Growing Taller With The Ilizarov Fixator?

Picture from Quora

A friend fractured his arm after falling asleep while driving in the army. He had a huge circular contraption on his arm upon discharge from the hospital. This was when I first came across the Ilizarov fixator back in the 1990's. Of course I did not know what it was or what it was supposed to do back then.

It was only in my second year of physiotherapy school that I studied about it and saw it in the hospital orthopaedic wards, that I remembered my friend had the same thing on his arm. I never imagined that knowledge learnt all those years ago would help me write today's post.

The surgery was first invented by Russian doctor Gavriil Ilizarov to treat bone fractures that did not heal well. Especially those with fractures that did not grow back (non-union), those that had leg length discrepancies after breaking their legs and complex factures. The method and first prototype he designed was actually inspired by a shaft bow harness on a horse carriage using parts of a bicycle.

Picture by Troika Akron

The Ilizarov fixator is a ring-like brace that has a frame applied to the outside of the limb and connected through the unbroken part of the bone inside the limb via Kirschner or K wires. This provides more structural support than other external fixators and allows for early weight bearing.

Pic by Ahmad Zamani 

Many people around the world, obsessed with growing taller, are now resorting to using the Ilizarov fixator to extend their legs in a bid to make themselves taller. These people want to get ahead since they assume that by being taller they may get better chances in job interviews, modelling assignments, showbiz, colleges and even spouses.

You can get the procedure done in the USA, UK, Germany, Pain, Turkey, Italy, South Korea, India and China. Prices range from $USD 75,000-280,000 in the USA, 50,000-56,000 pounds in the UK to $USD 25,000 in India.

For the procedure, the leg bones are first broken in two, holes are then drilled into the bone.  A metal rod is fitted inside and held in place by a number of screws and wires. This rod is slowly and gradually lengthened by up to 1 mm a day. This continues until the patient reaches their desired height and their bones are then allowed to heal.

Several months of daily physiotherapy/ rehabilitation are then required to regain mobility. Yes, the patient has to learn how to walk again. If not done carefully, there are many complications like nerve injuries (since nerves have to stretch to match the lengthened limbs), blood clots and even the possibility of the bones not fusing back together. 

At times, the bones fuse but are not strong enough to bear the patient's body weight. Limbs can also end up being of different lengths, and shape, deforming knee and ankle joints.

Having surgery to grow taller is seen as cosmetic surgery, but there's no doubt it's also done for their self confidence and mental health. My main concern is the patients that prioritize cost over their own welfare. In my opinion, it is important to find a surgeon with a good track record no matter what surgery you may be considering.

References

Borzunov DY, KolChin S and Malkova TA (2020). Role Of The Non-free Bone Plasty In The Management Of Long Bone Defects And Non-union: Problems solved and Unsolved. World J Ortho. 11(6): 304-318. DOI: 10.5312/wjo.v11.i6.304.

Gubin AV, Borzunov DY and Malkova TA (2013). The Ilizarov Paradigm: Thirty Years With The Ilizarov Method, Current Concerns And Future Research. Int Orthop. 37(8): 1533-1539. DOI: 10.1007/s00264-013-1935-0.

Before vs after by Dr S R Rozbrusch from BBC

Instead Of Complaining About Wearing Face Masks..

He wore a mask, I didn't - posed lah ;) 

Almost daily during the circuit breaker (CB) period last year, my older boy and I went out to ride our bikes since there were hardly any cars on the road.  Most of the time we had our cloth face masks on. Needless to say, we found riding uphill more difficult when having them on. 

Made it to the top of Mt. Faber

Newly published research backs this up. Researchers had 28 young (18 to 29 years) and healthy participants perform 2 maximal exercise tests on a treadmill. One with and one without a cloth face mask.

Each participant runs to complete exhaustion as the treadmill speed and incline is increased every 3 minutes and the time to exhaustion is recorded. This is used to estimate VO2 max levels. Heart rate, blood pressure, rate of perceived exertion and the participant's perceptions of wearing a face mask while running were also recorded.

Key findings were that cloth face masks reduced run time to exhaustion by 14 percent and VO2 max by 29 percent. With masks on, the participants felt more short of breath and claustrophobic at higher exercise intensities compared to not wearing masks. Blood oxygenation levels (Sp O2 levels) were also lower when cloth face masks were worn. The reduced levels of oxygen in the blood show a definite physiological effect. 

The more effective the mask in filtration capacity (the more protection for the wearer), the more it will affect exercise performance. Take home message is that using a mask during exercise does make it a lot harder. The researchers recommend that exercise time, frequency and especially intensity be modified when wearing a cloth face mask.

The researchers also cautioned that their findings of impaired performance with cloth face masks may be in part due to the perceived discomfort. Meaning, the participants were less motivated to keep running at higher treadmill speed and incline. 

My racing days are long gone, but if I were still training and competing, I'll probably don a cloth face mask while training (sometimes) to up the intensity a few notches so that when I race without a cloth face mask, I'll be hard to beat. That's just like respiratory muscle training. But that is just me. Please do not take this as training advice! 

Reference

Driver S, Reynolds M, Brown K et al (2021). Effects Of Wearing A Cloth Face Mask On Performance, Physiological And Perceptual Responses During a Graded Treadmill Running Exercise Test. BJSM. epub first 13 April 2021. DOI: 10.1136/bjsports-2020-103758.

Does Dynamic Stretches Help Running Performance?

Our new physios doing the dynamic stretches

Previously I had written that performing any static stretches before exercise or competition can be detrimental to your athletic performance. Studies have also shown that doing static stretches before competing or exercising is more likely to cause an injury. In fact, performing just one static stretch of 30 seconds can reduce your maximum strength.

Meanwhile, fitness professionals, coaches and other studies have suggested performing dynamic stretches as an alternative warm up to static stretches instead.

Well, this published study had runners do both. An initial assessment was done to get the runners VO2 max levels. The researchers had a group of well trained university runners do a general warm up (GWU) on one day versus doing a general warmup (GWU) plus dynamic stretching (DS) before getting them to run until exhaustion on a treadmill on another day.

The GWU consisted of running on the treadmill at a speed equivalent to 70 percent of each runner's VO2 max for 15 minutes. Each runner then did a standing rest for 5 minutes. This was followed by the run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

When doing the GWU plus DS, dynamic stretches were done for all the lower limb muscle groups (10 reps each), see picture below. That took 3 min 45 seconds in all. After resting for 1 min 15 seconds, the runners started their run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

Well, this published study had runners do both. An initial assessment was done to get the runners VO2 max levels. The researchers had a group of well trained university runners do a general warm up (GWU) on one day versus doing a general warmup (GWU) plus dynamic stretching (DS) before getting them to run until exhaustion on a treadmill on another day.

The GWU consisted of running on the treadmill at a speed equivalent to 70 percent of each runner's VO2 max for 15 minutes. Each runner then did a standing rest for 5 minutes. This was followed by the run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

When doing the GWU plus DS, dynamic stretches were done for all the lower limb muscle groups (10 reps each), see picture at the top. That took 3 min 45 seconds in all. After resting for 1 min 15 seconds, the runners started their run to exhaustion on the treadmill at a speed equivalent to 90 percent of their VO2 max. 

The results showed that the GWU plus DS group lasted significantly shorter (10:40 min)  than the group that just did the GWU (12:40 min). Distance covered was between 2.3 to 5.4 km.

The authors of this study were hypothesizing that performing GWU plus DS may help improve endurance running performance. Unfortunately the results indicated otherwise. 

Another study by the first 3 authors (Yamaguchi et al, 2015) showed that performing the same five DS (10 reps) followed by a rest period of 1 min 23 secs actually prolonged the run time to exhaustion (an extra 18.2 percent) compared to a sit down rest. Run to exhaustion on the treadmill was also done at a speed equivalent to 90 percent of their VO2 max.

What is good about this study was that there was real attention to detail. The testing was done during the off season for the runners so no prior vigorous training was done. The runners were also asked to avoid performing intense exercises or training on each test day and the day prior. 

The runners were also instructed to have similar meals and drinks on the test days and previous day and to finish any meal 2 hours before running. Runners were also asked to avoid alcohol the day before running and caffeine on the test day. Each runner wore the same attire for the test runs and performed the test at the same time of day in consideration to circadian rhythm. The laboratory temperature was kept constant at 20-24 degrees Celsius throughout. In short, the authors tried to keep everything else constant other than the warm up. 

What wasn't as good? Bear in mind that the study only had 8 runners. They are definitely fast runners (looking at their profile), but the sample size is small. The rest period after the dynamic warmup was also extremely short (150 seconds). Fatigue after the DS was attributed by the authors as the cause for worse performance.

When I was competing in events like 1500m - 5000m on the track, I'll do a rather languid jog of 2-3 km to warm up followed by some limbering movements to loosen up. This was followed by repeating some striding (or goal pace running) 5-8 times for 150-200 meters. Then it would be resting and waiting for our event to start. Definitely longer than 1 minute 15 seconds before racing. Definitely did not do any sort of stretching then.

My advice would be to try out dynamic stretches or whatever that is new (shoes, bike, run technique etc) in your off season, not before an important competition, to see if it would be something that might work for your body. Most importantly, do what works for you. Every body is different.

References

Yamaguchi T, Takizawab K, Keisuke S. (2015). Acute Effect Of Dynamic Stretching On Endurance Running Performance In Well-trained Male Runners. J Strg Cond Resc. 29: 3045-3052. DOI:10.1519/JSC.0000000000000969

Yamaguchi T, Takizawab K, Keisuke S et al (2019). Effect Of General Warm-up plus Dynamic Stretching On Endurance Performance In Well-trained Runners. Res Quart Ex and Sport. 90(4): 527-533. DOI: 10.1080/02701367.2019.1630700.

*thanks to Thiviyan and Rashid Aziz for getting me the articles

Am I Crazy To Feel Pain In My Knee When My Scans Are Normal?

My patient came in yesterday saying that his knee started clicking even though he didn't feel any pain with the clicking. There were occasional twinges of pain only occasionally. However, he was worried that his knee will get worse. After assessing his knee (which turned out fine) and reassuring him, I told him my own experiences.

After I had my third knee operation (within the space of a year), my right knee started feeling better. Of course I started training again as soon as the surgeon permitted. For a start, I ran almost exclusively on grass (since it was the softest surface I could find), often going multiple rounds, to ensure that I can get my mileage since I was hoping to compete again after my injuries.  

However, I was much more sensitive about my right knee, to the point of being paranoid about every sensation I felt in the knee. Each time I was on the bus or MRT and if someone came close to my right knee, I'd move away and glare at the person for coming too close to me. Does this sound like you?

Well, it turns out this action of pain sensitization is common across other painful knee disorders as well. In patients with knee osteoarthritis, pressure from placing your hands on the knees alone can trigger pain. The good news is that this sensitization for painful knees can be treated.

The following systematic review investigated 52 studies that studied pain sensitization across four different painful knee disorders. The authors found evidence of pain sensitization in people with knee osteoarthritis, patellofemoral pain and post meniscectomy patients. They however found conflicting evidence in patients with patella tendinopathy.

The researchers found that the extent of structural joint damage in the observed knee disorders does not correlate to the severity of symptoms. Hence, pain is not necessarily a 'signal' from a joint or area that is damaged.  Meaning x-rays or MRI results does not correlate with pain. Some patients have no 'damage' on x-ray/ MRI but have a lot of pain, while others with lots of damage on film may have no pain.

Many factors play a role to determine if a person will perceive a stimulus as painful or not since pain can be a complex experience that is associated with memories, belief and social context. Anxiety, depression, fear of movement, viewing their condition considerably worse than it actually is may also play a part.

It is suggested that repetitive stimulation may lead to subsequent sensitization of the nervous system. This include loading of the knee joint, ongoing inflammation at the knee joint or related tissues and altered biochemical markers. These factors contribute and maintain the pain sensitization in the knees.

In patients with knee osteoarthritis and patellofemoral joint pain, pain sensitization can be treated through exercise therapy, mobilization, pharmacological (yes, painkillers) and surgical intervention. Correct exercise is recommended for treatment of painful knees. There is the incorrect belief that exercise may harm the joint cartilage in patients with osteoarthritis.

If doctors, surgeons and physiotherapists focus less on x-rays/ MRI's and more on factors (including psychosocial factors mentioned above) relating to each patient's pain and disability, there will be more opportunities for collaboration and improved treatment outcomes.

Reference

De Oliveira Silva D, Rathleff MS, Petersen K et al (2019). Manifestations Of Pain Sensitization Across Different Painful Knee Disorders: A Systematic Review Including Meta-analysis And Metaregression. Pain Med. 20(2): 335-358. DOI: 10.1093/pm/pny177.

Stationary Cycling Just As Good As Pilates For Chronic Low Back Pain?

The Pilates instructors reading this post along with those of you who do Pilates aren't gonna like me a lot, not with a heading like the one above. But before you get upset, please let me be clear, I have nothing against anyone doing Pilates or any Pilates instructors. I'm just sharing what I read from a published study.

This study compared the effects of specific trunk exercises (or Pilates) versus stationary cycling on subjects with chronic non specific low back pain. 

One group was randomized to undergo specific trunk exercises (SEG) for 8 weeks while the other group did stationary cycling (CEG). The SEG group performed Pilates with attention to muscle control, posture and breathing. 

THE CEG group were informed that they were performing a style of cycling called Pilates Pedal. This is to reduce bias so that their group will not wonder why their exercise program did not include trunk specific exercises. Look at the diagram below, you will see that the CEG group just did a mixture of mixed resistance cycling and no core exercises.

Pain was reduced in both groups after exercises compared to the start of the study. Even though disability was significantly lower in the SEG group compared to the CEG group after 8 weeks, the overall data pattern suggested no long term differences between both groups 6 months later.

Fear-avoidance beliefs (FAB) or activity avoidance behavior scores were lower in the SEG group at 8 weeks only, the CEG group had lower FAB scores at 6 months.

The authors concluded that an 8-week supervised group of Pilates had only better short term but not long term clinically meaningful improvements compared to stationary bike cycling.  

If a patient with chronic non specific low back pain stick to either Pilates or stationary cycling (or any exercise program  for that matter), similar improvements will be achieved as long as a minimal level of adherence is maintained.

If you look in detail at the baseline scores for pain and disability, you will notice they were mild to moderate. Hence, results from this study may not be transferable to those with severe back pain and disability.

Pilates or stationary bike cycling (or any general exercise), your choice really, as along as you stick to it, will help with your recurrent low back pain. Find exercises you enjoy and keep at it.

Reference

Marshall PWM, Kennedy S, Brooks C et al (2013). Pilates Exercise Or Stationary Cycling For Chronic Nonspecific Low Back Pain. Does It Matter? A Randomized Controlled Trial With 6-Month Follow-up. Spine. 38(15): 952-959. DOI: 10.1097/BRS.0b013e318297c1c5.

*thanks to Byron Tan who got me the article. Email me if you like to have a look at the article