdoor Natural Environments Have A greater Effect On Physical And Mental Wellbeing Than Physical Activity Indoors? A Systematic Review. Environ Sci Technol. $5(5): 1761-1772. DOI: 10.1021/es102947t.

Monday, June 5, 2017

Should I Be Using A Standing Desk?

Now, that's a different standing desk. By Liz Henry from Flickr
Sitting kills. That's the headline many of you would have seem or read in the last few years. You've also read or heard that sitting is the new smoking. And if you've been following our blog, I've written before that despite exercising a lot, if you sit too much at work, you can be what is known as an active couch potato. Worse still, all that sitting can negate the benefits of your exercise.

Well fortunately for me, I hardly get to sit much when I'm working in the clinic.

Many of my patients have asked about the benefits of a standing desk. I even found a picture (below) of former British Prime Minister Winston Churchill working on his slanted standing desk.
Kurt Hutton/picture post via Getty
Standing desks have been suggested as an alternative to the ills of sitting. And there's studies to show that working upright (at a standing desk) can help correct your posture and tone your stomach and legs without compromising your focus.

And in kids, standing desks seems to increase their energy levels and reduce hunger.

My take on standing desks? I've seen many of my patients go straight from sitting to a standing desk get different problems. Being unaccustomed on their feet all day long poses new risks. It can inhibit proper circulation and add additional pressure to your hips, legs and lower back. Sort of like jumping from the frying pan into the fire if you ask me.

And unfortunately, research shows that sitting once or twice throughout your work day will not offer you enough relief. So don't switch to a standing desk if you've been sitting all day straight away, make sure you gradually phase it in.

What are the alternatives? I prefer the stability ball or better still the saddle stool with adjustable height so that you can perch on it if you're not quite used to standing yet.
Our clinic's saddle stool
There's also the desk cycle, though I definitely haven't tried it yet.
Desk cycle

Commiassaris DA, Konemann R et al (2014). Effects Of A Standing And Three Dynamic Workstations On Computer Task Performance And Cognitive Function Tests. Appl Ergon. 45(6): 1570-1578. DOI: 10.1016/j.apergo.2014.05.003.

Garcia MG, Laubil T and Martin BJ (2015). Long-term Muscle Fatigue After Standing Work. Human Ftr and Ergo Society. 57(7): 1162-1173. DOI: 10.1177/0018720815590293.

Monday, May 29, 2017

Steroid Injection Not Better Than Placebo For Low Back Pain

Picture by Army Medicine from Flickr
It seems like another of my patients has been asked if he wanted a cortisone (or corticosteroid) injection for his low back pain after I wrote about my shoulder pain patient last week who was asked by another doctor to get a steroid injection.

Evidence that they (cortisone or corticosteroid injections) work no better than placebo is mounting though.

The article referenced below is a systematic review. A systematic review is a computer aided search for all randomized and clinical controlled trials, meaning it's top of the line in terms of quality.

Researchers pooled data together from 30 placebo controlled studies of epidural steroid injections for radiculopathy (back pain that radiates to legs) and eight studies for spinal stenosis (back/ neck pain caused by narrowing of the spinal canal).

For radiculopathy, the steroid injections provided only short term relief. Over time, they were not more effective compared to placebo injections. They also did not reduce the need for surgery later for patients with more severe conditions.

The pooled data was similar for spinal stenosis.There was only some moderate temporary pain relief after the corticosteroid injections. There were no differences between steroid injections and placebo injections in pain intensity or functional ability lasting six weeks or longer after the injections.

The authors did note that some studies did not have many subjects while others had shortcomings their methodology.

The researcher in charge also suggested that there was probably some financial motivation to carry on using steroid injections despite the lack of evidence for its effectiveness. There is also a worry among professional societies (for doctors) due to implications for insurance coverage.

Other mentioned less selfish reasons is that doctors see their patients in horrible pain and concede that they do get some pain relief after the injections.

Please come to our clinics if you need help with your low back pain. We definitely do not give steroid injections.


Chou R, Friedly J et al (2015). Epidural Corticosteroid Injections For Radiculopathy And Spinal Stenosis: A Systematic Review And Meta-analysis. Ann Intern Med. 163(5): 373-381. DOI: 10.7326/M15-0934.

Sunday, May 21, 2017

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck
I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement
Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.


Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.

Saturday, May 13, 2017

Rachel Plays Her Part Helping VJC Win 5th Straight Football Title

On Sunday night (7/5/17), my colleague Rachel asked me if she could leave work early on Tuesday 10/5/17. She wanted to watched her alma mater play in the 'A' division girls football final against Meridian Junior College.

Rachel was top scorer before in her time at Victoria Junior College (VJC) when she herself represented VJC. As I wrote previously, she scored a hat trick when VJC beat my alma mater's team 10-1 in the semi finals of the same tournament eight years ago.

When I introduced her to a physical education teacher from the losing school, he immediately remembered the trashing our school received and he was in awe of her. Still famous as ever eight years on. Well done Rachel!

Of course she could go! She had been volunteering her time (with the clinic's blessings) most Wednesday's afternoons at VJC since the beginning of the year.

On days before a match, if you come to our Holland Village clinic you might be lulled into thinking VJC was near our  clinic (and not in Marine Parade) or that our clinic was a mini VJC gathering place.

Definitely businesses near our clinic like Sunday Folks and The Daily Scoop have benefited when the students come for treatment as they go there after treatment.

So congratulations to VJC for the fifth consecutive football title and Rachel Wong for a job well done!
Rachel with the victorious team.
Note: Rachel also treats students competing in other sports and not just the girls from football. So perhaps next year we'll see more VJC students in our clinic this time of the year?

Saturday, May 6, 2017

Eccentric Exercises

Ting Jun and Rachel going down stairs outside our clinic
I was talking with a patient of mine earlier who exercised by climbing up and going down the stairs at his 40 storey flat while carrying a 16 kg backpack. He knew about my past results climbing stairs and wanted to know why walking down a flight of stairs seems to be more effective at building his muscle strength than walking up the same flight of stairs.

Going down the stairs with his 16 kg backpack meant he had to really control his step and lower himself down slowly rather than just letting himself go. This meant that he was doing an eccentric exercise.

Say you want to train your biceps (arm muscles). When you bring the dumbbell up, the muscle is shortening, that is also known as a concentric muscle action. If you lower the dumbbell slowly (which is more difficult), the muscle is lengthening or an eccentric muscle action.

Eccentric exercises are more demanding on the muscles and fatigues then far more than concentrically. It also damages (or breaks down the muscle) to a greater extent, so there is greater stimulation and subsequent growth.

Try this if you want get better leg strength in a shorter time. Bend your legs more deeply when going down stairs of hills. Your legs will be sore from DOMs or delayed onset of muscle soreness. Once your muscles recover (after a few days), they'll be stronger and it will require much more eccentric exercises to get the same effect.

In fact, this was exactly what researchers found in a group of elderly men with chronic heart failure. Going down stairs appeared to be easier and more pleasant compared to the climbing stairs which the subjects found to be more demanding.

Changes in muscle strength were similar or even greater when going down stairs compared to going up stairs after six weeks of training.

To put this into practice, try bending your legs more deeply when going down stairs or slopes, lower your body more slowly doing push ups or pull ups. You'll be amazed at the results ..... after recovering from  the soreness.


Theodoru AA, Panayiotou G et al (2013). Stair Descending Exercise Increases Muscle Strength In Elderly Males With Chronic Heart Failure. BMC Res Notes. 6:87. DOI: 10.1186/1756-005-6-87.

Sunday, April 30, 2017

Retired Pharmacist Comes To Kinesio Taping Course

I forgot to mention yesterday that we have Mrs Chong, who's a grandmother (and trained pharmacist) at 73 years young attending the course with her daughter Alyce.
Mrs Chong in action
Mrs Chong's granddaughter (and Alyce's daughter) competes in gymnastics and equestrian and both of them decided to come and attend the course together (to bond) and to be able to tape competently for their granddaughter and daughter respectively. Now that's real love.

By the way, Mrs Chong also paints, takes many other classes and still takes exams to keep her pharmacist license.

I really respect Mrs Chong's attitude. Note to self - never stop learning.

Back to the course and the day started with some questions on whether participants left their tape on overnight (and many did) and what they felt. None reported any adverse reactions

We continued Day 2 of the course learning all about the six different corrective techniques in Kinesio Taping. Mechanical correction, fascia correction, space correction etc.

A few of the participants brought along different brands of tape to try and none (according to the participants) matched the high standards of the Kinesio FP tape.

Check out the "Heroll" tape

Here are some pictures from the course.

Theresa and her amazing technicolor dream tapes
Both the netball coaches admiring a Team Singapore attire?
Group picture of the participants

Saturday, April 29, 2017

Explaining About The Homunculus At The Kinesio Taping Course

Sports Solutions hosted the Kinesio Taping Level 1-2 course today and no surprises, the course was fully subscribed.

It was bright sunshine after the early morning storm and the day started with explaining the science and rationale behind how Kinesio Taping works.

After my own learning journey from the Anatomy Train courses, lessons from Andrew Hutton, Flossband (with Sven Kruse) and David Butler, I can definitely explain and teach the course better. Well, I'd better because I had to explain what the homunculus was to the class.

Teaching the homunculus
Of course we spent some time going through anatomy and surface landmarks.

Palpating for C1 after finding the mastoid process
Finally after all the talking, it was time to tape.

All eyes and ears
Stay tuned for Level 2 tomorrow.

Sunday, April 23, 2017

Don't Ignore That Ankle Sprain

Now that's a nasty ankle sprain
We've seen quite a few cases of ankle sprains in our clinics recently. Most of these patients are young school athletes representing their school or participating in sports.

We've always managed to get our patients playing/ competing again quite quickly. Even ankle cases that were deemed serious, we've managed to get them up and running so quickly that their parents/ coaches were pleasantly surprised.

Hence I was surprised to read that ankle even if sprained only once but not treated properly can have lifelong consequences. Especially if the sprains keep recurring.

In the study referenced below, the researchers had students who had chronic ankle instability (caused by ankle sprains) wear a pedometer for a week. Their steps taken were compared with a control group of students who had normal ankles. Gender, BMI and general health were the variables controlled in both groups.

Turns out that the students with chronic ankle instability moved significantly less than the other group. They took about 2000 steps fewer on average.

The researchers were concerned with the obvious decrease in step count as this decrease may be secondary to other functional limitations. If this decrease in physical activity continues for an extended period,it may lead to other more substantial heal risks.

Next time you sprain your ankle, make sure you get it checked and treated properly, even if it seems to be mostly healed as it can lead to lifelong consequences.


Hubbard-Turner T and Turner MJ (2015). Physical Activity Levels In College Students With Chronic Ankle Instability. J Athl Trg. 50(7): 742-747. DOI: 10.4085/1062-6050-50.3.05.

Note to self and my colleagues: be wary even of a simple ankle sprain

Friday, April 14, 2017

Is It Necessary To Cool Down After Exercise?

Stretching after a run in the rain
Back when I was working at the old National Stadium, I'll very often before work or during lunch time run on the track or grass surrounding the track.  Straight after I was done, I'll head right in to the clinic. A person walking past commented how I could do that.

I said I just stopped after running and am heading for the showers as my next patient was due soon. He said I should be doing a cool down after such a hard run.

Well, I was in a hurry to get ready for my patient. I'm sure the patient wouldn't like a sweaty, dripping physiotherapist treating him.

Looking back since primary school, I recall our physical education teachers telling us that we need to cool down after exercise and especially after a race/ competition.

Personal trainers will tell their clients that slowing to a jog and/ or lessening the intensity of the workout followed by stretching to transition out of the exercise session so as to prevent muscle soreness and improve recovery.

Some exercise machines in the gym automatically include a cool down period. After your work out time that you keyed in, the machine automatically reduces the workload and continues for five minutes so you can cool down.

I tried looking for scientific evidence regarding that and it seems none of those beliefs were true.

A study had subjects do a strenuous one time session of forward lunges while holding barbells. This is certain to make untrained people extremely sore due to DOMs over the next few days.

Some of the subjects warmed up before by cycling 20 mins gently. Others didn't warm up but did a cool down after the lunges with a similar 20 mins of gentle stationary bike riding. The rest of the group just did the lunges without warm up or cool down.

The next day, the subjects who warmed up had the least pain while there those who did the cool down and the control group had similar pain. Cooling down brought no benefits to the group.

Two other studies I found on professional football players performing cool down versus no cool down yielded the same result. Measures of performance, flexibility and muscle soreness were similar.

One valid reason to cool down after exercise is to prevent venous pooling (or build up of blood in your veins) after vigorous exercise. Blood vessels in your legs expand during prolonged vigorous exercise, allowing more blood to move through them to supply oxygen. When you stop exercise abruptly, the blood stays in your lower body. This can lead to dizziness or even fainting.

It's easy to avoid venous pooling, just keep walking for a few minutes at the end of your workout/ race and you'll maintain normal blood supply to the brain. Would you consider that as a cool down?

So, there's no real published research showing any negative effect if you don't cool down. If you are used to performing a cool down after your exercise, you can definitely carry on. If you don't feel like it, then you probably don't have too.

Unless future research shows otherwise, don't worry if your friend/ trainer/ coach tells you that you need to cool down after exercise.


Olsen O, Sjohaug M et al (2012). The Effect Of Warm-up And Cool Down Exercise On Delayed Onset Muscle Soreness In The Quadriceps Muscle: A Randomized Controlled Trial. J Human Kinetics. 35: 59-68. DOI: 10.2478/v10078-012-0079-4.

Rey E Lago-Penas C et al (2012). The Effect Of Immediate Post-training Active And Passive Recovery Interventions On Anaerobic Performance And Lower Limb Flexibility In Professional Soccer Players. J Human Kinetics. 31: 121-129. DOI: 10.2478/v10078-012-0013-9.

Rey E Lago-Penas C et al (2012). The Effect of Recovery Strategies On Contractile Properties Using Tensiomyography And Perceived Muscle Soreness In Professional Soccer Players. J Strength Cond Res. 26(11): 3081-3088.

Sunday, April 9, 2017

Luna Mono Running Sandals Review

I've had the Luna Mono Mgt running sandals for a while now and feel ready to write about them after my most recent run in the rain. Despite being wet, the soles were truly non slip, I was truly impressed as I thought they'll be slippery but they were not at all.

Like I wrote before when I first received it, they were nice and soft to wear, almost no breaking in required compared to my other running sandals, the Earth runners huraches. They were also super light, great to bring them while traveling so they can double up as your running sandals.

With normal walking, I didn't mind the strap between my first web space (between big and second toe), but during the runs, I've had some minor discomfort and upon using normal or toe socks they went away.
Normal socks instead of toe socks
I found the "over the top" ankle strap very useful as it helped tighten the sandal to prevent my heel from slipping out (my right foot is slightly smaller than my left so I need to tighten the right sandal more).

I've even had my own version of running mini intervals with them. 3-4 times a week when I bring my two boys to the playground near our place I'll end up playing "big bad wolf" with most of the kids at the playground. I have to run hard to chase them and I must say the Lunas stay on my feet much better than my Havaianas slippers.

My calfs were a tiny bit sore the very first time I used them probably due to the fact they were new. I didn't have a problem with that thereafter.

The Luna Mono's have a fair ground feel and feel good to walk and run in. And they definitely don't give you black toenails. Thanks to Fred from Run Minimal  for the sandals.

Saturday, April 1, 2017

I Bit Off More Than I Could Chew Today

I kinda bit off more than I could chew today..... yes I'm writing that down again to remind myself not to do it again.

Waiting ..... for me to be ready
On Saturday afternoons when we have the Floss band course at Sports Solutions, I normally stop seeing patients half an hour before so I can get my act ready.  I have to get the computer and projector ready, whatever anatomy models I may need, laser pointer etc as well as eat some lunch.

Today, I had a patient who was gonna take part in a race tomorrow. And that patient requested that I do some taping as the last time we did the taping, the patient was able race pain free. The only time I could spare to do the taping was the half an hour before the course.

That of course ate into preparation time and I was late for my own course right here in the clinic. I wasn't happy with myself! As someone who takes care to always be early for my patients and appointments, I messed up.

A thousand apologies to all who turned up for the course today. I promise it will not happen again. And by the way we had a chiropractor (for the first time) who turned up for the course today too.

Right in the thick of action

Capt America watching ...while Trevor doesn't

The physio students having a go
A big thank you to Danny, Ekina and Jane who came really early and got the place ready for the course again. Couldn't have done it without them. And for helping me tidy the place after too. Please contact them at Sanctband Singapore if you want to attend the next course.

Sunday, March 26, 2017

Anatomy Trains Course

The three amigos 
Aized and Sham did the Pediatric Craniosacral Therapy course two weeks ago, while Reggie, Ting Jun (TJ) and I attended the Anatomy Trains workshop this weekend.

TJ has been at the course for the past four days and since Reggie and I did the first two days last year, we came only for the third and fourth day this year.

It was good to have done a little last year and then review some the concepts while adding on to it this time around.

Here are some pictures from the course.

More theory

TJ has the best view for this practical
At the end of the course the presenter was saying "if all of you go in to see and patients tomorrow and wonder what you need to do then I've done my job. "

He was challenging us to look at and treat our patients with a whole new perspective instead of trying to treat our patients the same way we've done.

This has been a most interesting and stimulating course. It ties in nicely with many of the things we already do with fascia while treating our patients.

Well, I'll share what I've learnt with the rest of our team and we'll all be looking to treat our patients and make them better quicker.

Saturday, March 18, 2017

Mirror Mirror On The Wall

Rachel training while waiting for her patients
When you go to a gym, one of the first things  you notice is there are mirrors almost everywhere. And you see lots of people training in front of the mirrors. In theory, the mirrors are there to ensure you hold correct and proper form during exercise. Can mirrors really be helpful?

Previous studies showed mixed results about using mirrors for exercise. Some studies show workout benefits, some no effects while others show negative effects depending on the specific task and experience level of subjects.

Currently, there is a lot of evidence showing that external focus leads to better performance than internal focus while performing physical tasks. Let's say you're shooting a basketball on the free throw line. Focusing on the rim rather than the movement of your wrist will get you better results. One reason is external focus (focusing on the rim) allows well-practiced movements to take place on auto pilot. This is more efficient than trying to directly control wrist action (internal focus).

A group of researchers studied the role of mirrors in attentional focus by getting subjects to do two series of tests. One involved flexing the elbow as hard as possible (single joint movement). The other test involved jumping as high as possible (multi joint movement).

In both cases, tests were done four times under the following conditions. Internal focus, external focus, neutral and finally with a mirror.

To sum up, external focus was best for both series of tests, while internal focus was worse. Using mirrors were no different (statistically) from the neutral condition.

So for both tasks, the mirror didn't really matter. Perhaps while doing resistance type training with heavier weights, mirrors may be helpful for maintaining symmetry of movement or correct form. What is important is that external focus trumps internal focus.

Runners take note that a previous study found that focusing on your form or your breathing (internal focus) results in worse running economy than if you focused on the surroundings (external focus).


Halperin I, Highes S et al (2016). The Effects Of Either A Mirror, Internal Or External Focus Instructions On Single And Multi-joint Tasks. PLOS One.

Schucker L, Hagemann H et al (2009). The Effect Of Attentional Focus On Running Economy. J of Sports Sciences. 7(12) : 1241-1248.

Saturday, March 11, 2017

Stress Fractures In Teenage Female Runners

Icing the shin
The Singapore National School's competitions are usually held between March and late May every year since 2009. And it's that time of the year again where we see many patients in our clinics with shin splints. Mostly adolescent and teenage girls and the occasional boy.

Why are girls more susceptible to shin splints and stress fractures? Well, some new data shows that if teenage female athletes don't eat enough to support their training, there will be complications regarding their subsequent training and health.

The study tracked 323 female athletes at Stanford University in 16 different sports including cross country running. Bone scans and questionnaires were used to assess the runners based on the components of the "female athlete triad" consisting of "low energy availability, with or without disordered eating, menstrual dysfunction and low bone mineral density. "

Risk status were calculated based on an article published in the British Journal of Sports Medicine  in 2014. Have a look at Figure 4 in the article if you're keen to know more about the calculations.

Looking only at the cross country runners (47 runners) data, half the runners were classified as low risk, and three of those later developed stress fractures.

Sixteen of the runners had moderate risk and 50 percent of these developed stress fractures within a year. These girls were about four times as likely to get injured compared to the low risk group.

Seven runners were in the high risk group and five of them developed stress fractures. They were nearly six times as likely as the low risk group to get injured.

Well, if you're thinking like me, not so good news for the girls if you're a runner and in the moderate to high risk group.

The researchers suggested the following guidelines for female athletes in the moderate to high risk group. The athletes need to ensure they're getting enough calories to support their training along with calcium and Vitamin D. Their menstrual function, bone health and nutrition needs to be monitored on an ongoing basis.

Higher risk athletes may have to consider using low impact cross training more often in their weekly routine. Good sleep and recovery are important too.

Stress fractures occurred mostly in the foot for the low risk athletes, probably as a consequence of biomechanics and jumping sports (due to higher forces).

In the higher risk categories, many of the stress fractures were in the sacrum, pelvis and femoral neck (where the bones tend to be softer). These areas may be due to weakened bone rather than biomechanical forces.

So all the doctors, physiotherapists, physical education teachers, coaches, heads of departments and administrators in charge of female teenage athletes reading this post, please take note.


Tenforde AS, Carlson Jl et al (2017). Association Of The Female Athlete Triad Risk Assessment Stratification To The Development Of Bone Stress Injuries In Collegiate Athletes. AJSM. 45(2): 302-310. DOI: 10.1177/0363546516676262.

Friday, March 3, 2017

Current Hydration Guidelines May Well Be Wrong

Picture by richseow from Flickr
We've been told in the past by articles, journals and research scientists that if you lose more than 2 percent of your body weight (through sweating) during endurance exercise/ racing your performance will be affected.

Moreover, advertisements from Sports drinks companies keep harping on the fact the you need to drink up or else you get dehydrated.

However, some recent studies (as well as anecdotal evidence from the world's top distance runners) suggest that it may be possible to lose more than 2 percent of your body weight (from sweating) with little or no loss in your performance.

Research scientists from New Zealand's High Performance department have suggested that previous published dehydration studies were conducted in "relatively windless environments (i.e. wind speed less than 12.9km/h) with participants being aware their hydration status." They stated that such conditions do not simulate real race conditions.

In their own (albeit) small study of 10 cyclists, they found that weight loss of up to 3 percent did not slow down the cyclists nor their power output decrease in a 25 km time trial.

Another study on elite male marathoners examined their drinking behavior during 13 major city marathons. Haile Gebreselassie was found to have lost 9.8 percent (and that's a lot) of his body weight during the 2009 Dubai Marathon and still won in 2:05:29 hrs. All drinking by the elite runners were ad libitum (or at their own time and pleasure).

Granted the above study was done on elite runners. Does that even apply to mere mortals like us?Especially in hot and super humid Singapore.

Here are my own thoughts. From the time I started running cross country as a twelve year old kid, I've noticed that I tend to drink less than my team mates and other competitors. And definitely less than what the Sports drinks companies recommend. In fact I often had a side stitch after drinking. That also deterred me from drinking too much then.

So despite what you've heard or read before, at least give it a try in your next few long bike or run sessions. Try to get through those long sessions drinking as little as you can. You'll be pleasantly surprised that you may not need as much fluid as you think.


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.

Friday, February 24, 2017

Is Income Inequality Slowing Us Down Too?

"Beep" Test
A new study has found that kids from the United States are among the least fit in the world (out of 50 countries). And it may be due to their unequal income distribution as researchers found a correlation between income inequality and fitness.

Researchers pooled data from 177 previous studies conducted around the world to understand the link between a country's income inequality and youth fitness. They specifically compared a country's Gini Index (which measures how income is distributed throughout that country) with a 20 metre shuttle run test in that same country. 

When there's a large gap between the rich and poor in a country (i.e. higher Gini Index), there tend to be large sub populations of poor people within that country. And poverty is linked with a whole bunch of poor health outcomes. One of those outcomes is poor aerobic fitness in children.

The researchers found that the greater the Gini Index (i.e. the higher the number), the less likely their kids were to perform well in the shuttle run test (also know as the "beep" test or the multi-stage fitness test).

Two parallel lines are drawn 20 metres apart in the "beep" or multi-stage fitness test. The children must run back and forth between the two lines, reaching each line before a beep sounds.

The time between beeps decreases as the test goes on, forcing the kids to run faster. If a child fails to reach the opposite line before the "beep" sounds twice in a row, he / she is eliminated from the test.

This test is popular around the world as many people can be tested simultaneously and research scientists use it to draw conclusions about a country's level of fitness by pooling and comparing data.

Our Singapore readers may remember this "beep" test was highly unpopular among our "S" league footballers who had to achieved Level 13-2 before they can play in our professional league.

Now, you must be wondering what does income inequality have to do with obesity?

The data suggested that poverty tends to make people less fit primarily when they live in a relatively rich (or developed) country while the opposite is true in undeveloped countries.

Researchers suggest that for the young people in developed countries with low income, they tend to not have access to healthy food. They normally have access to cheap but very high calorie, energy-dense food. Being poor but surrounded by fast food, cars and television seems to be more detrimental than being poor in a rural environment where physical activity is a necessary part of life.

The young people in undeveloped countries differs in that they may not have access to parks, playgrounds, equipment and facilities. They tend to be physically active out of obligation as they have to walk or cycle to and from work. They may also need to walk greater distances to access fresh water or groceries.

No Singapore kids were included in this study, but our Gini coefficient is on the high side so does this mean the poorer kids are less fit in Singapore too?

Maybe it's timely that it's announced in today's Straits Times that all pre-school children will have at least one hour of physical activity a day including time spent in the sun (to reduce myopia) and also be served healthy meals including fruit.

Front page in today's Straits Times 240217

When it comes to being fit and healthy, it's good to start them young.


Lang JJ, Tremblay MS et al (2016). International Variability in 20 m Shuttle Run Performance In Children And Youth: Who Are The Fittest From A 50-country Comparison? A Systematic Literature Review With Pooling Of Aggregate Results. BJSM. Published online first :20 Sptember 2016. DOI:

Saturday, February 18, 2017

World Champion Athlete Comes To Floss Band Course

We had a Pencak Silat World Champion attend the Floss Band course today at Sports Solutions along with coaches, and sparring partners from the Singapore Silat Federation.

Yes, you read correctly, Muhammad Shakir Junda (above right) is a 2-time Pencak Silat World Champion (in the over 85-90 kg category). He was crowned World Champion in 2012 and 2016.

While I was still working at the Singapore Sports Council (now the S'pore Sports Institute), I had treated 3 Silat World Champions before and I found out today they were still involved with grooming future world champions.

Of course there were also other Physiotherapists, Personal trainers, Physical Education teachers and Occupational Therapists attending the course today. It was good to see some familiar faces in the participants today (Jocelyn and Tommy).

Hey, I thought it was the Floss band course, not foam rolling

Tommy Yau explaining how it's done

Lenis and Jacq do the cha cha?
A big thank you to Amy, Danny and Ekina for coming early and getting the place ready so I can eat a little after seeing patients in the morning. And for packing up after the course too. Please contact them at Sanctband Singapore if you want to attend the next course in April.

Thank you to all who came to the course today, glad you guys found it useful. And hopefully we'll get more World Champions in Pencak Silat too.