Sunday, December 30, 2018

The "What The Hell" Effect

All mine
This time of the year is usually special for most people. For our family, it is filled with holidays, parties and feasting. Christmas has just passed and we have New Year's day soon.
My wife and older boy's birthday is next week followed by my younger boy's birthday at the end of January. In between we have cousins, nephews and nieces celebrating birthdays and Chinese New Year after that.

For those of you who are done with training and racing, it must be nice relaxing and recovering both physically and mentally. It's also a good time to take stock of your season, to reflect and review so you can learn from it and do better next season.

Hopefully, you haven't been like me (eating too much) and piling on the pounds. I read about the "what the hell" effect which describes the the cycle where you indulge (and eat too much), regret what you've done and then go back for more.
Lots of jelly still ......
Your brain rationalizes your behavior by telling you that you already blew your goal of eating only two fruit tartlets, so what the hell, you might as well eat the whole tray. The phrase originally came from dieting researchers, but the effect may be applied to any setback or willpower challenge.

You definitely don't want the whole of this period to be a long "what the hell", if not it will take you a fair bit of time to regain your previous fitness levels.

I find it helpful during the holiday period to just do something first thing in the morning. A short run, a spin on the stationary bike or some weights is usually what I do now. Even if I do over indulge, I know that I'd already done some exercise to help my overeating.

Don't be dismayed that your weight has gone up during this period. Think of it as having increased glycogen (carbohydrate) stores that you can use on your next long run/ bike session.

Those potato chips or crisps (or other Christmas goodies) that you've snacked on also contains salt. Consumed in excess, salt causes more water to be absorbed into your system. That excess water can also show up as extra weight when you weigh yourself. The good news is extra water is easier to lose than fat.

Lack of sleep from family gatherings, office parties etc can have a impact on your weight too, Research shows that lack of sleep makes you eat more. Since you've trained all year round it's hard to lose everything that you've built up just don't overdo it.

While I was still racing, I never train for up til two weeks after my racing season ended. Yes, two weeks of no cycling, running or swimming to recuperate. I think of the rest period as taking a few steps back so I can move forward over the new year.

Then I'll pick a date on which I'll start to train again. I don't expect to be at the same level, physically or mentally. The time off usually makes my legs "start to itch" so I know I'm ready to start training again.

This is the last post for 2018, thank you for reading and Happy New Year to all.


Polivy J and Herman CP (1985). Dieting And Bingeing: ACausal Analysis: Am Psych 40(2). 193-201. DOI: 10.1037/0003-0666X.402.193.

Prinz P (2004). Sleep, Appetite, And Obesity- What Is The Link? PLos Med. 1(3): e61. DOI: 10.1371/journal.pmed.0010061.

Friday, December 21, 2018

Running, Weight Training And Your Tongue Muscles

Michael Jordan and his tongue. I like Rodman too!
Last week, I wrote about why strength training and aerobic exercises are both critical to us aging well. I'm sure most of us kinda knew that already.

Turns out now that exercise, particularly endurance exercises may be useful in preventing and perhaps even treating sleep apnea and dysphagia (difficulty swallowing). Your tongue, just like the rest of your body, was made to move.

Let me present the latest benefits of exercising. VanRavenhorst-Bell and colleagues (2018) has shown that exercise is associated with greater tongue strength and endurance. Just as written before, not all exercises are equal.

Before you start laughing or stop reading this post, consider the following information.  You'll need good strong tongue muscles to keep your airways open while you sleep (to prevent sleep apnea). If the slow twitch muscle fibers at the back of your tongue lack endurance, it increases your chances of mouth breathing and sleep apnea.

The fast twitch muscles near the front of your tongue is important for swallowing. Our tongue muscles do get weaker as we age, which can lead to dysphagia (difficulty swallowing), making it easier for you to choke.

Ideally, you you need great endurance at the back of your tongue to avoid airway breathing problems and great strength at the front of your tongue to prevent swallowing problems.

In their study comparing weight lifters and runners who trained at least four times a week, weightlifters were found to have greater maximal tongue strength and runners have greater endurance. Reason being weightlifters would use the front of the tongue to produce forceful inhales and exhales while the rhythmic panting of endurance runners would help in greater tongue endurance.
Here's a runner with his tongue out
If you're keen to know how they test tongue strength have a look here.

So here's another reason reinforcing that there's way more physical benefits to exercising then what we know. We are definitely made to move.


VanRavenhorst-Bell HA, Coufal KL et al (2018). A Comparative Study: Tongue Muscle Performance in Weightlifters And Runners. Physiol Rep/ 6(22): e13923. DOI: 10.14814/phy2.13923.

Read the article here.

Here's 2 pictures of Michael Jordan when he was way younger.
Winning shot for North Carolina in 1982 in college
With a young John Stockton 
All the pictures I took with my iPhone X from this book "For the love of the game".
Since Michael Jordan and Dennis Rodman retired, I hardly watch the NBA now.

Sunday, December 16, 2018

Aerobic Exercises Key To Aging Well?

Me on the left. Picture by Jeffrey Keng from Cycleworx
Slightly more than a year ago, I wrote that strength training may be just as important (if not more) than aerobic exercises. Why? Strength training has been found to decrease rates of early and cancer related death.

And earlier this year I disagreed with a funded study by Les Mills International when the article suggested that lifting weights was more beneficial for losing weight compared to running or cycling (aerobic exercises).

Now, some new research seems to show that aerobic exercises (like running, cycling, rowing or swimming) can make our cells younger. That same study found that weight training may not cause the same physiological changes in our cells.

Way back in 2009, a study found that competitive middle-aged runners had extended telomeres compared to inactive people of the same age. What are telomeres? All of us have telomeres at the tips of our chromosomes. Telomeres help protect our cells from damage and have been found to shorten and fray as a cell ages.

Many of the researchers in that 2009 study came together for this recent study to investigate whether exercise would change our telomeres.  They also wanted to know what type of exercise were needed and whether intensity played a part. It is hypothesized by the scientists that exercise helps lengthen the telomeres.

The researchers recruited a group of healthy middle aged men and women who did not exercise. They were tested for  their aerobic fitness and telomere length. In addition, blood markers of telomerase (an enzyme that influences telomere length) were tested as well.

Some in this group were randomly assigned to continue with their lives as normal as a control group. They did no exercises.

Others started a supervised program of brisk walking or running for 45 minutes three times a week or a high intensity interval program of four minutes of strenuous exercise followed by four minute rests with this repeated four times.

A third group took up weight training, doing a circuit of resistance exercises three times a week.

Heart rates were monitored and the exercise program was carried out for six months. Results were tested after this and all the subjects who exercised were found to be more aerobically fit.

At molecular level however, there were differences. Those who did the aerobic exercises and interval training had much longer telomeres than before starting the exercise program and more telomerase activity.

Those who weight trained and those in the control group (who did not exercise) had no change in telomere length. Some even had shortened telomere lengths.

Those who did weight training produced less nitric oxide, which is thought to affect telomerse activity and contribute to lengthening telomeres.

Even though weight training was strenuous, overall heart rate was lower compared to running in the study. This results in less blood flow and probably less physiological response from the blood vessels.

The researchers suggested that exercise needs to be aerobically taxing to extend telomere length and slow cellular level aging. In this aspect, endurance exercise was clearly ahead of resistance training.

The findings do not indicate that weight training does not combat aging as it also helped improved fitness, which itself is a very important indicator of longevity.

Like I wrote before, current research shows that both strength training and aerobic exercises are necessary to be healthy and functional. So run, bike or lift weights, (or whatever exercise you prefer) as they are all beneficial, it's much more important to keep moving.

I wanna for live a long time, so I lift weights too


Werner CM, Furster T et al (2009). Physical Exercise Prevents Cellular Senescence In Circulating Leococytes And In The Vessel Wall. Circulation. 120 (24): 2438-2437. DOI: 10.1161/CirculationHA.109.861005.

Werner CM, Hecksteden A (2018). Differential Effects Of Endurance, Interval And Resistance Training On Telomerase Activity And Telomere Length In A Randomized Controlled Trial. Euro Heart J. ehy585.

Sunday, December 9, 2018

Is Drinking Too Much Sparkling Water Bad for You?

In the fridge of our rented house 
One of the houses we rented during our recent trip had some fizzy (or sparkling) drinking water in the fridge. My younger boy tried it and seemed to like it. It was just a novelty to him. At home in Singapore, we drink filtered water and my wife doesn't allow our boys any sodas or fizzy drinks.

On the topic of sodas, some of you may remember I used to drink lots of Coca Cola while I was still competing. Actually until just before my accident. Sometimes I still get an urge to drink them, especially after a long bike ride.

Very few things beat the refreshing taste of an ice cold Coke or 100 Plus after a tough workout. One of my patients tells me he drinks sparkling Perrier water with lime to get the refreshing sensation without the sugar. He was also concerned about whether the bubbles (or carbonation) was bad for his teeth.
What my patient drinks after exercise
Yes, remember I wrote previously about how endurance athletes had significantly higher rates of tooth erosion.

So I decided to do a little search. Here's what I found regarding sparkling water. Unlike sports drinks, the carbonation in the sparking water will probably not erode your enamel and wear out your teeth (Reddy et al, 2016). Since sparkling water has no phosphoric acid, it won't affect your calcium absorption and leech the calcium from your bones.

Unlike here in Singapore, sparkling water is very popular in the United States of America and Europe. In America, sales of sparkling water from La Croix went from $10 million in 2010 to $667 million in 2016.

So the evidence seems to suggest that plain carbonated (or sparkling) water is just as hydrating and healthy as regular (flat) water. Just be wary of the flavored varieties as some may have added sugar. That's when your dental health may be affected if your consume too much of it.

 If your crave some flavor, I'll recommend adding some fruit. I often add lemons (yes, you read correctly) in my drinking bottle while cycling.
Lemons in my cycling bottle
Other than lemons, at home I like mint and watermelons. But that's just me.


Avanija R, Norris DF et al (2016). The PH Of Beverages In The United States. J Am Dental Assoc. 147(4): 255-263. DOI: 10.1016/j.adaj.2015.10.019.

Plain sparking water is best

Sunday, November 18, 2018

From Stressful To Pleasant Memories

Guess where we went?
Every time before we travel, I get really stressed. Patients who have not seen me for a while suddenly asking to be seen on short notice. There are also many other things to be done in the clinic before leaving not to mention packing. My wife and kids often bear the brunt of my stress.

Even though we often think of vacation as a time to relax and recharge, traveling with two young boys sometimes come with definite difficulties. Especially when my older boy fractured his arm last year while we were in Brisbane.

This time we made sure to plan for mishaps and disasters. This often leads to bickering over the slightest thing with my wife and leaves me feeling stressed out. Thankfully, my wife does all that planning, taking up time, finances and stamina. I just pay.

The houses we find are often big and beautiful, but ultimately they aren't home. My older boy likes feeling safe and secure and we make sure both of them have that.

We never ever travel red-eye anymore after a particularly bad experience when my younger boy didn't sleep a wink and all hell broke loose when we landed and had to wait a long time at immigration. After the birth of our boys, we only fly with Singapore Airlines as the boys get a toy/ game once on board, are served their child meals first and they can be entertained by the in-flight entertainment system.

Fortunately, we didn't plan hours of walking, sightseeing or other touristy stuff. Too many activities make our boys tired.  In fact, we normally avoid the touristy places and plan plenty of down time. We normally rent houses near rivers or beaches and farm stays. Both my boys especially the little one love farm stays, feeding the animals, collecting your own herbs, vegetables and fresh eggs.

My wife pack lots of snacks so that the boys don't get hungry and have temper tantrums. We often go through pictures taken during the trip and laugh at what we did. Our boys really like this time together as we share new experiences, conversations and laughter.The best memories seem to come from these spontaneous moments.

During stressed times while traveling, which may be due to family, children or indignities of bureaucratic travel, I just need to calm down and think of the happy times.

Everyone in my family is sleeping as I type this, so that I can give them my undivided attention during the other times. So please excuse me for not writing until I'm back in early December.
Fireworks at Darling Harbour last night

Sunday, November 11, 2018

Breakthrough Performances And Hot Streaks

A few fellow physiotherapists that I've treated recently commented that they were quite amazed that I've gotten them (and patients) better so quickly that it almost seems difficult to believe.

To which I'd always say that nothing really improves in a straight line. Except our age, nothing really goes up in a straight line. Just like the stock market gyrations, there are days when it rises, some days it drops like a rock or days where it moves sideways.

Success in getting a breakthrough performance (or getting a patient better) is similar. It is almost never about a single monumental shift.

Think of a glass of water that you put in the freezer.  The water starts to freeze when it goes under zero degrees celsius (or 32 degrees Fahrenheit). This does not mean that the energy needed to lower the temperature from three degrees, two, one degree and zero isn't important. In fact, you will never get the water to freeze if all the prior work to cool it down isn't done.

Similarly, breakthrough moments are often the result of many previous actions, which slowly accumulate to unleash a major change.

In order to make a significant change, you need to work persistently to break through inevitable plateaus. Just like the water gradually turning into ice, you are gradually changing and improving as you slog along.

A patient (who used to race aquathlons) recounted the following experience. He and a fellow team mate were stuck at swimming 1:40 minute for the 100 meter swim intervals for a very long time. Without any real change in training, they suddenly got it down to 1:30 minute.

A patient of mine who runs got his kilometer repeats down from 4 minutes to 3:45. Or another athlete shared that he was squatting 100 kg for three months suddenly improved to 120 kg.

Many of my patients are now done with their racing season, while some are tuning up for their last race of the year. For those preparing for the year end Singapore Marathon, remember it's almost time to taper. When you resume training after your break and perceive no change, remember that just like water that is slowly beginning to freeze, you too are putting in the work for your breakthrough performance.

Back to my conversation with the physiotherapist I treated recently. My "hot streak" on getting good results treating patients definitely rest on a foundation of prior work, during which I try to become a better physiotherapist every year (since I can probably not get faster as an athlete).

In a journal, Nature, which was published recently, researchers found that most people have a "hot streak" in their career - a specific period during which an individual's performance is substantially better than his or her typical performance although the timing is somewhat unpredictable.
Talking it through just 2 days ago
Thanks to my wife and fellow colleagues, we regularly discuss and break down segments of courses we've gone for to make it unique to us. We will strive to make sure this "hot streak" of getting patients better as quickly as possible continues.

Putting it all together

L Lu, Y Wang, R Sinatra et al (2018). Hot Streaks In Artistic, Cultural, And Scientific Careers. Nature 559: 396-339. DOI: 10.1038/s41586-018-0315-8.

Friday, November 2, 2018

Farewell Car Park Party At Holland Village

As we were walking back, my 8 year old boy asked me "why don't you write about the car park party?"

My younger boy was at home with my wife as he was having a fever and my older boy and I happened to walk past the farewell party for the partial closure of the Holland Village car park just behind the old Buona Vista swimming pool.

Incidentally, both of us attended the farewell pool party at the old Buona Vista Pool back when it closed in February 2014. Our patients did their deep water rehabilitation there at the pool after surgery. In fact, I learnt to swim in that pool and I taught my boy to swim in that pool.

The old swimming pool area is now a car park. This car park is going to be a huge mixed development built by a Far East Organization led consortium.

The landscape here will truly change. We will find out how it turns out in 2024. Below is an artist impression of how it will be ......

Sunday, October 28, 2018

Know Change Know Pain

Blue marker indicates cleat postion
My last patient yesterday came in to see me with anterior knee pain. This patient recently changed to a new pair of cycling shoes and started having knee pain since 15/10/18.

Despite resting for a few days, the anterior knee pain was still there after trying to cycle on 19th and 24th October.

This patient tells me "cycling is an almost daily affair" and spends a considerable amount on the saddle.

After asking my patient a few more questions and assessing thoroughly, I was convinced the pain was triggered after changing cycling shoes.

I'm reminded of a previous post back in 2012 when Rafael Nadal changed his tennis racquet in his quest to serve better. Tennis fans would clearly remember how Roger Federer had problems affecting his back after a racquet change in 2013. In fact, after an extended period on the sidelines because of an elbow injury Novak Djokovic had to make adjustments to his tennis racquet early this year as well.

Back to my cycling patient. Before my accident when Sports Solutions was still at 108 Amoy Street, I used to cycle to work and back daily. I was very aware of the riding position on my bike. Any slightest change in saddle height, stem length or "strange noises" on the bike I would be able to notice it quickly. If you ride you bike regularly enough, you'll know I'm not exaggerating.
Superficial Front Line
After treating my patient's Superficial Front Line, it's back to cycling yesterday (after treatment) and today albeit on the trainer first and a slight change in pedaling technique.
Able to ride yesterday and today
Don't try to make key changes to your cycling, running shoes, swim technique or golf swing etc right smack in your regular season if you're competing. Just like you wouldn't use a new pair of racing shoes without trying it way before the race.

In my opinion, it's much better to use the new gear after your time off at the end of your season after you've not been riding or running etc. Your body will not be so sensitive to the changes. This I've learnt the hard way.

White marks the spot
Just in case you're wondering, we do mark the insert inside the cycling shoe too.

Monday, October 22, 2018

Tensegrity Of The Spine

Lining up half the participants to compare their necks and backs
After Aized and Rachel did Arches and Legs last week, it's the turn of the three amigos this this two days as we do "Tensegrity of the Spine" over the next two days.
Range of movement in the spine

This course is very intense and heavy going as there's a lot of rationale behind the theory involved. Everyone (yes, you read correctly) got lost at some point today, including yours truly.

Let's hope we get a clearer picture tomorrow.

Sunday, October 14, 2018

The Amazing Fiona Oakes

Picture from
I've never heard or read about Fiona Oakes before. Until my wife told me about her two days ago. She is so unassuming, humble and in her own words "I'm not really a runner". Actually she is a fantastic runner. Fiona Oakes is the fastest woman in the world to run a marathon on all seven continents and the north pole both in cumulative and elapsed time.

I thought I had it bad when I've had three knee operations before but Fiona has had seventeen knee operations and no patella (or knee cap)! Can you even imagine the rehab she has had to go through?

She was told when she was fourteen that she would find it hard to walk properly, let alone run again. It is truly amazing that she is still able to run so well. All this while being a vegan who eats one meal a day while while running an animal sanctuary.

So maybe we really don't need to eat meat and definitely not the sports and dietary supplements that are being marketed at us.

Watch the video, her partner Martin wonders how she can wake up at 3:30 am to start feeding the animals, run 20 km, come back and work all day cleaning and tending to the animals.

This just shows that the human body is truly resilient, amazing and and can perform really tremendous feats when there is a bigger cause (saving animals in Fiona's case).

If you're a runner, you have to watch the film, it's free until tomorrow.

*In case you're wondering why her running shoes look odd (I did) in the Marathon Des Sables, she's taped them up to avoid them falling apart.

Monday, October 8, 2018

Does Exercising Later In The Day Affects Your Ability To Sleep?

Zzz after a hard ride ...
I've written before in a previous post that I'm a poor sleeper. If you're like me, when I pushed myself too hard at training, I actually found it harder to fall asleep. The more I need (and want it), the harder it is for me to get it.

And sleep you know is critical for your mental and physical well being. If you're athlete, sleep is the easiest and cheapest intervention you can utilize to help your performance.

Hence, I was quite intrigued when I saw work from researchers who tested the effects of whether morning or evening workouts will affect your sleep by measuring melatonin levels. Melatonin is a hormone secreted in the pineal gland that regulates sleep and wakefulness.

Melatonin levels start to rise around your bedtime. It helps to lower your body temperature (now you know why it's so hard to fall aslleep when it's been so hot recently) and a rise in sleepiness. Melatonin levels usually peak around 3 am for most people.

The volunteers in the study were tested on three different days. A day with no exercise, a day when they exercised at 9 am or another at 4 pm. Their workout was a 30 minute  run at 75 percent VO2 max. Melatonin levels were measured with a saliva test at 8 pm, 10 pm and 3 am.

The results showed that those who did the 4 pm exercise session had much lower melatonin levels at 10 pm and 3 pm compared to the 9 am exercise group. It means that those who exercised in the afternoon (or those of you who can only train after work) will have a tougher time falling and staying asleep. End of story, period?

Not really. Don't worry if you're like most other Singaporeans who mostly have time to train only after work hours.

Melatonin is just one part of the equation in your quest to fall and stay asleep. Melatonin levels may not be the main reason why you cannot fall asleep.

For you to get a good night's sleep, it may depend on what you you eat/ drink, the wavelength of light emitted by your smart phone, the temperature of your room, your exercise routine/ intensity and not just your workout time rather than just your melatonin levels.

If you're going for a "relaxing" evening run, and clearing your head over stresses you've encountered during the day, it's gonna be a lot easier than doing sprint intervals. Although some runners may even say that the intervals make them tired and thus make them sleep better. This alone may be far more important than melatonin levels.

Another factor that is not addressed in the paper by the authors is whether genetically you are a "night owl" or a "lark"? The New York Times has a good article on how there's a strong basis on a person's natural inclination with regards to the times of day when they prefer to sleep or when they're most alert.

Some of you reading this now (after exercising late in the day and not sleeping) are likely to be "owls" and not likely to get up early to exercise since you sleep later. This may may due to your circadian wiring rather than exercise timing. So shifting your exercise timings to the morning may "rob" you of your morning sleep without helping you to fall asleep earlier.


Carlson LA, Pobocik KM et al (2018). Influence Of Exercise Time Of Day On Salivary Melatonin Responses. Int J Sp Physiol Perform. 30: 1-13. DOI: 10.1123/ijspp.2018-0073.

*Picture by Jeremy Ong

Sunday, September 30, 2018

First She Wins 100 Km Race, Now PS Summits Cho Oyu (8201 Meters)

Remember PS, winner of the Cameron Ultra-Trail 100 km race who saw me for her plantar fasciitis three days before her race on 25th July 2018?

Here's another feather to her already impressive list of achievements. She recently climbed to the top of Cho Oyu, a 8201 m high mountain!

She sent me this message last night. Still pain free after seeing just two times for her plantar fasciitis. Once before Cameron Ultra-Trail 100 km race and once after she came home from the race.

Well done PS!!! Come home safely soon.

Sunday, September 23, 2018

Popping Vitamins Or Other Dietary Supplements?

I often get patients asking me if there's something they can take to recover faster (from their injury). Most of them seem to be taking some form vitamins or other dietary supplements already.

Have a look the next time you walk into a Guardian or Unity Pharmacy here. You’ll see lots of vitamins and supplements there for sale. Not to mention the few sales assistants who will tell you what you need to be taking.

In fact, earlier in April this year, The New York Times published an article on how older Americans are hooked on vitamins.

Do we really need to be taking any extra vitamins and supplements. I've written before why there is no evidence for taking glucosamine. If you're interested you can read more here.

This may seem as a shock for those of you who are already taking vitamins or any sort of dietary supplements. Many supposedly muscle building supplements make unproven claims and may even come with side effects.

In the journal article referenced below (Gliemann et al 2013), researchers found that resveratrol (an antioxidant found in red wine) actually limited the positive effects of cardiovascular exercise. It affects your VO2 max when taken daily in high concentrations.

Those of you who take fish oil supplements beware. There is evidence that men with high levels of the omega-3 fatty acid DHA in their blood (from the fish oil supplements) are at a higher risk of getting prostate cancer.

In fact, well known researcher Professor Pieter Cohen (who was sued by a supplement maker but Cohen won) said there are only two types of supplements. Those that are safe but don't work. And those that might work but have side effects, especially at higher than normal levels.

Most vitamins are in the first category. Taking a multivitamin daily will not harm you, but it usually won't help too much either. This is why major health organizations don't recommend supplements to healthy people.

Now don't get me wrong here, If you don't have enough Vitamin C, you can get scurvy. Without iron, you can become anemic. And if you don't get enough sunlight, you may need some Vitamin D. However, all three of the above can have negative effects at high doses. Same for Vitamin E and calcium.

Unless blood tests show that you're super deficient in a particular vitamin or mineral, there is no evidence that you should be popping those pills. Even so, it's better to be getting them from real food sources.

If you're an athlete, and you're taking antioxidants to boost recovery take note of what Dr Mari Carmen Gomez-Cabrera (who is a world leading researcher on anti-oxidants) published. The antioxidant pills that you pop suppresses the oxidative stress that signals to your body to adapt and get stronger. Meaning regular use of something seemingly mild and innocent like Vitamin C can actually block gains that you've trained so hard to get in your endurance boosting mitochondria (cells).

Dr Gomez-Cabrera suggests eating five servings of fruits and vegetables daily and you won't need to pop vitamin or other pills.

To put it bluntly, vitamins and other dietary supplements just plain useless or worse than useless. Of course you can still buy them and take them if you wish. You're just lining the pockets of those of manufacture and sell them.


Cohen P, Travis JC et al (2014). A Synthetic Stimulant Never Tested in Humans, 1,3- Dimethybutylamine (DBMA), Is Identified In Multiple Dietary Supplements.  7(1): 83-87. DOI: 10.1002/dta.1735.

Gliemann L, Friss J et al (2013). Resveratrol Blunts The Positive Effects Of Exercise Training On Cardiovascular Health In Aged Men. 591(20): 5047-5059. DOI: 10.1113/physiol.2013.258061.

Gomez-Cabrera MC, Domenech E et al (2008). Oral Administration Of Vitamin C decreases Muscle Mitochondria Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance. Am J Clin Nutr. 87(1): 142-149. DOI: 10.1093/acjn/87.1.142.

PS -After I wrote the article, another patient who runs frequently asked about taking magnesium for muscle cramps. Read the article I wrote on what causes muscle cramps and save your money.

Sunday, September 16, 2018

Mid Life Crisis In The Older Athlete?

Singapore National Games 2012 by RS from Flickr
I had a patient who recently turned 50 years young and decided that she would like to finish running a marathon. She had never ran much before (unless you count physical education classes in school) and she would consider herself pretty much inactive previously. She started training with a local running group, and within 6 weeks of training got injured and ended up seeing me in our clinic.

Here's a trend I've been noticing, a fair bit of participants in local races are above the ages of 40. I just looked up the results of the 2017 Singapore Triathlon and the 2018 Singapore OCBC National Road Race Cycling championships. The 40-49 age group has the largest number of participants and among the most competitive. I didn't look up the statistics, but with the number of participants we've treated in our clinic, I'm sure this is similar for the Spartan races too.

If you look up the 2018 Boston marathon results in April this year and last year's New York marathon the statistics are similar.

Research backs this up too. A research paper by Hoffman and Fogard (2012) found that the average age of participants in a 100 mile trail race was 44 years.

My 50 year old patient calls this urge to run her her first marathon her "mid-life crisis". I looked up "mid-life crisis". This concept was first presented in 1957 by Canadian psychologist Elliot Jacques to the British Psychoanalytical Society and later published as "Death and the Mid-life Crisis" in the International Journal of Psychoanalysis in 1965.

His theory was that as we approach middle age, we begin to realize our own mortality (or death) and we begin to freak out. As we grow older, we start to focus on how much time has passed, how much is left and what to do with whatever time is left. That can create anxiety and that anxiety can be multiplied by anxiety, depression and stress.

My 50 year old female patient says that unlike what you usually read or see in movies (where the older white guy buys a sports car and dates a younger girl in a desperate bid to feel young again), her "mid-life crisis" is to take on physical challenges.

Her goal is not to cling on to whatever is left of her "youth" or be young again. It is more about building up for the years ahead. Sounds like a good mid-life crisis to me.

Whether you are a young and older athlete, and starting a new game or beginning to exercise, pace yourself and start gently. There are big benefits from minimal running. However, if you do get injured, come and see us in our clinics.


Hoffman MD and Fogard K (2012). Demographic Characteristics Of 161-km Ultramarathon Runners. Research in Sp Med. 20(1): 59-69. DOI: 10.1080/15438627.2012.634707.

Sunday, September 9, 2018

Heat Acclimatization Can help Exercise Performance

Other than the heavy rain the last two days, it's been very hot recently. I used to love training and racing in the heat. Living in sunny and super humid Singapore meant that we're used to such conditions.

I'll often train in the hottest part of the day so that when race day came, whatever sweltering conditions encountered (on race morning) will seem like a breeze. There was a year (2001) when the Osim Singapore Triathlon was held in Sentosa and it was 38 degrees Celsius on race day and I used that advantage to finish 3rd overall behind Dimitry Gagg (former World Triathlon Champion in 1999).
On the podium with Dimitry Gagg in 2001
Turns out I may have been right in getting an edge over my competitors. And you can use that to your advantage too.

Heat is now hot! This shift towards heat training has been trending for the past few years. From running marathons to even climbing mountains, athletes around the world have been trying to get potential performance benefits of heat training.

Many of these heat studies started because of the 2008 Beijing Olympics. Many runners were preparing for the sweltering conditions and that lead to a whole lot more research done on heat acclimatization.

There are even studies of using heat therapy to fight heart disease and repair muscles.

Most heat acclimatization protocols help athletes perform better in the heat. This includes lowering core body temperatures, increasing perspiration rates and increasing volume of blood.

And what if after all that training in the heat race day wasn't hot? What if race day turns out to be as cold as the 2018 Boston marathon?

Fret not, results of a study (Lorenzo et al, 2010) on whether being well adapted to heat might affect your performance in cool conditions put that worry to rest. Scientists had cyclists train for ten days in 41 degrees Celsius (105.8 degrees Fahrenheit). Their VO2 max improved by 5 percent while their one-hour time trialing performance improved by 6 percent! This was when they were tested at 12.8 degrees Celsius (55 degrees Fahrenheit). Just in case you were wondering, they improved by 8 percent in hot conditions for both VO2 max and the one hour time-trial.

Control group cyclists had no improvements in V02 max, one-hour time trial performance, lactate threshold and other physiological parameters.

Suddenly, hot rooms, saunas and even non breathable training suits were the latest must haves and even suggested to be a cheaper and more convenient alternative to altitude training.

When it is too hot, it is a shock to our system. This is similar to what happens to our system when we exercise or train in altitude.

When we exercise in altitude, the decrease in oxygen triggers the body to produce more red blood cells. Heat training increases the volume of blood plasma in our bodies and this help send more oxygen to our muscles.

However, it is not totally certain that increasing blood plasma volume may lead to improved athletic performance. What may happen from the resulting dilution of blood is that it may trigger a natural response for the body to produce new red blood cells - just like altitude training.

Training in hot conditions does not only change blood plasma. Other benefits include psychological resilience (or the ability to endure) and altered perception of high temperature. Just like what I intended for by training in the hottest part of the day.

Before you head out and train yourself silly in the heat, make sure you gradually increase your intensity and heat exposure. Drink enough but do not overdrink.


Lorenzo S, Halliwill JR et al (2010). Heat Acclimation Improves Exercise Performance. J App Physiology. 109(4): 1140-1147. DOI: 10.1152/japplphysiol.00495.2010.

Saturday, September 1, 2018

Can Your Calf Muscle Cause Your Knee To Hurt?

Now that's some very defined soleus muscles
Really? You must be wondering how and why after looking at the title of this week's post. Well, my last patient today had knee pain caused by her soleus (or calf) muscle. She had recently been doing a lot of step ups in her gym classes and her knee pain started soon after.

Runners' knee or patellofemoral joint pain (pain under the kneecap) is very common in runners. I've written before about how this may be due to heel striking, heavy landing and hip dysfunction.

There is also some evidence where the length of the soleus muscle can influence patellofemoral joint pain (PFP). It has been suggested that in runners with PFP, there is a greater activation in the muscle compared to runners without knee pain (Piva et al, 2005).
See soleus after you cut away gastrocnemius
Your calf muscles consist of the more superficial gastrocnemius muscles and the deeper soleus muscle. If you peel off the gastrocnemius muscles, the soleus muscle lies underneath. Together they end as the Achilles tendon finishing at the heel bone (picture above).

The soleus muscle is largely thought to help with our posture as it is mostly made up of Type I slow twitch muscle fibres. The gastrocnemius muscle is made up of mainly Type II fast twitch fibres.

The fast twitch muscles of the gastrocnemius allows you to sprint. However, the gastrocnemius muscles tire easily.

The slow twitch soleus muscle is very important for your walking and running. Since they're more fatigue resistant, you use them a lot chalking up mileage whenever you run.

One of the main functions of the calf muscles is to absorb shock. If they're overused, they can't absorb shock well, your knee takes more of the load and you get knee pain.

A very simple way to take load off your soleus muscle is to take smaller steps when walking or running. Increasing your step rate, especially while running will ensure you're not over striding and heel striking. This reduces impact loading and lessens your chances of knee pain.


Piva SR, Goodnite EA et al (2005). Strength Around The Hip And Flexibility Of Soft Tissues In Individuals With And Without Patellofemoral Pain Syndrome. JOSPT. 35(2): 793-801. DOI: 10.2519/jospt.2005.35.12.793.

Sunday, August 26, 2018

Don't Turn Childhood Into A Race

Picture by RS from Flickr
I didn't expect my article on not to force your teenage athletes to be so well received. I received many requests to share the article and comments from readers and patients alike.

And in the clinic, there were patients who asked me about that article. Turns out one of those conversations became the inspiration for this week's post.

One of my patients had been deciding whether or not to go for football practice. Not her or her husband but their two boys. The commitment required though makes it seem like the whole family is involved. Even their helper helps to pitch in by making sandwiches and sports drinks (although I thought they were a little young for sports drinks).

The twice weekly practices, requiring a 30 minute drive one way ends quite late on a week day leaving just enough time for dinner and bedtime (but not homework). The Saturday or Sunday practice often conflict with family lunches, birthday parties and family time for just lazing or goofing around at home.

Their boys are only six and eight and I feel they shouldn't be on such a "rigid" supervised program for sports (but that's just my opinion).

I've read from articles in Red Sports and the Straits Times that increasingly for children in Singapore, kids start playing organized team sports younger. They are often encouraged to specialize in a single sport sooner than later. Especially those kids who are hoping to enroll in a school of their choice under the Direct School Admission (DSA) scheme.

This creates pressure for kids to be proficient and exceptional only at one sport. When I was in primary school, I played table tennis, football, basketball, badminton and also competed in the running events during my school sports day and won medals for all of them.

Now, I'm not disputing the fact that sports are very good for kids. When kids take part in sports, it teaches them teamwork, sportsmanship, improves their self esteem while letting them try risk taking (safely). And of course it makes them healthy and strong. Both physically and mentally.

I, for one have seen first hand (while treating these young athletes) that these children/ teenagers who focus too early on a single sport lose interest when the going gets tough. They're often more prone to injury, stress and burnout.They sometimes fail to develop basic movement skills. Just watch a bunch of young elite swimmers (no disrespect intended) play basketball or football.

In today's Straits Times, in an article on why we should not turn childhood into a race for results, the author wrote about how US Olympian Katie Ledecky describe swimming as "really just for her still a hobby". She has by the age of 21 won five Olympic gold medals and a silver, owns six world records and a US$7 million dollar deal with a swimwear company.

She was quoted in a New York Times article saying "I feel lucky that I could enjoy swimming," and "people need to relax ... and take a step back and realize that you don't have to be great at this young age. It's not about immediate results". Ledecky said she recalled she had not raced in events longer than 25 yards (22.9 metres) until she was eight years old.

My observations mirror those of studies published. Kids who wait until their older teenage years to specialize are better all round athletes and more likely to stick with sports and continue to be active throughout their life.

So what's the solution? Try to do everything in moderation. If your child is keen on a single sport, try mixing other activities on their off days. Make sure they have off (or total rest) days.

My own two boys do lots of outdoor free play- climbing, jumping and running around in the playground nearby. Other than football once a week for the older boy (at his request) there are no other art, music or other enrichment activities for both of them.

I suggest that your child should not be involved in more hours of organized sports than their age. Expose them to as many different options as possible while waiting as long as you can to find a sport for them to specialize. Then you can support them as much as possible.

We also value adventure in our family. My wife and I hope that our boys will be competent and enthusiastic outdoors. So we try to make sure they're climbing, hiking, going for nature walks and biking. Travelling and farm stays (which the boys love) will remain an essential time for our family and this keeps us connected and is a welcome change to our over scheduled wired and connected world.

Competitions? Do your best to keep them in perspective. Your goal as a parent is not to raise an Olympic athlete but to raise a nice child that grows into a nicer, well balanced human being who will contribute to society.

ST article 260818

Sunday, August 19, 2018

McConnell Taping Versus Kinesio Taping

Me holding court
Day 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques started with me reviewing material we had gone through yesterday on Day 1.

After that we went straight into material for Day 2 and some of the questions the participants asked was how Mechanical Correction taping from Kinesio Taping would fare against Jenny McConnell's McConnell taping for the knee. Yes, Jenny McConnell's taping technique was first published (and made famous) in the Physiotherapy Journal way back in 1986. I remember reading the article and using the taping technique before.

McConnell's taping (L) vs Kinesio Taping
Here's a close up of what I did for Michelle's knees.
McConnell's on the (L)
No prizes for guessing which came out tops.
Michelle's happy
We had many fruitful clinical discussions on applications for the Medial Collateral Ligament (MCL), pes anserinus area, the Achilles tendon and of course the plantar fascia.

With the physiotherapy students
The four Physiotherapy students from SIT requested taking a picture with me after the course. Thanks for coming Sara, Mark, Priscilla and Dominic. The pleasure is all mine.

Group picture
A big thank to all for coming, especially to Nada and Faisal from Saudi Arabia, Tim from Loue Bicycles, Nisa and the Physiotherapy students and teachers, hope it was useful for everyone.