Don't Give Up On Physiotherapy

Megan, Thiviyan and Byron

This past week, we saw a few new patients in our clinics who had almost given up on physiotherapy. They felt this way because the physiotherapy treatment that they had received, consisted of brief sessions of exercises or the use of machines like ultrasound, interferential currents and shock wave (ESWT).

There is no wonder why many people who have had such experiences with physiotherapy conclude that physiotherapy does not work.

We are grateful that those patients gave us the chance to show them that physiotherapy does indeed help!

This is what we do in our clinics. We start by doing a thorough assessment of a person's lifestyle and goals. Then we observe how their body is when they are static and when they are doing functional activities. We do not chase the pain. Treatment plans are drawn out based on how each patient presents him/herself at that moment and where a patient wants to get to in the near future. We mainly use our hands, not machines or modalities.

We had 3 newly graduated physiotherapists join our team 12 weeks ago. Megan, Thiviyan and Byron.

Megan saw the gentleman below last week. He complained of some neck and shoulder pain and discomfort possibly due to working from home last year. 

Left picture before treatment

He sits for long hours and does not exercise. After assessing him, Megan decided to treat his feet. Yes, you read correctly, she did not treat his neck, shoulders or lower back, not yet anyway. She was able to significantly change his pain and his posture in less than hour.

From the side view (picture above on right), his feet are not pointing outwards as much. His knees are not as hyperextended, he seems to have 'lost' his tummy since he is standing more upright. His neck is also not poking forward as much with respect to his body.

Left picture before treatment

From the back view, the space between his left arm and body and right arm and body is more equal. His right hip is not tilting down as much as before. Well done Megan!

Thiviyan recently received an email of commendation from one of his patients. She had gone to a surgeon before seeing him and he got her better quickly using the approach that we use in our clinics. 

Bravo 

Lastly, there is Byron . He saw a patient with an interesting foot condition that the doctor the patient saw missed. That will probably be another post.

We're really pleased with how the three of them are progressing. 

As experienced physios, we are grateful that we get to teach our young physios and we are learning from them too. They see the world through different lenses. When we consider all the different perspectives in the assessment and treatment of our patients, we become stronger as a team and more skilled at helping our patients. 

As we previously wrote, we do not aim to be the biggest physiotherapy clinic, we just want to be the best at helping our patients reach their goals.

Choose A Pink Drink For Your Next Run

Megan getting ready for her run

If you're lacking some motivation prior to your next run, it may help to consume or even just rinse and spit out a pink drink rather than just clear regular water.

Skeptical? I was. Until I read the article (Brown et al, 2021) where researchers got runners to run at their own desired speed on a treadmill for 30 minutes. Throughout the run, they rinse their mouths with an artificially sweetened drink that was either pink or clear. Yes, just rinse and spitting the drink out, not even drinking. Actually both the drinks were the same, save for a few drops of food dye in the pink drink to get the colour. 

During another treadmill run, the runners had the other drink (pink if they got clear in the first run and vice versa).

When the runners rinsed with the pink drink, they showed more endurance and intensity compared to when they rinsed with the clear drink. When rinsing with the pink drink, the runners ran 212 meters further and ran faster by 4.4 percent. Here's what was even better. The runners reported higher levels of enjoyment while running when rinsing with the pink drink. This result is similar to what previous similar studies reported.

The authors commented that in another taste study, participants reported that the pink drink was sweeter compared to the clear drink even though they were the same except for the colour. There is definitely a relationship between colour and our mental and physical response. This powerful placebo effect can definitely be harnessed for better running experiences.

This effect of colour in sports is not new, with red in particular thought to provide a performance advantage. Remember Tiger Woods always used to wear red when he was so dominant in golf. Well, what we also teach during the Kinesio Taping courses uses similar concepts in the colours available when it comes to taping.

Pink was used in this study because of its perceived sweetness. And we usually tend to associate sweet tastes before exercise in anticipation of using glucose to fuel our exercise.

The authors wrote that this effect is mainly cognitively (acquiring knowledge/ understanding through thought, experience and senses) driven. Once receptors in the mouth detect the sweet taste, this activates the areas in the brain associated with reward and motivation. Once these areas are activated during exercise, it leads to exercise feeling more enjoyable and easier. One can then run faster and harder based on this feeling.

Drinking or even just rinsing like what the participants did will work just as well. This will help for exercise up to an hour. For any exercise of longer duration, there needs to be actual carbohydrates in the drink that you use (unlike this study where the pink drink is artificially sweetened and has no calories). I've written previously on carbohydrate rinsing in 2018 and way back in 2010.

This no calorie pink drink rinsing cannot sustain you for an indefinite period, especially if you are doing a really long training session or race. 

This is especially useful and will work when you're bloated from drinking too much in a long distance race. If you're doing this in a race, there needs to be actual carbohydrates in the drink that you use, unlike this study where the pink drink is artificially sweetened and has no calories.

Reference

Brown DR, Cappozzo F, Roeck DD et al (2021). Mouth Rinsing With A Pink Non-caloric, Artificially-sweetened Solution Improves Self-paced Running Performance And Feelings Of Pleasure In Habitually Active Individuals. Frontiers Nutr. 12 May 2021. DOI: 10.3389/fnut.2021.678105

4 Exercises To Avoid If You Have Shoulder Pain

We've seen quite a few patients in our clinic recently with shoulder injuries after exercising at gyms. Often, the patients will ask how soon they can get back to their regular gym exercise routine. 

I haven't found any published evidence for what I'm suggesting. They are based purely on my personal observations, treating many patients with shoulder pain and of course doing the same exercises myself.

So here are a few exercises to avoid in the gym (at least until the pain ceases) if you currently have shoulder pain.

First up is the behind neck Lat (Latissimus Dorsi) pull downs. The bar behind the head position potentially creates a situation where the humerus (arm bone) can move too much in front. Majority of the time, it is due to lack of scapular retraction. This creates a scenario whereby they need more than average shoulder extension to get their elbows behind the body so the bar  can clear the back of their head. This places high loads on the front of the shoulder  and can potentially damage the anterior glenohumeral ligaments and the Biceps Brachii tendon. 

Next is behind the neck shoulder press. This is similar to the Lat pull down, but more damaging. When pressing up, the Deltoid muscles have to work, whereas during a pull, the Latissimus Dorsi works. The Deltoid abducts the shoulder and also elevates the humerus into the acromion process. So a pulling movement with the Latissimus Dorsi will pull the humerus away from the acromion and reduce shoulder impingement. However, the behind the neck shoulder press can potentially cause shoulder impingement.

The upright row. A lot of people 'cheat' by extending their lower back to get the bar up when the weight is too heavy for them. At the top of the pull, the elbows are in a higher position than the arms putting the shoulders into abduction and internal rotation. This position can cause or worsen shoulder impingement since our shoulder should naturally externally rotate with shoulder abduction. 

Dips. I used to do lots of parallel bar dips as a kid, but I hardly do them now. Try it yourself, when dipping, there are super high tensile loads on the front of the shoulder at the bottom of the dip. The Biceps tendon, anterior shoulder capsule, and Subscapularis tendon are all under huge loads. The scapula is also tilting anteriorly at the bottom of the dip. Much worse if you add weights attached to the waist.

If you do the above exercises occasionally, I'm fairly certain no harm or damage is done. But if done regularly, with high load and especially if you have a pre-existing shoulder dysfunction, they can definitely make your shoulder worse.

Don't get me wrong, the above mentioned exercises are not bad exercises to do at the gym. It's just that some of us do not have the perfect joint placement for certain exercises, due to imbalances and underlying movement restrictions, that makes those exercises damaging.

About Intervertebral Discs

Picture from M.A. Adams et al, 2010

Having learnt in anatomy class (when I was a physiotherapy student) that our intervertebral discs (IVD) are avascular (has no blood supply), I was instantly surprised when recent research showed that it may not be totally true.

picture from springer link

A little anatomy lesson before I tell you more. Our IVD's are fibrocartilaginous joints that are thought to be the largest avascular structures in the human body. They are made up of three distinct and interdependent tissues. The outer most cartilage endplates are thin layers of hyaline cartilage that anchor the IVD to the adjacent vertebral bones. The vertebral end plates have plenty of blood supply and this allows for diffusion of nutrients into the IVD through the cartilage end plate.

The annulus fibrosus (AF) is a series of super strong well organized concentric lamellae of fibrocartilage that surround and protect the nucleus pulposus (NP) of the IVD. 

The NP is the innermost jelly like substance made up mainly of water and proteoglycans. The NP helps distribute pressure evenly across the IVD and prevent excessive forces loading the spine. This is what can herniate through the AF, causing what is commonly know as a 'slipped disc' or prolapsed intervertebral disc (PID).

A group of researchers performed a comprehensive *scoping review on peer-review publications on the blood supply of human IVD's excluding disc herniations. 22 out of 3122 articles found met the inclusion criteria of fetal to > 90 years old, various health status and both sexes using gross dissection, histology or medical imaging to assess if there is blood supply.

Consistent observations from this review were that there is no blood supply in the NP of the IVD throughout life. 

Both the cartilage endplates and AF have considerable blood supply during fetal development and in infants, but decreases over our lifespan. A common feature of the cartilage endplate was the presence of channels throughout the tissue, likely from the well vascularized vertebral endplate from the adjacent vertebrae. Between birth and ten years of age, there is a drastic decrease in blood vessels within these channels; which are not seen at all in adults.

However, there are blood vessels growing into the endplates and inner layers of the AF especially when there is damaged or disrupted tissue regardless of age. This is more common in older adults. Location of blood vessels are variable. 

It is thought that annular fissures or tears associated with degenerated discs are perhaps more conducive to the ingrowth of blood vessels since there is a loss of proteoglycans (a protein compound found in connective tissue) due to the healing process. Interestingly, there are also nerves found together with the blood vessels suggesting some patients may get more pain than others with such conditions.

Through this scoping review, we now know that the IVD is not entirely avascular as often thought and cited. This is great news for patients. We always knew that you can heal from a "slipped disc", but the discs having a blood supply means a better chance that it can heal from an injury.

Reference

Fournier DE, Kiser PK, Shoemaker JK et al (2020). Vascularization Of The Human Intervertebral Disc: A Scoping Review. JOR Spine. 15: 3(4): e1123. DOI: 10.1002/jsp2.1123.

*A scoping review has a broader scope compared to traditional systematic reviews with correspondingly more expansive inclusion criteria.

* you can read more about slipped discs and how slipped discs can heal here.

Mouthwash Reduces Exercise Benefits

I brush my teeth at least 3 times a day, but usually do not use mouthwash. Actually I do, I grind my teeth at night and wear a night splint so as not to wear out the enamel in my teeth. Sometimes, I soak my splint in mouthwash to have that fresh minty sensation when I'm wearing it.

Do you use mouthwash? A study (Cutlet et al, 2019) found a surprising link between mouthwash and nitric oxide levels. Yes, using anti-bacteria mouthwash can affect your nitric oxide levels.

We know that exercise helps to lower your blood pressure (BP). When we exercise, the cells in our blood vessels and muscles produce nitric oxide. Nitric oxide helps widen our blood vessels and lowers our BP. This continues after exercise and our BP remains low. The bacteria in our mouth helps to recycle nitrates produced during exercise into nitric oxide. 

So if you use mouthwash to kill those helpful microscopic bugs, you are also spitting them down the drain and this can affect your blood pressure. This can also mess with your sporting performance.

Researchers from that study (Cutler et al, 2019) had a group of healthy man and women  run two 30-minute treadmill tests. After the first run, the runners rinsed their mouths with either an anti-bacterial (0.2 percent chlorhexidine) mouth wash or an inactive, mint flavored rinse.

After the second run, their mouth washes were switched. Neither the runners nor researchers knew which mouthwash the runners were rinsing with each time. BP and blood samples of the runners were taken before each session and two hours after the run.

When the mint-flavored placebo rinse was used, their systolic BP ( the highest BP level when the heart is squeezing and pushing oxygenated blood into circulation) was reduced by an average of 5.2 mm Hg one hour later. However, when the anti-bacteria mouthwash was used their BP fell by only 2mm Hg (> 60% less than the placebo) over the same time period.

What was worse was that the BP lowering effects completely disappeared  after two hours when using the anti-bacteria mouth wash. 

Moreover, their blood nitrate levels did not increase after the runners used the anti-bacteria mouthwash. However it spiked when they used the placebo rinse.

This shows that oral bacteria play a key role in the cardiovascular effects of exercise, specifically the vasodilation and lower BP after exercise. The nitrates formed during exercise are absorbed by the salivary glands and secreted in the mouth. Oral bacteria in the mouth then reduces it to nitrite in the recovery phase after exercise. Once the nitrite is swallowed, it can be absorbed into the bloodstream to form new nitric oxide to help sustain the blood supply to previously active tissues.

Since mouth wash lowers nitrite availability, this may impair cardiovascular response associated with exercise, although more research is needed to study this in greater detail.

Since we already know that runners and other endurance athletes  tend to have poorer dental health, it may not be wise to rinse your mouth with anti-bacteria mouth wash. Instead, eat less sugar and brush your teeth regularly to maintain good dental hygiene . Otherwise, you may not get the most out of the the vessel widening, circulation boosting benefits from exercising. This would be a real pity.

References

Cutler C, Kiernan M, Willis JR et al (2019). Post-exercise Hypotension And Skeletal Muscle Oxygenation Is Regulated By Nitrate-reducing Activity Of Oral Bacteria. Free Rad Biol Med. 143: 252-259. DOI: 10.1016/j.freeradbiomed.2019.07.035

Forward Lunges To Strengthen Your Knees?

Lunges by our 3 physios

A patient came in complaining of knee pain after running. Since she also did strength training with a personal trainer, she was instructed to do forward lunges (FL) to strengthen the muscles "around the knees" to avoid knee pain. Yes, the lunge is a very popular strengthening and loading exercise that is often prescribed by many health professionals. 

Alas, the front lunges made her knee pain worse.

After examining her, I explained that her knee pain was more likely coming from her hip. Meaning, she feels the pain in her knees, but the cause of her problem is her hips.

In addition, FL exert a much greater load on the patellofemoral joint compared to backward lunges (BL). I recall just reading a published article where researchers studied a group of young healthy females comparing front and back lunges.

47 body markers were placed on different parts of their bodies to record data from two force platforms in addition to 15 motion analysis cameras. The female subjects performed 10 consecutive forward and backward lunges and the researchers analyzed the middle six. 

The researchers found that peak patellofemoral joint (PFJ) reaction forces were 18.1 percent higher in FL compared to BL during the upward phase. Peak PFJ stress was 9.55 percent higher in FL compared to BL.

Peak quadriceps (or thigh) force was 18.3 percent higher in FL.  Knee bending angles were 5.85 percent larger in the upward phase of FL compared to BL. Most importantly, average PFJ loading rate was 124 percent higher in FL compared to BL. 

These results suggest strongly that there is much higher PFJ loading in the FL compared to BL. Exactly why my patient's knee pain got worse after doing her lunges. 

So if you're having knee pain, it may be best to avoid doing forward lunges until it settles. It may also be wise to strengthen your calf muscles instead.

Reference

Goulette D, Griffin P, Schiller M et al (2021). Patellofemoral Joint Loading During The Forward And Backward Lunge. Phy Ther in Sport. 47: 178-184. DOI: 10.1016/j.ptsp.2020.12.001

How Much Exercise Is Good For Your Brain?

I rode 105 km before work this morning. No prizes for guessing I was thirsty, hungry (despite eating before I started work) and needless to say, tired. 

There are days when after a run or ride I feel alive, my mind is laser clear, and all my synapses are firing. Today's ride was definitely not a ride where I felt clarity afterwards. 

There's plenty of evidence that short bouts of moderate exercise improves your performance in the ability to perceive, react, process and understand, store and retrieve information, or do cognitive tasks afterwards. You may not feel it, but the finding is highly repeatable.

However, we do not know how much exercise is enough to trigger this effect. Or whether how fit you are or what type of cognitive task you're doing matters.

I found an article where researchers in Australia tested 21 trained cyclists and triathletes (11 male, 10 female). These athletes did 15 minutes of moderate cycling followed by a pair of cognitive tests lasting 4 minutes. They rode another 30 minutes moderately before repeating the same cognitive tests. This was followed by an incremental ride to exhaustion (taking about 11 to 12 minutes on average) before doing a final round of cognitive tests (McCartney et al, 2021). Three different timepoints were measured, after 15 minutes, 45 minutes and exhaustion.

Moderate cycling was done at 50 to 55 percent of peak power from a previous test and this got them to average 75 percent of max heart rate (HR) after 15 minutes and 80 percent of max HR after 45 minutes.

Results showed that 45 minutes of exercise trumped 15 minutes. For these trained endurance subjects, their cognitive performance decline definitely did not happen after 45 minutes of moderate exercise.

Contrary to what the researchers expected, the decline did not happen after complete exhaustion as well, being better than after 15 minutes. Note that there was a 2 minute delay from the moment of exhaustion until the start of the cognitive tests so this delay may just be enough to recover.

Bear in mind that exercising for longer does not always mean better since there will be a point for everyone where if you exercise long enough your cognitive performance will start to drop. 

These subjects were also not allowed to drink during the testing. Male subjects lost 2.3 percent of their starting weight while the females lost 1.7 percent. This is well above the threshold suggested to cause cognitive impairment. 

The subjects repeated the testing twice. In one testing, they were given 2 capsules and told that the capsules were "designed to enhance cognitive function" during exercise. 

The capsules were just placebos, as the researchers wanted to test whether the subjects were influenced by this. The placebos did not have any significant effect which supports the case that this is a physiological effect - a result of enhanced blood flow to the brain or elevated levels of neurotransmitters.

There was another study done in 2015 where researchers from Taiwan found that 20 minutes of moderate exercise produced the biggest cognitive boost, compared to 45 minutes. The biggest difference between the two studies is that this Taiwanese study used healthy but non athletic university students (Chang et al, 2015).

Since the 2021 study used trained endurance athletes, it makes sense that they will probably benefit from a longer exercise duration compared to the university students.

There you have it, exercise does makes you improve your brain function. However, we cannot always go out for a run or ride before an important meeting, deadline or decision. It can also be shooting hoops or lifting some weights or any other exercise if running or cycling ain't your thing. Just do it when you have the opportunity.

References

Chang YK, Chu CH, Wang CC et al (2015). Dose-Response Relation Between Exercise Duration And Cognition. Med Sci Sp Ex. 47(1): 159-165. DOI: 10.1249/MSS.0000000000000383

McCartney D, Desbrow B and Irwin C (2021). Cognitive Effects Of Acute Aerobic Exercise: Exploring The Influence Of Exercise Duration, Exhaustion, Task Complexity And Expectancies In Endurance-Trained Individuals. J Sp Sci. 29(2): 183-191. DOI: 10.1080/02640414.2020.1809976.

Our Sat ride before Covid-19