Sunday, December 26, 2021

Training Through This Holiday Season

Picture by Jeffrey Keng on 010119
This is usually my favourite time of the year. The weather is a little cooler from the rain. The international school just down the road from where we live is closed for the year which means little or much less cars along our street. Many of our patients are traveling or visiting families so we see less people in our clinics.  

Handling the extra social meetings, holiday shopping, festivities and of course, the extra eating while keeping your training intact is going to be challenging for many.

Here are some suggestions to keep your training intact if you keep your long term objectives in mind while keeping your expectations realistic.

I would usually have slightly more time to ride in the wee morning hours during the weekdays the last 2 weeks of the year. Not this year after my recent accident. My only time on a bike currently is on the stationary bike. Not that I have a choice, doctor's orders.

If you're a cyclist, early starts are great these 2 weeks since all school kids are on holidays. No need to drive your kids and definitely less morning traffic as well. Get your ride in early and have the rest of the day free for your family or other social engagements. Personally I find riding or running with your group of friends helpful as they help to make sure you turn up.

Whether it is cycling, triathlon or ultra running, consistency is key. You may not be able to fit in that extra long run or bike ride during this period. What matters more is you try to  fit in a session on most days, i.e. cutting overall training time rather than reduce frequency of your sessions. So if you're running an hour most weekdays and 2-3 hours on the weekends, running 30 mins on most weekdays and an hour on the weekend may suffice to keep your running routines, habits and adaptations intact.

Caught this view on my morning run
If some training sessions must be wiped off from your calender, lose the slow, easy aerobic sessions as retaining the intensity is key to maintaining fitness.

Do leave room for days when you really cannot fit any exercise in. Your child or other loved ones may fall sick, your boss may give you no notice for a last minute project or other stuff can happen. Take a deep breath and tell yourself that you definitely will not win or lose a race later in the upcoming season by missing a workout in December. There will be many other opportunities to train specifically in the new year. You're only getting ready to train in January. Don't sweat the the fact that you are too busy and distracted to follow the strictest training plan.

When I was still competing, this would be the time when I took 2 weeks off training. No swimming, cycling, running or weights training. Just resting, chilling, time with family, eating etc. I'll be raring to go by the time the new year came round. You may want to take time off to recharge too.

The holiday period definitely brings another layer of complexity if you're still training. However, it also provides a chance to celebrate and connect with traditions and people that matter most to us. Personally, it has given me a chance to be thankful since Covid-19 has delivered more struggles than most of us admit.

We already squeeze our training into our typically demanding schedules and this time of the year provides us a chance to slow down and reflect. Merry Christmas to all our readers.

Sunday, December 19, 2021

Monetary Incentives Are The Best

I was amazed when I saw the crowd of people shopping at Orchard Road in today's paper (above) this morning.

Well, at least they are out getting some 'exercise' while buying presents for their loved ones. Are you wondering how to motivate someone to exercise? Well, this week's post does exactly that. And yes, rewards are very important to get people to exercise.

Just like the proverbial dangling of the carrot in front of the donkey,  evidence suggests that monetary rewards plays a big role in motivating one to exercise. 

This mega study involved 61,293 gym members from the American 24 hour Fitness chain, 30 scientists from 15 universities and more than 50 motivational programs.

Incentives include a free audiobook for gym use, cheery instructions from instructors to reframe exercise as fun and reward points under an umbrella program called Step Up. After signing up, these gym members earned Amazon reward points worth US$1 (S$1.36) and new ways to motivate themselves to exercise.

The scientists divided these participants into 53 different groups. Each group had at least 455 participants. In an example group, members earned US$1.75 reward points each time they visited the gym. Other groups shared workouts on social media, signed fitness pledges etc. Each intervention lasted a month.  Of course there was a separate control group that changed nothing about their daily lives or gym time. 

Here are the results. The most successful intervention was giving people US$0.09! Yes, 9 cents worth of reward points if they returned to the gym after missing a planned workout. This increased visit rates by 16 percent compared to just planning in advance and text reminders. Giving participants US$1.75 everytime they worked out was almost as effective, it increased exercise participation by 14 percent.

So as we approach the coming new year with new fitness resolutions, other than planning a reasonable workout schedule, putting the program reminders into our phones or having a spouse/ training buddy, the above findings suggest finding a small way to reward ourselves when we do exercise, works best. Perhaps the shoppers in the above picture were also thinking of buying themselves a present after dealing with Covid-19 for almost 2 years now.

Ministry of Health officials reading this, can we reward participants with some monetary incentive from NTUC with every hour walked or a workout done? That may help with our growing diabetes problem too.

Remember the free fitness trackers given out were highly popular and it motivated people to keep up their daily steps when it was first launched. In fact the latest version of trackers were snapped up quickly as seen in the yesterday's newspaper report (picture above).

What about you? Would a monetary incentive motivate you to workout more regularly? How much would it take before you proceed? Appreciate your comments please.

Reference

Milkman KL, Gromet D, Ho H et al (2021). Megastudies Improve The Impact Of Applied Behavioural Science. Nature. 600: 478-483. DOI: 10.1038/s41586-021-04124-4

Sunday, December 12, 2021

Don't Feel Like Eating After A Workout?

This was in Oct 2018
Before my recent accident, most Saturday mornings before work, I made time to ride my bike. It's my longest exercise session for the week. Sometimes, distances in excess of 100 km would be covered.

105 km before work
Most of the time after the ride I'm starving, except when our group rode a lot harder and faster under hot conditions. Then my appetite would be blunted, I would normally just prefer an ice cold drink rather than eating.

Evidence regarding this has been mixed. Some studies show that prolonged and strenuous exercise tends to blunt one's appetite, sometimes for hours or even into the next day. Other studies suggest the opposite, finding that some people feel hungrier after workouts of any kind and quickly eat the calories they expended and continue to eat more at the next meal.

Consider the following study. Participants in this weight loss study did not feel like eating after running or strength training. The physical activity prevented them from overeating. But it was not the strenuous exercise that blunted their appetites.

In that study, 130 participants (between 18 to 70) were asked to exercise for one year. Other than light physical activity, the fitness program also had moderate to vigorous physical activities of up to 250 minutes a week. Each of them wore a fitness tracker and was given a daily calorie goal based on their body mass index (BMI).

Results showed that when the participants did not exercise, they were 12 percent more likely to overeat (or exceed their daily calorie goal). However, when the participants exercised for 60 mins, their risk of overeating was lessened to 5 percent. For every extra 10 minutes of exercise after 60 minutes, the chances the participants would overeat dropped by a further 1 percent. 

To my surprise and the surprise of the researchers, light physical activity (walking at a slow leisurely pace) showed the strongest effects against overeating compared to moderate (brisk walk) to vigorous physical activity (running or strenuous fitness class).

The researchers explained that exercise causes peptide YY, a hormone which suppresses appetite to spike, while causing grehlin (which stimulates appetite) to drop. This led to the participants not feeling hungry after exercise.

Another possible reason is that exercise boosts mood and self esteem, which may improve one's motivation not to overeat.

Also note that participants in the study had participants with BMI values between 27 to 50 (overweight or obese) and they were looking to lose weight. What they perceived as moderate physical activities may be different to what you and I may perceive.

For most of us, exercise can affect our hunger and weight in unexpected and contradictory ways. So during this holiday season, do not worry that if you exercise you will overeat. A short period of indulgence should not affect your weight in the long term if you exercise regularly .


Reference

CrochiereRJ, Kerrigan SG, Lampe EW et al (2020). Is Physical Activity A Risk Or A protective Factor For Subsequent Dietary Lapses Among Behavioral Weight Loss Participants? Health Pysch 39(3): 240-244. DOI: 10.1037/hea0000839.

Sunday, December 5, 2021

How Long Do You Sit For?


When I first read this article, I could not imagine sitting for 4.5 hours at a stretch. Even with my recent accident, I did not sit longer than an hour. But then, I recall that it's fairly normal according to what my patients tell me, especially with most people who still work from home (WFH).  

Many patients tell me that with WFH, they end up sitting for hours at a go. We know that prolonged sitting is the new smoking, that prolonged sitting without regular movement may lead to low back pain, other musculoskeletal problems and other lifestyle diseases.


Back to what I read. Participants in that study sat for 4.5 hours in a controlled environment (see picture above) while researchers investigated how the participants fared with regular muscle contractions on muscle stiffness. These participants had neuromuscular electrical stimulation applied to the lumbar region of their back to simulate movement.

The results showed that prolonged sitting without regular movement significantly increase stiffness in our back muscles. This may explain why prolonged periods of chair sitting increase chances of low back pain. There was no mention that poor posture or slouching contributed to this.

The good news is that with regular movement (through regular muscle contractions), stiffness in your lower back can be prevented.

The researchers concluded that it is important that we move regularly and consistently throughout the day. 

If I had to be sitting in front of a computer, I will get up and move around as often as I can. Otherwise, I will do so with one or two trigger balls at my low back area (see picture right at the top) since it reminds me to move more frequently.


Reference

Kerr AR, Milani TL and Sichting F (2021). Sitting For Too Long, Moving Too Little: Regular Muscle Contractions Can Reduce Muscle Stiffness During Prolonged Periods of Chair-sitting. Front Sp Act Living. 03 Nov 2021. DOI: 10.3389/fspo.2021.760533

Saturday, November 27, 2021

Thankful For Accidents

Talking to my boys at the hospital
I definitely had my fair share of accidents, actually 2 major ones I will never ever forget. I'm sure you know and remember yours. When you slipped and grazed your knees or broke a bone. Or that illness that took a long time to get better. It could also be a job or a gig that you failed to land.

Then there are the positive 'accidents' too, too many that we often forget to mention. A friendly smile or nod from a fellow runner or cyclist. A kind act from a stranger who happened to be passing by.

I am thankful to be born here. To be surrounded by family and friends and to be given opportunities that many others never even dreamed of. And from those opportunities given, the belief that we have in others and efforts that enabled results. 

To be able to read, to talk and to connect. To have others give us the benefit of the doubt. To be able to smile at times, and the chance to contribute towards our community.

With 2002 Commonwealth Games silver medalist, Patrick Lau
So many things to be thankful for. I am very thankful I met up with a old patient (pictured above) and friend yesterday. I am also thankful that many old friends and newer friends and patients who have reached out to me after my recent accident. Some of these friends met by chance or accident. 

Not many of us celebrate Thanksgiving in Singapore. I definitely have many things to be thankful for, my wifefamily and friends for sure. Accidents included. 

Thursday, November 18, 2021

11 Weeks After His Accident

His shirt says 'Rather be riding'

A
t almost 11 weeks post spinal fracture after a cycling accident, we find ourselves back in Prof Hee's clinic. Today we compared his MRI films from the day of his accident with the imaging done after 10 weeks of healing. It's 60% healed, which is great for his age and fitness level. 

But Gino being Gino, is raring to go and felt a little disappointed that he can only return to work gradually at the end of November. To maintain his fitness, he is allowed only intermittent running with brisk walking, light weight training and cycling on his stationary bike. I thought that was great news! 

But looking at his face a few hours after the appointment with his doc, I could see that he was trying to wrap his head around the fact that he wasn't closer to full healing. It is tough being a patient, waiting for our bodies to take the time it needs to heal fully. I guess that's why we're called patients when we seek treatment!

I know that he's grateful to be well and have the chance to return to work soon, but it takes time to accept that his body doesn't heal as quickly as he wants or needs to. He has done the best that he possibly could be done in terms of healing, now the hard part .. to wait.

Aized

Saturday, November 13, 2021

Are You A 'Difficult Patient'?

*Have to walk with crutches - 2003
I had a patient call me yesterday asking if he could see me in our clinic as he had been called a 'difficult patient' by the last health professional he saw. I explained that I was still on medical leave after my cycling accident, and he could perhaps see my colleagues in our clinic. However, I would be happy to answer his queries if needed.

Picture from coreimpodcast.com
Of course I then asked why he was called a 'difficult patient' and his reply was "because I ask too many questions". My immediate thoughts were how can any healthcare professional tell patients that they are 'difficult patients'  when they are just asking questions about their own health?

Actually, I'm probably a very 'difficult patient' too. Make that the worst 'difficult patient'. I've been a patient before while still racing/ competing triathlons with three knee operations. Following that a skull and spine compression fracture and now another another spine compression fracture just ten weeks ago. 

Aized will tell you that during ALL of my doctor's appointments, I'm always in the doctor's clinic asking the poor guy lots of questions. "Ok Dr A, B or C, the the million dollar questions are; when can I cycle, run, carry my child, lift weights or go back to work?" These were questions that were very important to me. Still are now. Even though as a physiotherapist I should know most if not all the answers myself.

Borrowing the words of Aized's wise friend, "Healing isn't a bed of roses, it isn't a fluffy fairytale. It is tiring, gruesome and painful". I can definitely vouch for that.

Most times, it's just that patients want confirmation of what they have researched on the internet. Most of us have all done this at some point or other. Of course we need to bear in mind that answers off the internet may not necessary be medically sound advice or correct diagnoses. 

For me, personally, patients who ask a lot of questions are actually good, but wanting me (or another healthcare professional) to tell them what they want to hear may not always happen.

Back to my patient. I asked that patient what his questions were.  His reply was "I'm so glad you asked, I have quite a few on my list!"

That is also why I usually end my time with each patient by asking, "Any questions so far?", "Which questions have we not answered today?" or, "Is there anything we should have talked about that we have not?"

In our clinics, I actually give out my personal mobile phone number, in case patients have questions any time after their appointment. Why? Because I do expect questions from patients. Or they can message or email me if they think of some after their treatment session.

*The picture above was taken on 16th July 2003 after my 3rd knee operation in Adelaide, South Australia, where I was studying for my Masters in Musculoskeletal and Sports Physiotherapy. The surgeon said I had to be non weight-bearing on my R leg for 6 weeks after the operation. However, he said cycling was fine since the articular cartilage he repaired would benefit from exercise that stimulated the repaired area without weight bearing forces. 

So I taped the crutch to my bike, cycled to university and walked around with crutches. Aized thinks I'm a DIFFICULT patient ;)

Sunday, November 7, 2021

My Basic Guidelines For Running

Screenshot from the talk
Thank you to those of you who took time to attend the talk on running we had 3 days ago. From the 'live' questions and those I received via email, it seems like many Singaporeans did take up running last year during the circuit breaker/ lockdown. Good to know that many have continued running since then.

Many of these runners are not aspiring to complete a marathon (not yet anyway). However, they all seem to want to run faster. Well, as runners, we all want to run faster and longer for some reason. 

Over the years, I've put together a set of guidelines for runners, my patients or anyone who wants to keep running for health, fitness or performance.

Some runners swear by their heart rate monitors (HRM). Those who know me know that I do not like training with a heart rate monitor (HRM) even though I was sponsored by Polar Heart Rate Monitors when I was still competing. I just used their HRM as watches. (FYI - Polar was the market leader for HRM before Garmin came along and disrupted that market). 

I am not against anyone training with HRM's. My take is that our bodies do not work in physiological zones where exceeding aerobic zones is a crime. When feeling good, your easy runs can be a little faster, But if you're tired or not recovering quickly, then I'd say your easy run can be at a snail's pace. Better still take a rest day. No doing planks, core exercises etc, just total rest. 

The next few suggestions are specially for those who run ultras. Please don't feel obligated to follow anybody's training, especially if they're pro or semi-pro. This means trying to clock 100 km a week, running twice a day etc. All of these tips/ suggestions on training have too many cofounding factors and variables so do not even venture there. Plus in sunny and super humid Singapore, it takes a lot more to recover from all that mileage.

Don't keep chasing mileage and vertical (climbs) totals. They are variables for stress, but they are not the actual stress experienced by your body. A 20 km run is just a 20 km run. Or it may act like a 30 km run if you have been up at night with a sick child or rushing a dateline at work. Our bodies know the distance we've covered, but stress from other non physical factors mentioned above is interpreted as stress by the body too. More stress is not always better. Our bodies can adapt to lower or higher volume as long as the stress is appropriate for you.

I have patients who deliberately fast before training to improve performance. Perhaps it MAY improve energy efficiency in some (very few) athletes, but I rather they eat and find their 'strong' to train harder instead of messing with their sensitive metabolic pathways.

Those of you who listened to my talk will know that I'm not recommending minimalist nor maximalist shoes for everyone. Wear shoes that are comfortable for you and not anyone else. Different shoes work for different people.

Do stay active and engaged in activities and groups you find meaningful and care about you, as they help increase both quality and quantity of life. Social interaction is critical for mental and physical health.

Saturday, October 30, 2021

Can Exercise Prevent Memory Loss?


My son was watching me go through my Prezi slides for my talk on running next Wednesday when I came across an interesting article on the last page of the Business Times (below).

BT 301021
The author, a medical doctor was writing on preventing memory loss, about how when we find ourselves forgetful, we should not pass it off as aging.

He goes on to talk about how high blood pressure increases in mid life and this appears to be an important risk factor for developing dementia later in life.

There also seems to be a detrimental effect on our health if resting heart rate (HR) is high. The author quoted a Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) study, where those with a prior stroke who had a higher resting HR than 67 beats per minute had an accelerated cognitive decline.

So a high HR may be considered as a risk factor for cognitive decline and dementia.

Wow, straight away I thought that this definitely serves as a huge incentive to keep exercising and keep my blood pressure and resting HR low.

So here's good reason for you to attend my Zoom talk on running next Wednesday (3/11/21) so you can keep exercising to prevent memory loss and cognitive decline.

Here is the link to register.

Sunday, October 24, 2021

Running Faster May Not Cause Shin Splints

Frequent site of shin pain/ stress fracture

We runners have always been told to train and don't strain. Running too fast, too often, can be a sure recipe for injury. That's why we always have an easy day for recovery after a hard session, to reduce our risk of injury. No runner wants to hear that they have a stress fracture or a small crack in their bones caused by overuse.

We think that when we run faster, we put more strain and load through our muscles and bones. So chances of a muscular or bone stress injury should be higher when we run faster.  We all assume that running slower (or slowly) causes less strain on our legs than running fast.

According to newly published research, fast paced running does not put any more pressure on your tibial (shin bone) which is a common area for shin splints and stress fractures than slow easy runs.

Runners in that study were asked to run at their own selected pace of slow, moderate and fast (but not all out). Reflective sensors were attached to their hips, knees and feet while they ran over force plates that measured impact (load) with each step.

I was really surprised to read that the slow paced runs (and not the fast runs) resulted in the most strain. Running at 'normal' or moderate pace for these runners caused less cumulative load than running the same distance at fast and slower speed.

The authors concluded that running fast does not necessarily cause more load on your tibial (shin bone) than slow running. Well, no excuse not run intervals once a week then if you're training for a race.

However, it may be too early to use this information to change our training habits as fatigue definitely does affect load when we run. Personally, I do feel I need an easy day of training to recover after a hard bike, run or weights session. Even when I was competing, it's usually 2 hard days of training back to back with a easy day (or total rest day) after. That way you won't have to worry about getting injured. Until an an accident strikes ......


Reference

Hunter J, Garcia GK, Shim JK et al (2019). Fast Running Does Not Contribute More Cumulative Load Than Slow Running. Med Sci Sp Ex. 51(6): 1178-1185. DOI: 10.1249/MSS.0000000000001888

Thursday, October 21, 2021

Sports Solutions Turns 12


The picture above was taken just outside the clinic when we started at Amoy Street in 2009. So that means our clinic turns 12 today!

We moved to Holland Village in 2014 after my bike accident in 2013 so I didn't have to cycle to the clinic. That was the main reason we moved (now you know).

We are most grateful to everyone on our team and patients that have stood by and supported us all this while. We will continue to do our best to update, improve and progress for our patients. Thank you from the bottom of our hearts.

Sunday, October 17, 2021

Ultrasound Or Ultra Bullshit?

When I was doing postgraduate studies in Adelaide back in 2003, I was fortunate to have David Butler as one of our tutors teaching Pain Sciences. He also introduced us to the term 'ultra bullshit' when it came to what he thought about the effectiveness of using ultrasound to treat patients. Especially those patients with chronic pain.

For those of you using therapeutic ultrasound, please do not be offended. I'm not suggesting that you cannot, should not or better not be using it, I'm just saying that we almost never use ultrasound in our clinics to treat patients.

However, I've been receiving therapeutic ultrasound almost daily since my T4 spine fracture last month. Why the sudden change? There have been studies showing that pulsed ultrasound can accelerate bone union by up to a week. I'm up for anything that helps my fracture heal better and faster!

Therapeutic ultrasound appears to effectively heat tissues (muscles, connective tissues etc) but research has not established the ideal temperatures for tissue benefit or tissue damage. Current research also suggests that therapeutic ultrasound will not help pain reduction, delayed onset of muscle soreness (DOMS) or iontophoresis (deliver medicine under the skin), BUT it does appear to facilitate fracture healing. That previous sentence you read was 'a sight for my sore eyes'!

So my beloved wife has been helping daily with my ultrasound regime, although she does delegate the tasks occasionally to my boys as she says it's terribly boring holding on to the ultrasound device.

Looking forward to my next MRI to see how my fracture has healed.


Reference

Eberman L, Schumacher H, Niemann AJ et al (2013). Research Evidence For Therapeutic Ultrasound Effectiveness. Int J Ath Trg. 18(4): 20-22. DOI: 10.1123/ijatt.18.4.20. * Thanks to Byron who got me the article.


Sunday, October 10, 2021

The Intricacies Of Our Thoracic Spine


Vertebral body of thoracic spine
Since my accident, I've been researching and reading so I know how to best treat the thoracic spine when it's someone else who's hurt their thoracic spine and ribcage. So this week's post is to share what I've been reading up on the anatomy, structure and function of our thoracic spine.  Also by writing it here, I can always send this link to patients who want to know more. 
Cancellous bone
The vertebral body is not a solid block of bone. In fact, it is just a shell of dense cortical bone (outer surface of bone) surrounding cancellous bone (pictured above). This shell is not strong enough for lengthwise compression and it collapses like a cardboard box with too heavy loads (see picture below).

It is reinforced by vertical struts between the top and bottom surfaces. A strut acts like a solid, but narrow block of bone. As long as it is kept straight, it can sustain immense longitudinal loads.

Vertical struts straining under load (b)

However, struts tend to bend or bow when longitudinal forces are too strong, although a box with vertical struts is still stronger than an empty box.

Stronger with horizontal cross-beams
When cross-beams that are connected are introduced to the struts, the strength of that box is further enhanced. So, when a load is applied, this cross-beams hold the struts in place to prevent them from deforming and preventing the box from collapsing. 


Our vertebral bodies follow this internal architecture described above. The struts and cross-beams are formed by thin rods of bone called vertical (VT) and transverse trabeculae (TT). This trabeculae provides weight bearing strength and resilience to the vertebral body.

Any load applied to the vertebral body is first borne by the vertical trabeculae. When the load is too much, the horizontal trabeculae picks up the slack. Hence the load is sustained by a combination of vertical pressure and transverse tension in the trabeculae.

The advantage of this design (when it is not a solid block of bone) is that a strong but lightweight load bearing structure is constructed with minimal use of bone.

Another benefit is that the space between the trabeculae is used as channels for the blood supply and venous drainage for the vertebral body. Under some conditions, it allows for haemopoiesis (making new red blood cells) and this helps with transmitting load and absorbing force.

So how did my T4 fracture when it is supposed to be strong and resilient? Well, it wasn't just a simple fall, I was rear ended by a motorbike.


References

Bogduk N and Twomey LT (1987). Clinical Anatomy Of The Lumbar Spine. Longman Group UK.

Oliver J and Middleditch A (1991). Functional Anatomy Of The Spine. Butterworth-Heinemann Ltd.

Sunday, October 3, 2021

Running With Ankle Weights

Picture by Megan
This week's post is requested by one of our blog's readers who asked about the benefits of running with ankle weights. This reader started using ankle weights when Covid-19 caused gyms to close last year and thought that by strapping on ankle weights, it would be like adding strength training while out walking or running.

Strangely enough, I've noticed a couple of ladies who run pass my home (now that I'm stuck at home mostly after my accident) with ankle or wrist weights too. I suppose once you're aware of them, you start looking out or noticing them.

Let's get into it. We shall start with the benefits first. Running with the ankle weight makes (some of) your leg muscles work harder since the extra weight makes it heavier to walk or run.  Over time, (some of) your muscles get stronger. For instance, if you were running with the ankle weights, it would work your hip flexors more than your hip extensors as the former have to work harder to lift your leg off the ground to prepare for the next foot strike. 

When you take the extra weight off, it makes it easier to run, you can run faster or you may find it easier to run longer distances. The heart and lungs work harder too and over time, your cardiovascular endurance improves. I found a study in 2016 which supports this (Yaacob et al, 2016).

Now for the not so good part of running with ankle weights. Your gait definitely changes when you run with them. There is now added load on your joints, especially your knees, hips, ankles and lower back. This can lead to improper or faulty technique, which may create muscle imbalances and cause injury.

What's worse is if your muscles cannot handle the extra weight, this added load gets transferred to your bones, joints and the articular cartilage. So the risk of carrying a heavier load may outweigh the potential improved performance for runners.

My take? If you have been using them and have no issues or injuries, you can probably carry on. However, if you're a new runner then I will suggest other ways to add training load to improve so as to minimize your chance of getting injured.

Would I run with ankle weights? Most probably not. The closest I came to using something similar was a weight vest. I did this way back in 2000 and 2001 when I was training for the Oxfam 100 km Trailwalker event and I used to walk (not run) up and down the steps in the spectator stands at the old National Stadium to get stronger. 


Reference

Yaacob NM, Yaacob NA, Ismail AA et al (2016). Dumbbells And Ankle-wrist Weight Training Leads To Changes In Body Composition And Anthropometric Parameters With Potential Cardiovascular Disease Risk Reduction. J Taibah Uni Med Sci. 11(5): 439-447. DOI: 10.1016/j.jtumed.2016.06.005

Sunday, September 26, 2021

Eat More And Triumph

Picture from Runtastic.com
I remember a fellow cross country runner who was on the stockier side, was really strong and fast (of course now I know he had what we call a mesomorph body type). The teacher in charge back then suggested that he '"needed to weigh a certain amount so he could run even faster".

This teacher had good intentions no doubt, but he was a Math teacher 'assigned' to be in charge of cross country running and not a 'real' running coach. Looking back, I'm not even sure if that teacher himself ran at all.

Anyway, my friend took his 'advice' and tried to lose weight mostly by not eating or eating a lot less. Not only did he lose weight, he lost a lot of his natural strength and his confidence to boot as he fared poorly in races thereafter. He quit running soon after. 

We now know that being a good athlete is all about finding what works for you. It's about finding YOUR 'strong'. We need to fuel our bodies adequately if we want long term growth and success.

For some runners, that means following that advice my cross country teacher gave to lose weight. For others, it means having a body that looks different (to the norm) and weighing more or less. All body types can work given our different and unique genes and backgrounds.

The problem with that advice is that it is often interpreted from elsewhere, an outlier perhaps, a person that won an Olympic medal. Interpreting data from outliers may be great if you're an exercise scientist writing up research to publish in a scientific journal. Definitely not great for giving advice to other athletes.

Athletes that go against their unique genes and background will not fare well with this training stimulus. They will be like a ticking time bomb and will almost always get slower with time, just like my former team mate.

Consider the *New Zealand rowing team, A survey they did found that all but one rower was at risk of having low energy because of their beliefs and eating habits. Coaches and Rowing NZ officials worked with their rowers to take up a challenge and eat more, thus changing their approach and culture to fueling. The rowers became faster, stronger and happier. Rowing was New Zealand's most successful sport at the Tokyo Olympics and four female boats won medals.

Here's what rower Brooke Donahue, who won a silver medal at the Tokyo Olympics recently said, "Now I understand being lean isn't a priority, being strong is," and "It doesn't matter what I sit on the scales. It's opened us up to understand it's not about a number but more about a good feeling, knowing we're fueling well." 

Eating well and eating enough can fuel your performance and recovery for long term growth and adaptation. Food can be your legal and natural performance enhancing 'drug'.


Reference

McFadden S (2021). Tokyo Olympics: How Our Female Rowers Ate More And Triumphed. Published on 17 Aug 2021. *Article on the New Zealand rowing team is taken from Stuff.

Sunday, September 19, 2021

Minimum Dose Of Training To Stay Fit

2 months after accident in 2013
I've written about how quickly you can lose your running fitness in the past. With my recent accident, I'm definitely losing fitness as the days pass. 

However, I'm probably not the only person who worries about losing fitness. Many people have lost their fitness during this Covid pandemic. I remember a few of my patients who are security officers for ministers/ VIP's whose ability to train while on duty is severely restricted. Similarly for military personnel on certain postings. Others with personal conflict, family commitments, caring for an ill family member and injury may face the same situation.

Since I'm in the same boat, I'm reading up to find out exactly how or what I need to do so I don't lose too much, or better still maintain whatever fitness I have left 2 weeks post accident.

Let me share what I found out from researchers from the US Army Research Institute of Environmental Medicine. They looked at three key training variables, frequency (how many days a week), volume (how long the session, how many sets or reps to lift) and intensity (how hard or how heavy the weight). 

Only studies on athletic performance (not weight loss or health) in which the training was reduced for at least 4 weeks were considered. This is to distinguish them from research on tapering before a big competition (usually a 3 week taper).

Most of the studies reviewed were based on work done by Robert Hickson in the early 1980's (Hickson and Rosenkoetter, 1981). Hickson's subjects were put through 10 weeks of brutal training. They involved 6 days of cycling or running for 40 minutes at 90-100 percent maximum heart rate (HR) at the end. Then for the next 15 weeks, they reduced the number of weekly sessions to twice or four times a week. Duration was reduced to 13 or 26 minutes and intensities of the sessions were reduced to 61-67 or 82-87 percent of max HR.

Picture from Med Sci Sp Ex article

In Hickson's original study , VO2 max is shown on the Y (or vertical axis) on the left of the picture above. You can see that after the 10 weeks (albeit brutal) training block on the X axis, VO2 max have improved by a impressive 20-25 percent. For the next 15 weeks, their VO2 max stayed at their improved values, despite training dropping down to 2-4 days a week. The subjects were recreationally active but untrained. 

Overall conclusion of this review is that you can get away with just 2 sessions a week as long as you maintain volume and intensity of your workouts. This is similar to what Hickson found with further confirmation in some areas. 

However, please bear in mind that maintaining your VO2 max is not the same as your ability to perform long duration activities (oops for me then since my Saturday bike rides go up to 3 hours). Similarly, don't expect to run your best marathon time after a few months of 2 times a week training. Your leg muscles will definitely not be able to handle it.

When duration of training was reduced by one (13 minutes) or two thirds (26 minutes), VO2 max gains were preserved for 15 weeks. The study included short (5 minutes) and long (2 hours) endurance. No prizes for guessing that short endurance was preserved when comparing the 13 and 26 minutes group, but those who reduced their training to 13 minutes fared worse in the 2 hour test.

When training intensities were dropped by a third (from 90-100 percent to 82-87 percent), VO2 max and long endurance declined. When training intensities were dropped by two-thirds (61-67 percent), most of the training gains were wiped out. Takeaway message is you can get away with training less often, or for a shorter duration but not with going easy.

A few other points to note. These conclusions were based on what I'll say is an "unsustainable training protocol" of hammering 6 days a week with one rest day! Most of us would surely have a more balanced training program of hard and easy days. 

The subjects used were not trained athletes nor military personnel. If you've been  training for years, you would have some structural changes like a bigger heart and a more extensive network of blood vessels that would hopefully take longer to take away (yay for yours truly).

Of course elite athletes would probably have a higher level of absolute fitness which may fade away quicker initially.

All you gym rats will be happy to know that the overall pattern is fairly similar when it comes to strength training too. Both frequency and volume of workouts can be reduced as long as intensity is maintained. Several studies found that even once a week training is enough to preserve maximum strength and muscle size for several months.

However, for adults above 60, evidence suggests that twice a week strength sessions are better at preserving muscle. Same for training volume, older people will need two sets while one set per exercise for young populations will suffice.

Now you (and I) definitely know what it takes. 

References


Hickson RC and Rosenkoetter MA (1981). Reduced Training Frequencies And Maintenance Of Increased Aerobic Power. Med Sci Sp Ex. 13(1): 13-16

Sperring BA, Mujika I, Sharp MA et al (2021). Maintaining Physical Performance: The Minimal Dose Of Exercise Needed To Preserve Endurance And Strength Over Time. J Strength Cond Research. 35(5): 1449-1458. DOI: 10.1519/JSC.0000000000003964


Sunday, September 12, 2021

Sugar Is Not Your Enemy

When can I drink Coke again?
Those of you who know me well know that I have a sweet tooth. I love eating chocolate and drinking Coca Cola. However, now that I'm not able to do much exercise over the next 6-8 weeks after my accident last week, I definitely won't be eating much sugar!

There is a huge difference between consuming too much added sugar when not exercising and fueling your exercise with sugar. This always confuses athletes, myself included previously. So let me try to explain this.

Too much sugar in our diet can definitely harm our health, but consuming carbohydrate, including simple sugars can be beneficial to your athletic performance. During intense exercise and in the latter stages of a long endurance session/ race, when our muscle glycogen gets low or depleted, bananas, Coca Cola, gels and other concentrated sources of simple sugars get into our bloodstream and muscle cells much quicker. Some of you must have experienced this while on the verge of bonking and getting a sugar boost when you consume an energy gel. 

This then presents a dilemma for some of you who want to fuel high performance and simultaneously reduce sugar intake.

Carbohydrates include whole grains, fruits, vegetables, processed grain, rice, noodles, pasta, table sugar (sucrose) and monosaccharides (fructose and glucose).

When a food contains extra or "added sugar", it means that sugar that was not naturally present in a food or ingredient but was added during preparation or cooking, then you have to be careful. These are mostly in packaged foods although it goes by names like high fructose corn syrup, cane juice crystals, muscovado, brown rice syrup etc.

So when doctors or dieticians warn about health risks associated with consuming large amounts of sugar, they are not referring to carbohydrates, but excessive added sugar.

Excessive consumption of added sugar, also known as 'free sugar' is the problem and it is associated with obesity, *insulin resistance, Type II diabetes, cardiovascular disease and **other health problems.

How is this different from consuming sugar while exercising? During prolonged exercise (greater than an hour at least), simple sugar is useful, effective and does not come with risks and problems mentioned above. This is also true (although to a lesser extent) immediately before and after exercise.

The problems associated with simple sugars are tied to consuming it when you are at rest (or not exercising). Since your body needs to do something with the energy in the sugar you are consuming when you're not active enough to burn it, your muscles are still full of glycogen and you cannot store it, your blood sugar levels stay elevated longer and the excess is stored as fat.

When we exercise, our bodies use carbohydrates differently. Our muscles use glucose to produce energy and the amount of glucose they transport from our bloodstream into our cells increases, without needing insulin. 

Kipchoge monitors his sugar levels

Since exercise reduces blood glucose levels, insulin secretion decreases and glucagon increases. Glucagon does the opposite of insulin, it helps free glucose from its storage form (glycogen) in muscle cells and the liver to increase blood glucose levels. All that in simple terms means that during exercise the sugar you ingest does not cause your insulin levels to spike.

After a hard, long exercise session (> 60 mins), both muscle and liver glycogen levels are low, there is an opportunity to quickly store sugar (this can be Coca Cola, banana or even prata) as glycogen. This is when you can consume simple sugar (until your glycogen stores are replenished) without the ill effects described above.

So now you know, you do not have to avoid added or simple sugar during exercise and perhaps immediately after a long intense session or race, but that does not mean you should ONLY consume added or simple sugar while exercising. Complex carbohydrates and other real food that contains fiber, fat and protein are all parts of a sound nutrition that our body needs.

So, when added sugar does not serve a useful function (like exercise), and this is usually more than hour before or after exercise, you definitely should be eating real food, without added sugar.


Reference

Burke LM (2004). The IOC Consensus On Sports Nutrition 2003: New Guidelines For Nutrition For Athletes. Int J Sp Nutr Ex Metabolism. 13(4): 549-552. DOI: 10.1123.ijsnem.13.4.549

*Since added sugar is absorbed quickly, our blood sugar levels spike up quickly which leads to insulin being release rapidly to remove sugar from our bloodstream. This can lead to insulin resistance over time where more insulin needs to be produced before sugar is being absorbed. Over time insulin resistance leads to Type II diabetes.

**Other health problems include affecting leptin levels, which affect perception of hunger. When there are lots of leptin in the bloodstream, we feel less hungry. When we have low leptin levels, our brain thinks we are running low on energy and increases our appetite. Consuming too much sugar leads to leptin resistance whereby high leptin levels in the blood does not signal satiety and we either eat more before feeling full or feel hungry soon after finishing a meal.

Sunday, September 5, 2021

Gino Was In A Cycling Accident.. Again!

ECG in progress
This was yesterday. Gino needed an echocardiogram done after his accident. Let's rewind to the start of 4th September 2021.

Gino went for his usual Saturday bike ride with the CycleWorx group. They had completed about 60km when they were cycling along Nicholl Highway towards the city. The roads were empty and they were cycling on the left most lane. So it came as a shock when a motorcyclist rear ended him. Gino recalls that it all happened so quickly. He flew backwards and landed on his back. He got up to see his bicycle on top of the motorcycle and the motorcycle on top of the motorcyclist. His friends called for the ambulance and police.

I received a call from Gino at about 8am. It was words I'm not fond of hearing, "I've been in an accident." I've since learnt from his last cycling accident in 2013 that Gino has a high pain threshold and always says he's ok. When I asked him where it hurt and he said his upper back, I thought, "Oh man! Not his spine again!" He had sustained a fracture in his skull and lower back in 2013.

My dad drove me to the scene of the accident and I was relieved that the ambulance was still there. Gino was on his right side, strapped onto the gurney. He was inhaling painkillers and complaining of upper back pain. He also asked for his muesli bar that was squashed from the impact of the accident in the pocket of his jersey, which was ripped to shreds by the accident. We had to be transported to Tan Tock Seng Hospital. 

It was not a good experience there. Most of the nurses were great but the doctor who received us at Accident & Emergency was less than impressive. To cut a long story short, even after we repeatedly told her that Gino's pain was between thoracic spinal levels 3 to 6, the X-rays were done for the lower thoracic and lumbar spine. We were elated when the doctor reported that there were no fractures, and took her word for it. In hindsight, I'm questioning myself why I did not check the films! We were discharged from A&E and told we could go home. Gino was feeling less pain as he had been given meds.

I am grateful that our friend who I had called after the accident, who's a spine surgeon, called us as we were waiting for our Grab ride home. He was appalled that we had been discharged so quickly after a road traffic accident. He asked to see the X-rays again and only then did we realize that the upper thoracic spine levels had not been captured. We changed our destination to Mount Elizabeth Medical Centre.

As the effects of the meds started wearing off and after the thorough assessment done by Prof Hee, Gino stood up and exclaimed," Oh no! This feels like the same pain I had when I fractured my low back." I know Gino knows his body really well so we proceeded to get him admitted to be assessed more thoroughly with MRI and to be monitored. 

His MRI films showed a wedge compression fracture at thoracic spine level 4. Since it was at that level,  he had to have his heart assessed with an ECG and blood tests plus a CT scan to ensure that all his organs and vessels were not injured and also check that his ribs are intact.

Arrow shows the location of the fracture
CT scans of his thorax turned out to be clear. Phew! There were some abnormalities with his ECG readings so we have to follow up with a cardiologist. We are hoping that it was just the stress from the accident and that it will settle, but we will get his heart checked. 

The fracture in his spine will be treated conservatively, meaning no surgery as that particular thoracic level is well supported by his ribs and connective tissue. We will let the body heal itself. Gino cannot work and cycle for a few months. His surgeon advised him to maybe to stick to the park connectors or the gym when he can start cycling again. I don't know about that!

Aized
His ripped jersey

Happy after being told he can go home

Sunday, August 29, 2021

Locking In Your Knee May Not Mean A Meniscus Tear

Picture from ScienceDirect

A discussion with our three new physios recently revealed that they were taught that whenever a patient has a meniscal tear on MRI with mechanical symptoms it would usually mean surgery is indicated.

Mechanical symptoms are described as 'locking' or 'catching' in the knee joint that is caused by something being trapped or stuck in the knee. They were taught that it can only be removed by surgery. If the mechanical symptoms present with a tear in the meniscus, that is confirmed by MRI, it is usually attributed to the tear. Hence the rationale for surgery to remove the tear.

However, mechanical symptoms in the knee can fluctuate. Other clinicians and patients may have different variations and definitions of such 'locking' and 'catching' in the knee.

I have come across many patients with locked knees (knees that cannot fully straighten or bend), but they are seldom 'locked' all the time. We always match such symptoms in our clinic with a patient's medical or injury history and with objective orthopaedic and functional tests. 

However a study by Thorlund et al (2019) investigated whether unstable meniscal tears are more likely to cause mechanical symptoms compared to other concurrent knee pathologies like articular cartilage damage, ACL tears etc.

A wide range of meniscal tear characteristics like tear pattern, location, size of tear were included in the study. However, no important relationships were found between any of the included factors and patients reported catching or locking in the knee or inability to straighten their knees.

These results question the logic that mechanical symptoms are caused by specific joint pathologies. The authors also compared the frequency of mechanical symptoms between patients with and without a meniscal tear after knee arthroscopy. They found that half of all patients reported catching or locking. They were also unable to straighten their knee fully. However, these mechanical symptoms were equally common among patients with or without a meniscal tear.

This is consistent with my previous post where bucket handle and complex meniscal tears (both of which are commonly operated on) were found in the patient's MRI, but these patients were asymptomatic.

So if you are currently having a 'locked' knee or cannot straighten or bend your knee fully, it does not necessarily mean you need surgery. Two large scale randomized trials referenced below confirm this too. Please come and see us in our clinic for another opinion.


References

Khan M, Evaniew N, Bedi A et al (2014). Arthroscopic Surgery For Degenerative Tears Of The Meniscus: A Systematic Review And Meta-analysis. CMAJ. 186: 1057-1064

Thorlund JB, Juhl CB, Roos EM et al (2015). Arthroscopic Surgery For Degenerative Knee: A Systematic Review And Meta-analysis Of Benefits And Harms. BMJ. 350: h2747

Thorlund JB, Pihl K, Nissen N et al (2019). Conundrum Of Mechanical Knee Symptoms: Signifying Feature Of A Meniscal Tear? BJSM. 53(5): 299-303. DOI: 10.1136/bjsports-2018-09943

Sunday, August 22, 2021

Foot Strengthening To Prevent Running Injuries?


We had a 16 year old patient who came in with footshin and knee pain this week. She had been prescribed orthotics and had been wearing them for the last ten years. Every time she tried running, her knees and shin start to hurt during and the day after her run. Somehow, the orthotics did not seem to help with the pain.

She also mentioned that she wore her running shoes (with orthotics) everywhere she went as she was told that other footwear and slippers were 'bad' for her.

You have read from a previous post that contrary to several long held beliefs, most biomechanical and structural factors are not reliable at predicting running related injuries. Naturally, I was interested when a recent study investigated whether foot muscle strengthening reduced the incidence of injury rates over a one year follow up. Especially since I wrote that my patient (plus myself included) would be bored doing foot strengthening exercises.

Researchers had 118 runners who ran between 20-100 km a week for their study randomized into two groups. The foot muscle strengthening (FMS) group received 8 weeks of 12 foot-ankle exercises done once a week supervised by a physiotherapist and 8 foot-ankle exercises done three times a week at home with remote supervision.

A second control group (CG), did a 5 minute placebo static stretching protocol three times a week with weekly feedback from a physiotherapist. 

After the 8 week intervention, both groups were instructed to continue their respective exercises three times a week until the end of a 12 month follow up while recording their adherence.

The researchers suggestion that a stronger foot will better dissipate excessive and cumulative loads appears supported as foot strength gains were correlated with time to getting injured. 

Altogether, 28 runners ended up with a running related injury, 20 (32.8%) from the CG and 8 (14%) from the FMS group. The results showed that runners in the CG were 2.42 times more likely to suffer a running related injury compared to those in the FMS group. 

The researchers also found that the larger gains in foot strength over the 8 weeks of training correlated with the runners taking a longer time to get injured. They also reported that by the fourth month of follow-up, differences in cumulative running related injury risk were evident between the 2 groups and suggested that 4-8 months of the regime may already be effective.

However, each runners response to foot strength improvement and how this relates to different injury types or sites will require further investigation.

My thoughts are that this foot muscle strengthening regime is exactly the same as wearing the Vibram Five Fingers shoe. Remember them? They were really popular before the thickly cushioned or maximalist shoes became the rage.

In the study, the foot strengthening program takes 20-30 minutes to complete. This time commitment may be a consideration. As a physiotherapist, I should not be writing his, but if I had extra 30 minutes, I'd rather run outside than do foot strengthening exercises. 

I'm just being honest here. There are plenty of demands on my time being a father to 2 young boys, physiotherapist, business owner and trying to find time to exercise. Probably some of you who are also pressed for time would agree.

Back to our patient. I suggested that she remove her orthotics from her running shoes and gradually increase time walking with them first before attempting to run. The toe spring from her shoes and orthotics would lead to her having weaker intrinsic foot muscles and increase her chances of getting pain in her footshin and knees and possibly getting injured.


Reference

Taddei UT, Matias AB and Duarte M (2020). Foot Core Training To Prevent Running-related Injuries: A Survival Analysis Of A Single-blind, Randomized Controlled Trial. AJSM. 48(14): 3610-3619. DOI : 10.1177/0363546520969205.

My own minimalist version of the Vibrams that I use to walk around with and lift weights to strengthen my intrinsic foot muscles. My calfs get too sore when I run with them. My brother bought a few pairs for me when he was working in Shanghai for $RMB 30 (or S$6) , much cheaper than Vibrams ($149-$209 here in Singapore).