Sleepless In Singapore

The 3 amigos

My wife and both two boys recently started wearing an activity tracker. The boys have been very diligent regarding logging 10,000 steps daily. They would even pace up and down the room or hallway just to get more steps to meet this goal.

Actually, I'm much more interested in tracking how much they sleep since it is a well know fact that Singaporeans do not get enough sleep. In fact, a survey showed that 41 percent of Singapore adults get between 4 to 6 hours of sleep a night even though they should be clocking in 7 to 8 hours.

That is bad news as shown by neuroscience Professor Michael Walker in his 2017 New York Times bestseller Why We Sleep. More than 20 large scale epidemiological studies tracking millions of people over many decades showed that "the shorter your sleep, the shorter your life".

In fact Professor Walker suggested that "leading causes of disease and death in developed nations - cue disease, obesity, dementia, diabetes and cancer - all have causal links to a lack of sleep".

The cost to mental health is significant too. Sleep problems may increase risk for developing certain mental illnesses like depression and anxiety disorders, as well as result from them.

Back to kids. It is difficult enough raising a child, but when a child is a student athlete, another layer is added.

My boys and their trackers

I would suggest all student athletes eat five good meals/ snacks a day. This is to help fuel the child's body for long school days. From the time they leave home between 6-7 am in the morning to lessons ending at around 2 pm but most likely extended for training, competitions and tuition.

Think of it like a car. Your student athlete is the car and you need to have good fuel in the car. Parents and child can work together to plan meals based on the student's weekly schedule.

Sleep is the best way for your child's body to recover. It trumps all the compression garments, recovery food, sports drinks etc. With enough sleep there is less chances of your child falling sick and getting injured.

Quality sleep is better than long hours, but good to have both. And it's best to rest without distractions like a mobile phone buzzing through out the night. Also be wary that an activity tracker may overestimate total sleep time (Lee et al, 2019).

One of my patient's child used to be a elite junior triathlete. She would keep the child's phone at bedtime as her child would be using the phone and not sleeping if she didn't.

Conversing with your child athlete while having healthy sit down meals as a family (without your phones) will help touch on many of these points.

Good nutrition, regular, early sleep schedule and physical activity as a family.  Make that your priority in the new year.


Reference

XK Lee, Chee NIYN, JL Ong et al (2019). Validation Of a Consumer Sleep Wearable Device With Actigraphy And Polysomnography In Adolescents Across Sleep Opportunity Manipulations. K Clin Sleep Med. 15(9): 1337-1346.

The above article is done by Singapore researchers at the Centre for Cognitive Neuroscience, under the Duke-NUS Medical School.

I love this picture I took from a book - Goodnight Darth Vader which I bought for my son by Jeffrey Brown.

$677 For A Session Of Acupuncture Or Physiotherapy!!

Posed picture 

Recently I had a patient who rang me up saying he had right shoulder pain and he wanted to go for a MRI scan to rule out anything sinister. He asked if I can recommend him a doctor to hospitalize him and then do whatever necessary tests that was required. I told him that for a MRI he need not be warded. Then he said that if he was not warded he would have to pay for the investigations in full .....

I had to politely decline as I thought it wasn't right to make insurance pay for the scan if a patient does not want to foot the bill.

So I'm not surprised to read that there are mercenary physiotherapists, chiropractors etc who take advantage of the insurance system to bill excessively.

In New Jersey, school employees are covered by the state's School Employees' Health Benefits Program. This plan covering school teachers covers virtually anything the "out-of-network" providers charge.

In 2018, the teachers' plan paid out an average of more than USD $600 a visit to acupuncturists and physiotherapists! This is even higher than out-of-network fees of psychiatrists and gynecologists.

As a result, more than 70 acupuncturists and physiotherapists earned more than USD $200,000 in 2018 from their teacher clients alone. Data also showed that one acupuncturist earned more than USD $1 million dollars!!

To further sweeten the deal, some of these providers are suspected of waiving a co payment by the teachers so there is no out of own pocket payment by the teachers.

The same state fund paid out USD $11.2 million dollars to a clinic -Thompson Healthcare and Sports Medicine for providing chiropractic services, acupuncture and physiotherapy to teachers.

Thompson Healthcare and Sports Med during a school visit

Investigations by the state showed that these payments consumed hundreds of millions of dollars in the last four years. This has possibly affected all residents in New Jersey as homeowners in towns where the schools are located are all paying higher property taxes.

Six people (half are union members) make up the state panel overseeing the benefit plan have not done anything to stop the runaway costs. This is despite meeting transcripts showing discussions regarding this since 2014.

All these data and documents, along with interviews with state officials show this is what happens when savvy (and mercenary) health care practitioners find lucrative loopholes in a loosely designed employee health plan.

As expected, the teachers' premiums have increased by 8 and 13 percent in the last two years. The most popular family premium plan cost in excess of $36,000 a year. This is nearly twice the cost in other parts of the country.

I dare say that if the teachers realized the exploitation of the plan, they will definitely think twice about how they use their health care benefits.

Back in in Singapore, there was an article in the Today Online paper regarding some physiotherapists in private practices paying doctors and surgeons kickbacks to get patients referred to them.

You can also read our other blog, where we have previously written about these kickbacks in our Singapore Healthcare system too. Needless to say, private medical clinics and MRI/ X-ray companies in Singapore are implicated as well.

It is bad practices like this that will lead to increases in our health care visits, insurance premiums and Medisave-approved Integrated shield plans.

You can read the article I referenced here.

Teaching Kinesio Taping @Pilatique In Malaysia

Group picture

The last time I taught in Malaysia at the very same location was back in November 2013. Now that's a fairly long time ago.

So it was really nice coming back to a familiar venue to teach Day 1 and 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques (formerly known as KT 1 and 2) here at Pilatique.

Day 1

I'm friends with Steven and Melissa (they are Pilatique's owners) and I couldn't turn them down when they asked to come and teach in KL, Malaysia. Most of the participants were from Malaysia although we had three students hailing from Mauritius.

Day 2 of the course went much quicker as usual as we went through more practical applications such the association of Gluteus Medius and contralateral pelvic drop (or CPD), how a rotated pelvis would affect the shoulder blade and implications of the hip flexors and foot drop.

Here are some pictures from the past two days.

Clarissa having a go

All the boys listening

Watching the ladies

A big thank you to Steven and Melissa for having me over to teach. You guys organize the best courses here in Malaysia. The pleasure is all mine.

Also grateful to Mary Leou as well for coming to get me and sending me back after each day's teaching.

Consent And Unwanted Touching In Yoga

Picture of Pattabhi Jois on Karen Rain 

I treat many patients who practice Yoga regularly and diligently. A few of them have even gone for retreats in Mysore, (also known as Mysuru) India.

But lately, I've heard lots of horror stories from patients getting unwanted / not asked for adjustments from instructors. These improper touches happened in public right here in Singapore. One patient even stopped practicing after she felt so traumatized after one such adjustment.

Most of these patients practiced Astanga yoga. Ashtanga is physically demanding as there are many strenuous posture and dynamic moves. It was made popular by Krishna Pattabhi Jois.

Vinyasa, power or flow yoga are versions derived from Ashtanga yoga as well. Celebrities like Madonna, Gwyneth Paltrow and William Dafoe were early converts and helped popularize Ashtanga and Jois to the world. This made Jois famous and easily idolized. In Astanga, training under or with him was similar to a Catholic priest being trained by the Pope himself.

Jois also helped popularize touches or adjustments where yoga instructors physically touch, move or manipulate a student's body.

For a long time, much of the yoga community has been slow or perhaps unwilling to respond to such allegations. The fear may be that these instructors are fearful to discredit those seen as gurus.

Adding to this problem is that students are told that yoga is also part spiritual practice, anything that they did not understand, they have to trust what the instructors tell them.

Some teachers rely on just verbal cues to help students while others can either gently or forcefully move students into certain postures or alignments.

Karen Rain and Jois

Jois as you can see was definitely not about yoga postures or alignments as you can see from the pictures above. Due to his fame, power and perhaps devotion commanded by Jois, all these adjustments made in public somehow seemed to normalize them.

Nine women (including Karen Rain) went public about their experiences with Jois in 2018. The article written by Matthew Remski, a yoga teacher published in The Walrus, a Canadian publication. They described being groped, kissed, even fingered through yoga tights.

Prior to this in 2017, Rachel Brathen, a yoga studio owner asked her Instagram followers if they ever had inappropriate touches/ adjustments in yoga. Hundreds of women wrote back and shared how they were being propositioned after class, during retreats, forcibly kissed during private mediation sessions and even assaulted on post yoga massage tables.

In an article by Katherine Rosman published in the New York Times, she wrote about how she attended a class at a yoga festival when there would be many other yoga instructors and students with a producer, camera woman and sound engineer.

Her story "came to life" right before her eyes when the instructor demonstrated an adjustment with him placing a woman's bottom on his lap, spreading her legs apart and wrapping her legs around his waist. You can have a look at the article and watch the video here.

What is worse is being touched/ adjusted in improper ways during classes right in public. That somehow seemed to make the touches / adjustments legit. If forcefully done, adjustments have often caused physical injuries as well.

My patient tells me that now some local studios will have a "No adjustment" tag where students can place beside their mats to avoid unwanted adjustments.

Those of you who practice yoga beware and make sure you do not get hurt with unwanted adjustments.

Lunch With The Team

Sham is right behind

Staff from our clinics came together for lunch today at Real Food at Orchard Central today. It was great to be able to see everybody at the same time, catch up, share stories and of course talk in front of the bosses (rather than just talking behind their backs). Just kidding!

Some were late, others got lost finding their way while some others weren't sure what to order at this vegan/ vegetarian restaurant. But somehow we all managed. Since my accident, Aized has been super careful about what we eat. So no surprises that she chose this place.

While waiting for everyone, we took some pictures first of course.

Romaiza early for once ....

We're always early

Incidentally, this lunch doubles up to celebrate Sports Solutions turning 10 earlier in October this year as well.

Thanks to everyone who came and for those who couldn't make it, hope you can make it the next time. Have a great remaining rest of the year.

No meat!

Herlene's Going To The SEA Games

Unlike Herlene, I'm not going to the SEA Games in Philippines this time. Not as an athlete nor as a physiotherapist for Team Singapore. The last time I went to the Philippines I competed in the triathlon event in 2005.

But one of my patient's, Herlene is going to the SEA Games as a member of the triathlon and duathlon relay teams. I've treated Herlene since she was in Primary school. She came to see me today for a final tune up session.

So I took the opportunity to get a picture with her first before she leaves for the games on Friday.
Herlene was featured in the Straits Times on Monday 251119.

All the best at the games Herlene! We will be rooting for you.

The Correct Touch Is Really Important

My patient said to me that she will never see that doctor again. She was annoyed that despite her complaining of pain in her knees, he did not even bother to examine her. There was no eye contact from him at all too. He told her brusquely that she had runner's knee and should not be running. The Sports Doctor then prescribed her some pain medication and referred her for physiotherapy.

She had gone to the physiotherapist referred but did not get better. Her friend suggested that she come to our clinic since the referred physiotherapist was not a runner as well. So here she was in our clinic.

Like I've written previously, I can never be totally sure of a patient's condition if I don't assess them properly. All patients need and deserve gentle and thoughtful treatment. However, healthcare is evolving and become more businesslike. However, that human touch is still really important.

We should never take for granted that our patients give us consent to touch them to be able to assess them. Especially now in an era of electronic medical records, doctors and other health care practitioners may spend most of the allocated appointment time staring at a computer screen, tablet or looking at MRI reports.

I'm so glad that Dr Abraham Verghese, a professor at Stanford University's School of Medicine still prefers "the bedside chat, the old fashioned physical exam and the power of informed observation".

In his 2011 TED Talk, he said that by shortening the physical examination, doctors will lose a ritual that is transformative, transcendent and at the heart of the physician patient relationship.

Of course there are instances when patients are in pain and/or anxious, they will be much more guarded. Definitely patients of sexual abuse or assault may cringe at the lightest touch.

I have on many different occasions seen a patient come in for say neck pain but had a worried look that seems disconnected from their physical problem. After assessing and/or treating them and asking them if they are alright they become tearful and mention a family death, possible relationship problems or financial difficulties. That placing of hands, that human touch was the catalyst that allowed the patient to open up and release the pent up emotions.

With that human touch, we can comfort, diagnose and bring about treatment.

Be careful with your touch. It can show gentleness, compassion and heal someone. Or it can show roughness, carelessness or even incompetence.

Help! I Have A Snapping Hip

Yesterday, I saw a 13 year old boy who was brought to our clinic by his parents as he had knee pain as well as a "snapping" hip on the same side. After joining the school's softball team earlier this year, he had trained a fair bit more than in primary school.

He recently developed right knee pain and had a year's history of pain and "snapping" in his right hip. He had previously seen a chiropractor for the last few months. Treatment consisted of  stretching the hip flexors, the Iliotibial band (ITB) and manipulating his hip and spine. He did not get any better after all the treatment with the chiropractor.

I assessed him and confirmed that his knee pain was coming from his tibial tuberosity and indicative of doing too much too soon. That's not too difficult to manage. He definitely had a case of Osgood Schlatter's in his right knee.

There was no pain with clicking in his hip. Nor was locking observed at end of range hip flexion with added internal or external rotation (this rules out hip labral tear). Range of movement in his back, hips, knees and ankles was normal and symmetrical.

There was weakness in his right Gluteus Medius muscle, also his painful knee and snapping hip side, despite that being his dominant side. This greater contralateral pelvic drop was confirmed while watching him run.

The "snapping hip" sound was reproduced over his right greater trochanter when he was in left side lying when I straightened and bent his right hip. It was a fairly loud "clicking" and/or "snapping" sound each time I bent and straightened his hip. There was some local tenderness over his Gluteus Medius, Gluteus Maximus and Tensor Fascia Lata muscles and over the greater trochanter itself.

Snapping hip on outside part of R hip

This explained his "snapping hip" on the outer part of his hip. While my young patient did have pain over his outer hip, I've treated other cases where patients did not complain of pain there with the exact same condition.

Following treatment, my patient was pain free and I taught him and his parents what to do to maintain that.

This "snapping hip"condition is also known as Coxa Saltans, can also happen in adults. My young patient described above has a extra articular or outside the hip joint condition.  It can also be intra articular or inside the hip joint.

It's Psoas Major/ Iliacus if inner part of R hip

If the condition occurs on the inner part of the hip, extra articularly, it is usually due to the Psoas Major or Iliacus muscle. A snapping hip inside the hip is usually confirmed by an MRI. Those who have intra articular hip snapping will usually complain of hip catching, painful clicking or locking. And that will probably have to be another post.


Reference

Winston P, Awan R et al (2007). Clinical Examination And Ultrasound Of Self-Reported Snapping Hip Syndrome In Elite Ballet Dancers. AJSM. 35(1): 118-126. DOI: 10.1177/0363546506293703.

Still Getting Messages While I Am Away On Holiday

Even when I'm not in Singapore, I still get messages from patients asking about their pain or condition. After a patient sees me in our clinics, I normally give my personal number to them to let them know that they can reach me if they have a question. 

Of course I tell them I will not answer the phone if I'm treating patients, but I will always reply or call back after if the need arises. Except for once, I don't remember patients abusing that privilege. Don't get me wrong, I'm definitely not complaining, I do think it's great the patients trust me enough to ask me when they feel something is not right.

If I'm travelling, I will normally divert my phone to our clinic, but patients can still reach me with their messages or WhatsApp etc.

Of course after a particular posting that is popular, I get readers from overseas asking about the condition as well. Especially after this post on shin splints which is still our most popular article. I've politely declined offers to try and diagnose them. Even though some of them write and say that they'll be happy to pay me to describe what I did for treatment or chat to them via Skype or Facetime.

Accessory navicular bone?

There are currently a few telemedicine apps available in Singapore, MaNaDr, White Coat, Dr Anywhere, MyDoc and HiDoc. Majority are for patients to consult a  doctor through video-conferencing or messaging. Common health issues that come through these apps include upper respiratory tract infection, headache/fever, gastroenteritis and skin conditions. It also means you can stay at home when you're sick to get a medical certificate from the doctor.

I remember discussing with Aized quite a few years ago if we need to go this way as well after reading about about Dr Jay Parkinson and how he writes and talks about the future of primary care, healthcare delivery, healthcare entrepreneurship and healthcare business model transformation.

But then again, Dr Jay Parkinson writes about the United States healthcare system where patients may have to travel far and /or wait for days before getting an appointment. In Singapore, we have a different healthcare system altogether.

Convenient these apps may be for the patient, especially when it comes to the common cold/ cough and fever etc. However, I can definitely assess a patient much better in person when they tell me their neck or knee hurts. On the phone or email, it depends on how well the patient describes their condition. Of course I listen to my patients, but I definitely trust my hands more.

For those of you reading this, yes I'm away on holiday. But I will still try to answer your questions if I can get access to an internet connection. Thank you for putting your trust in us and our clinics.

My younger boy enjoying the sunset with 2 furry friends

Never Give Up!

Chapeau to  Ronald Susilo. This guy just keeps on going and going. After suffering many potential badminton career ending injuries while at the top of his game, he has always managed to bounce back.

After winning the Japan Open Grand Prix and then beating World Number One Lin Dan at the 2004 Athens Olympics with a torn shoulder labrum, he went under the knife.

More heartbreak followed after coming back from that when he tore his achilles tendon at the World Badminton Championships in 2005.

Yet he persisted. Tragedy again at the 2007 Sea Games when he tore his right forearm muscles playing against Vietnam. Again he managed to bounce back and we went to our second consecutive Olympics together in Beijing in 2008.

His wife sent him to Sports Solutions in this 

Even after retiring from national duty, he kept playing after he started coaching. And subsequently ruptured his patella tendon while tearing his ACL and medial meniscus at the same time. He needed 2 operations after this. Attaching the patella tendon first before repairing the ACL almost a year later.

And now this right shoulder again .....

Well, Ronald we've done this together too many times before. But I know you'll be back once more. You can do this!! Want to be a champion? Passion for the sport and persistence is what you'll need. Lots of it.

In the picture below, you see me celebrating and more excited than Ronald Susilo himself after he defeated Lin Dan in the 2004 Athens Olympics.

Yes, I used to sit on court with him and his coach every time he played.

Does Weight Training Stunt Growth In Young Adolescent Kids?

14 yo Miles with Dad Ving Henson at The Pit

I remember clearly being told by my teammates as a young runner at twelve that I should never do weights as it would stop me from growing taller.

This misconception about weight training often comes from fellow teammates, well meaning parents, physical education teachers and even some coaches. Actually, the sport your child participates in (sprinting, jumping or contact sports) will generate greater forces than training in the weight room.

This widely held belief that weight training especially when performed during puberty/ adolescence stunts growth still persist in the present day. Due to this, young athletes and children should only perform body weight exercises and not do any training with barbells, kettlebells or even dumbbells.

Fret not if you're a parent or teacher of a young athlete. There is simply no evidence to support this belief at all. Many studies have looked into this topic and found that weight training has no negative impact on skeletal growth. It will not stunt growth.

Actually, studies show consistent findings that young subjects have increased strength, speed and power, while losing weight, gaining muscle and stronger bones. There is also a reduction in injury rates. Good news for parents if your child keeps getting injured. This is especially true even when the young subjects have not reached puberty.

So it makes very little sense from a bone stress point of view if you stop your child from going to the gym but allow them to participate in sports.

So how soon can your child start weight training? We do not have any suggestions from any local authority but the Australian Strength and Conditioning Association suggest that a child can start weight training at six years old. As long as he/she can follow clear instructions and understand the dangers when training.

If you do send your child/ athlete for weight training, make sure the learn the correct techniques by a good strength coach who has experience working with young athletes. Remember, don't force the young athletes if they are not keen.


References

Barbieri D and Zaccagni L (2013). Strength Training For Children And Adolescents: Benefits And Risks. Collegium Antropologicum. 37(2): 219-225.

Faigenbaum AD and Meyer GD (2010). Resistance Training Among Young Athletes: Safety, Efficacy And Injury Prevention Effects. BJSM. 44(1): 56-63.

Falk D and Dotard R (2019). Strength Training In Children. Harefuah. 158(8): 515-519.

After seeing 14 yo Miles training above, my 9 yo was inspired to do the same

Is Your Running Style Causing Your Running Injury?

How's my running gait?

I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.

Picture A- Injured runner with CPD and right hip adduction 

Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.

Contralateral pelvic drop

CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.

Injured runner (L) heel striking, forward trunk lean vs normal

Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

Clam Shell Exercises?

Clam shell exercises?

My patient came in complaining of knee pain after running. She had seen another physiotherapist who after treating her knee, prescribed clam shell exercises for her to do as well. But she still had knee pain after running and climbing stairs despite doing them regularly.

How many of you have been asked to do clam shell exercises to make your Gluteus Medius (or hip) muscles stronger? If you have, maybe you need not bother any more.

Latest research (Moore et al, 2019) shows that clam shell exercises do not activate your Gluteus Medius as much as you think.

Right Gluteus Medius muscle

The Gluteus Medius muscle is very important for female runners, especially if they have knee pain. You can treat their knees but their pain will not go away until you have addressed the weakness  in their Gluteus Medius muscle.

View from the back, Left Gluteus Medius

In that small study, three sets of six common lower limb exercises were performed by ten healthy adults after a short warm up. They did single leg squats, single leg bridging, hip abduction (lifting) in side lying, clam shell exercise in side lying, running man exercise (simulates running motion of running one leg at a time) and resisted hip abduction-extension exercise.

The participants had electromyography or EMG electrodes to measure muscle activity attached to all three parts of the Gluteus Medius muscle (in front, middle and posterior).

Results showed that clam shell exercises were not effective in activating any part of the Gluteus Medius muscle. Highest levels of overall activity were seen in the single leg squat, single leg bridging and the resisted hip abuction-extension exercise.

Other than the knee, you need to know that weakness in your Gluteus Medius can also contribute to pain or problems in your Achilles. Make sure you are doing the strengthening correctly.

Reference

Moore D, Pizzari T et al (2019). Rehabiliation Exercises For The Gluteus Medius Muscle Segments: An Electromyography Study. J Sp Rehab. DOI: 10.1123/jsr.2018-0340.

Head, Neck And Jaw

Taking turns for a quick assessment

After Aized last week, yours truly attended the Head, Neck and Jaw course yesterday and today. This is the next course offered after we did the Shoulders and Arms course earlier in April this year.

Wow, time really flies, it's already October today.
It was a really interesting course looking at everyone's head, neck and into their mouths. Yes, you read correctly, we got to stick our fingers inside each other's mouths.

All five different necks

We learnt about the Masseter and Temporalis which are on our face and skull, we also learnt how to treat the Medial and Lateral terygoids, which are inside our mouths and how they connect to the neck.

Showing me my Lateral Pterygoids

Yes, we got right into each other's mouths.

Medial , Lateral Pterygoids

Back to work tomorrow. And if you need to get your head, neck or jaw treated .....

Magnesium Supplements For Muscle Cramps?

Available from my local pharmacy

A patient came in today saying she went to a local running store and was advised to take some magnesium supplements as she cramps occasionally while racing. So she went ahead and bought some. She wanted my thoughts on whether they truly work since they seem to be the latest "silver bullet" that most runners seem to be taking.

Magnesium is an essential nutrient that's actually found in many of the foods we're already eating. It is actually abundant in our bodies. Our bodies need it to create new proteins, for energy production in cells, DNA synthesis etc. As it is essential, our bodies store it in our bones, where it can easily be accessed if needed. Since our bodies cannot produce it, we need to get it from our diet.

An adequate magnesium is needed for a healthy pregnancy and to produce enough milk after giving birth. It is also useful if you take diuretic drugs, proton pump inhibitors and if you're diabetic.

It is suggested that adults need 300-400 milligrams a day and you will get enough if you eat enough legumes (chickpeas, black and kidney beans), nuts, seeds, veggies (broccoli, cabbage, asparagus, kale and spinach), fatty fish (tuna, salmon and mackerel) and some fruits (avocado, bananas, figs, guava and raspberries).

It is estimated that 10-30 percent of people in developed countries may have a mild deficiency in magnesium (DiNicolantonio et al, 2018). Severe deficiencies are uncommon but easy to spot. Symptoms include loss of appetite, vomiting and fatigue and following that numbness, muscle cramps, seizures, personality changes and heart artery changes if the deficiency continues.

It is why those who sell these supplements tell athletes to take them - to prevent muscle cramps! But note that the muscle cramps are preceded by loss of your appetite, vomiting and fatigue. Not the muscle cramps when you're training hard or racing. Note that the muscle cramps that occur when you have a magnesium deficiency happens with activities of daily living (not while exercising/ racing). Not only the muscles in your feet and legs cramp, but also your facial and masticatory (chewing) muscles.

Those who sell magnesium tablets, body sprays, serum and bath salts will tell you their products will boost recovery, energy levels and promote DNA synthesis, bone strength and other important body functions. When something sounds too good to be true, it probably is. If you eat a healthy diet of the food listed above that is rich in magnesium, then you wouldn't need any magnesium supplements.

You will not benefit from taking magnesium supplements unless you're deficient. This can only be verified via a blood test.

If you are lacking magnesium, you can either eat food sources rich in magnesium or take supplements. There is no evidence that any form of magnesium (whether it is magnesium oxide, aspartate or citrate) is more easily absorbed by our bodies. So don't buy the most expensive brand or version of it.

As for magnesium creams, oils, sprays, flakes and bath salts etc, evidence suggest that they are not as effective as claimed (Grober et al, 2017).

So if you have done a blood test and have a magnesium deficiency, load up on magnesium rich food or go ahead take a cheap supplement.

"So that means I wasted my money" went my patient? Now you know. And you've read what causes muscle cramps.


References

Grober U, Werner T et al (2017). Myth Or Reality- Transdermal Magnesium? Nutrients 9(8): 813. DOI: 10.3390/nu9080813.

DiNicolantonio JJ, O'Keefe JH et al (2018). Subclinical Magnesium Deficiency : A Principal Driver Of Cardiovascular Disease And A Public Health Crisis. Open Heart. 5:e000668. DOI: 10.1136/openhrt-2017-000668.