Sunday, June 26, 2022

Does Epsom Salt Work?

A patient came in earlier this week after an ankle sprain. She hadn't noticed that there was bruising all over the ankle joint. She told me that in order to recover quickly, she'd been told (by someone in a local running store) to soak herself in an Epsom salt bath. This reminded me of the patient who had been asked to take magnesium supplements for muscle cramps.

She was told by the very same person that once her body 'absorbs' the Epsom salt, it can reduce muscle sorenessinflammation and swelling.

So, are there any real benefits to soaking in Epsom salt baths? Or are they just old wive's tales?

You need to know that Epsom salt is also known as magnesium sulfate heptahydrate. It is made of magnesium, oxygen and sulphur. 

The proponents say that using Epsom salt in your bathwater helps your body absorb the 'much needed' magnesium to help flush away toxins and harmful heavy metals and help induce relaxation, reduce inflammation and help with muscle and nerve function. 

Getting magnesium directly into the blood intravenously or even orally is different from sitting in a bathtub and hoping the minerals get absorbed. There is only one small experiment done by researchers from the University of Birmingham in 2006 on some of their staff supporting this. 16 out of 19 of the subjects had higher levels of magnesium in their blood and urine after soaking in Epsom salt for an hour each day over 7 days.  

However Grober et al (2017) failed to find any proof of those claims. The authors also pointed out that the Birmingham study was never formally published in a peer review journal. No statistical tests were done and there wasn't a control group.

There is likewise no evidence that magnesium is absorbed through our skin (transdermal), at least not in relevant amounts scientifically.

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.

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. 

My patient was told that Epsom salt baths can reduce muscle soreness and relieve muscle cramps, that both are very important in exercise performance and recovery.

Please note that magnesium only helps when the muscle cramps are preceded by loss of your appetite, vomiting and fatigue. Not the muscle cramps when you're training hard or racing. Those who sell these supplements, probably choose not to mention this or perhaps they do not know the difference. The muscle cramps occur in your facial and masticatory (chewing) muscles too, not just the muscles in your feet and legs. 

Perhaps it is just the warm water (not the magnesium in the Epsom salt) with its capillary dilation which relaxes and relieves pain for those who seem to swear by it. I feel the water feels more silky after adding a big scoop of Epsom salt to it. The salt exofoliates the skin well too. Perhaps that's a better reason to use the Epsom salt?


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.

*Epsom salt was named after a spring in Surrrey, England that was first discovered in the early 1600's. The waters at the spring were thought to have healing powers and people started to believe that bathing in the waters would relieve them of sores and infections. 

Sunday, June 19, 2022

Sip it or Gulp it?

Gulp it
If you have been exercising continuously for over an hour, you know that you have to refuel at some point. Especially if you are participating in a race. Carbohydrate refuelling during a race or a long training session can definitely enhance your exercise performance since there is a limited store of glycogen (carbohydrates) in your liver.

Sip it
The amount of carbohydrates (carbs) in the stomach is one of the main factors that would determine the speed of gastric emptying. A larger volume will empty faster than a smaller volume.*

However, a large volume of carbs in the stomach is not ideal for runners. How many of you runners reading this can drink large volumes of fluid (or eat lots of energy gels) during races and endure the fluids sloshing around in your stomach and intestines

When I was still competing in triathlons, I always took small sips while running past the feed stations. I would mostly eat/ drink on the bike leg of the triathlon as it does tend to sit better in my stomach since there is less movement while I'm cycling

However, a study I read studied whether ingesting carohydrate sports drinks during prolonged running affects exogenous carbohydrate oxidation (sparing liver glycogen, and yet maintain exercise intensity)  and gastrointestinal discomfort. This means that your glycogen stores are not being used as quickly during exercise since whatever you are drinking is being used to fuel your exercise.

The runners studied did two, 100 minutes of steady state runs at moderate intensity. In the first run, the runners consumed 200mL every 20 min while they took 50 mL every 5 min during the second run.

The researchers found that exogenous carbohydrate oxidation rates were 23 percent higher during exercise when larger volumes were ingested every 20 minutes. They concluded that ingesting larger volumes would be better than frequently sipping small amounts since large volumes will stimulate gastric emptying and makes more carbs available for intestinal absorption.

More importantly, there was no difference in gastrointestinal problems whether a larger or smaller amount was ingested while running. The authors indicated that this was also similar to what was observed in earlier studies. They suggested that runners may be able to tolerate more fluids than they think they can during exercise.

Those who are still competing should try and practice ingesting more carhohydrate gels/ drinks in training to make sure you do not get any stomach upsets. This will train your gut to absorb more carbs and help you race faster.


Mears SA, Boxer B, Sheldon D et al (2020). Sports Drink Intake Pattern Affects Exogenous Carbohydrate Oxidation During Running. Med Sci Sports Ex. 52(9): 1976-1982. DOI: 10.1249/MSS.0000000000002334

*This topic has been well studied and recommendations are to consume 30-60 g/hr for exercise/ events lasting between 1 to 2.5 hours. For exercise/ events over 2.5 hours, up to 90g/ hr should be consumed. If more than 60g/ hr needs to be ingested, a combination of carbohydrates (e.g. glucose and fructose) needs to be ingested. 

Here's how I fold the paper cup to sip while running

Saturday, June 11, 2022

Are Cold Drinks Better When You Exercise?

A question I received from one of our blog's readers is whether one can drink cold water or beverage during exercise? He said that he was advised by friends that he should drink room temperature or even warm water/ beverage after exercise as cold drinks are 'too cooling' for the body.

Well, what does research and science tell us? Exercise authorities such as American College of Sports Medicine (ACSM) and the International Society of Sports Nutrition (ISSN) both recommend water and other hydrating drinks be cold when used during exercise (Kerksick et al, 2018). 

There are a few reasons for their suggestions. Our core temperature rises when we exercise and to keep cool, we lose fluids through sweating. Remember a lot of energy is spent regulating and keeping our temperature down when we exercise. Drinking ice water or ice slushie helps keep our core temperature from rising (Hosseinlou et al, 2013). This also prevents excessive water loss through sweating while exercising.

Moreover, cold drinks are definitely more palatable compared to a warm drink and one tends to drink more when cold drinks are available. A meta-analysis found that subjects consumed 50% more cold (0-10 degrees Celsius) or cool (<22 degrees) beverages than a control group (>22 degrees) during exercise (Burdun et al, 2012).

Researchers also found that drinking cold water improved performances in 49% of participants in the broad jump and 51% of participants in a cycling to exhaustion test (LaFata el, 2012).

I don't know about you, I definitely prefer an ice cold drink during and after exercise. However, if you prefer room temperature or even warm water, don't fret. Drinking whatever appeals to you during and after exercise to get adequate hydration is most important.


Burdon CA, Johnson NA, Chapman PG et al (2012). Influence Of Beverage Temperature On Palatability And Fluid Ingestion During Endurance Exercise: A Systematic Review. Int J Sp Nutr Ex Metab. 22(3): 199-211. DOI: 10.1123/ijsnem.22.3.199

Kerksick CM, Wilborn CD, Roberts MD et al (2018). ISSN Exercise & Sports Nutrition Review update: Research & Recommendations. J Int Soc Sp Nutr. 15(1): 38. DOI: 10.1186/s12970-018-0242-y

LaFata D, Carlson- Phillips A, Sims ST et al (2012). The Effect Of A Cold Beverage During An Exercise Session Combining Both Strength And Energy Systems Development Training On Core Temperature And Markers Of Performance. J Int Soc Sp Nutr. 9: 44. DOI: 10.1186/1150-2783-9-44

Sunday, June 5, 2022

Post Competition Blues

Picture by Getty images from Express
I was reading an online newspaper article in the Guardian (it's also in today's Sunday Times) about how Rafael Nadal was asked whether he would sign up for a magical new foot if it meant losing this year's French Open final. 

"I would prefer to lose the final without a doubt, a new foot would allow me to be more happy in my day-to-day life" he added. 

Injury ravaged Nadal fractured his rib about two months ago, so making this final at Roland Garros already seemed like a miracle. He also has chronic left foot ailment, Mueller-Weiss syndrome (osteonecrosis of the navicular bone), but has consistently dug deep to raise his game and win when it mattered.

Nadal knows that winning is lovely and it gives you a real high, but right after that high there is a big low. Life goes on and life is much more important than whatever title, personal record or victory. The term for this is "arrival fallacy", coined by Tal Ben-Shahar (Harvard Psychology lecturer) which refers to the false belief that once you accomplished a particular goal you will attain a sense of lasting gratification.

I was treating national cyclist Luo Yiwei (above) earlier this week, after she won a silver medal at the recent SEA Games in Hanoi. We discussed about how, once the race day euphoria wears off and our hard earned medals begin to collect dust in our display cupboards, we may be wondering if that was all?

This creeping sense of anti climax that you feel after a race that you've spent months preparing for, is often referred to as post race blues. (I recall feeling like this as well after my GCE 'A' levels. I told myself I'll be out celebrating once the exams were done but it instead felt like a big let down).

Post competition blues is not even tied to race performance. If anything, one can be more prone to post race blues after running the race of your life. When you perform badly, it's easier to ask yourself what went wrong and why and how you can train and race better next time. You can console yourself that next time you will do better.

It is generally more common in amateur athletes than in professional athletes. The pros have to decide when they should retire or whether they should continue to try and make a living as an athlete. This answers the 'is that all?' question as to why they keep going since they are still making a living. 

Not true for the competitive amateur runner who may have to put in 100 km training weeks and utimately has little to show for it other than bragging rights, a medal and a higher chance of a running injury.

Some of my patients who are competitive amateurs say the best 'cure' for post race blues is to simply sign up for another event and set new goals and targets. 

I have felt all that before, when training loses its appeal. For those feeling the post competition blues, I will say that you can definitely indulge in some brooding. Even when I've raced well after a big race, there's always a question of what am I going to do (that's definitely before having kids) in the days after without any concern about getting any training done.

It's a strange feeling not having to train since I've set up, planned, prepared and trained for months and years leading to the big race. It has been my entire life, outside my family and friends.

However, I always say to the athletes that I treat that post race glory is fleeting. I have definitely experienced getting slower in my Saturday rides as I age. It's like there is this invisible hand pulling me backwards when I ride with the younger riders.

That's when I realize that I have to shift my focus. I tell myself to become the best physiotherapist I can be, since I can't be the best athlete I can be anymore. 

Find a way to incorporate what you have learned from your marathon, cycling or football training into your daily life. Apply the same organization, focus, structure and goal setting to your everyday tasks. Then you will find that life and running (or other sporting goals you once had) will be just as exciting and fulfilling.

A younger Rafael Nadal and I at the 2008 Beijing Olympics