Sunday, December 25, 2022

Merry Christmas!

Missing Byron and Aminah
It's that time of the year again where we exchange presents. Here's wishing all our patients and readers a very Merry Christmas!

Sunday, December 18, 2022

Bluetooth Physiotherapists?

I definitely agree with the article (Davidson et al, 2019) that suggests that palpation should be used with caution when diagnosing and defining patient care. As defined by Wikipedia, palpation is the process of using one's hands to check the body, especially while perceiving or diagnosing a disease or illness.

The aim of the published article was to assess how 125 physiotherapists assess muscle stiffness on a 7-point palpation scale generated by a novel device. Measurements of displacement, force and stiffness were recorded.

Physiotherapists always use their hands to palpate muscle tension (or muscle tone), which is commonly known as muscle stiffness, among other assessments. It is then standard practice to base some subsequent treatment on these palpation findings. Of course these assessments can be considered subjective and may vary from one physiotherapist to another. It's accuracy and repeatability will depend on each physiotherapist's skill and experience.

At the same time, there are heated calls within the Physiotherapy profession to stop hands-on manual therapy (or passive physiotherapy treatment) since it creates dependence, low value in care and is not totally evidenced based. Physiotherapists who work in hospitals here in Singapore and elsewhere have practically eliminated this form of 'passive' treatment when treating patients. Physiotherapists who support these views are affectionately called 'bluetooth' (or hands free) physios.

Would a 'bluetooth' physio be able to palpate accurately and consistently compared to another physiotherapist who only uses their hands for assessing and treating? That is probably why the above mentioned research paper concluded that palpation is 'not reliable' to diagnose pathology and develop treatment protocols.

While the physiotherapy community argues whether we should or should not be using hands on manual therapy, the massage therapy, chiropractic, osteopathy, personal training and strength and conditioning professions will be watching us fight online, waiting to take over our patients while we complain that they are practising certain treatments 'beyond' their scope.

Do not complain if you don't want to do it, but just be aware others will. Remember when physiotherapists used to complain about doctors who don't even bother to examine their patients?

If you are a 'bluetooth' physiotherapist and do not want to use your hands to treat your patients, do not criticize another physiotherapist who does it appropriately. Perhaps consider asking yourself what your patients want and need. Patients will vote with their dollars and seek alternative treatment, if their physiotherapist isn't able to solve their problem.

Of course, even perfect palpation skills on it's own may not be enough, since muscle stiffness is just one aspect of the assessment. You have to put together history, mechanism of injury, interpret movement direction, symptom provocation etc to decide treatment selection for your patient. The muscles you are palpating may not even be the cause of the problem even though it is 'stiff'.


Davidson MJ, Nielsen PMF, Taberner AJ et al (2019). Is It Time To Rethink Using Digital Palpation For Assessment Of Muscle Stiffness? Neurourology and Urodynamics. 39(1): 279-285. DOI: 10.1002/nau.24192

From Tiktok
I almost never ever watch Tiktok, but someone sent me a link mocking the exercise a 'bluetooth' physiotherapist teaches. Have a look here. The comments section -- not good for physiotherapists! Still wanna just teach exercises for treatment?

Sunday, December 11, 2022

Can You Get Sicker If You Exercise With A Cold?

My son had a runny nose which worsened to a bad cough almost 3 weeks ago. Then my elder son and wife caught it from him. I was the only one unscathed so far or so I thought. Then I woke up on Monday with a slightly sore throat. Monday mornings I normally lift weights before seeing patients. 

Being a die-hard exercise devotee, there was no way I was going to miss my exercise session. Was that the right decision? Does that mean if you have a runny nose you need to skip your exercise session or could that workout actually do you some good?

In the past, I've always gone by the 'neck' rule. Symptoms above the neck (like a runny nose or low grade headache) means that a light workout usually will not make your cold or ailment worse.

The 'neck' rule was based on research done by Dr Weidner and colleagues. 50 adults that were infected with the common cold virus were randomly split into 2 groups. One group (34 subjects) had subjects do 40 minutes of moderate exercise every other day for 10 days while the other group (16 subjects) did no exercise.

The researchers found no difference in illness length or severity between the 2 groups. This shows that exercising moderately did not prolong or exacerbate their illness.

However, if you have below the neck symptoms like a hacking cough, chest discomfort, nausea, diarrhoea or whole body symptoms like fever, muscle aches or fatigue then it's not a good idea to exercise.

Please bear in mind that symptoms can evolve and what started as a runny nose can worsen to something more serious like the flu or even bronchitis. If your symptoms get worse, it's probably best to have a rest day. Rest till the 'below neck' symtoms go away. Relapse can happen if you try to come back too quickly and push too hard.

In rare cases, exercising intensely when you are sick or shortly after you have recovered can lead to new or lingering symptoms like exhaustion or unexplained pain. Researchers believe this is similar to how people develop long Covid or chronic fatigue syndrome.

If you are a die-hard exercise fanatic, try a brisk 30 minute walk outside or get on the stationary bike or elliptical machine. Lifting weights, like what I did, is probably fine too, just don't attempt to beat your personal best lifts. You will probably feel a psychological boost after exercising if all goes well.

Call it quits if you feel light headed or develop chest tightness or feel too much pain. Ease back slowly to your exercise routine when you're fully recovered before gradually increasing duration and intensity. Research actually shows that moderate exercise even when you're healthy helps to improve your immune response and lower your risk of catching respiratory tract infections.


Pedersen BK and Toft AD. (2000). Effects Of Exercise On Lymphocytes And Cytokines. BJSM. 34: 246-241. DOI: 10.1136/bjsm.34.4.246

Weidner TG, Cranston T, Schurr T et al (1998). The Effect Of Exercise Training on The Severity And Duration of A Viral Upper Respiratory Illness. Med Sci Sp Ex. 30(11): 1578-83. DOI: 10.1016/S0765-1597(99)80059-8

Wednesday, December 7, 2022

We Went Batik Painting

After our last team building session where we learnt pottery, there was a request to do batik painting for the next team building session. That is exactly what we did this time!

We learnt batik painting at Kamal Arts centre from Kamal Dollah (pictured above). He shared with us the history of batik painting, the different types of batik painting and the different ways to paint. 

Kamal actually apologized for telling us all that. But being interested in history, I was impressed by his passion and knowledge. I told him hat it was good he shared that.

Tools of the trade

The wax
Finally after focusing hard, we did it!

Here's us at the exhibition center.

Saturday, December 3, 2022

Shift Work And Pain

I've had some shift workers see me recently. They were on the graveyard shift. Night traders, nurses, hotel staff and security personnel. Some had low back painneck aches, knee and hip pain, you name it, they've got it. 

Shift work means businesses and organizations can be productive 24 hours a day. With the development of artificial lighting, manufacturing, service and retail sectors have used shift work to increase productivity and profitability. It also allows for the provision of continous healthcare and emergency services. 

I found out that the Cold Storage in Holland Village across the road from our clinic pays a monthly rent that is in excess of $200,000 a month. That's probably one of the reasons why they are open 24 hours. To maximise what they already pay for rental.

So I was not surprised to read that shift work, in particular night work is associated with chronic musculoskeletal pain (Matre et al, 2021). The mentioned study had 23,223 subjects which was adjusted for sex, age and education reviewed significant associations between shift work and chronic musculoskeletal pain and chronic pain sites.

It is estimated that 20 percent of the workforce are now shift workers, with 25 to 30 percent of those working nights.

Evidence now shows that working when you're supposed to sleep and rest disrupts your normal physiology. Growing evidence points to the disruption of the circadian clock caused by being awake or active at nigt when we're supposed to sleep.

All living species since evolution, from bacteria, plants to animals have acquired a circadian clock to optimize body processes in an environment that changes throughout the day. We are rhythmically organized to anticipate these daily changes.

Our immune system, muscular system and cognitive performances are higher in the day when the body is also storing nutrients from food. The functions decrease at night when the body starts to use he stored nutrients during this period of fasting. 

Just like a conductor of an orchestra, our central clock in the brain synchronises all the circadian clocks along with environmental light. If these clocks get input from other sources like food or other light sources at night, this synchrony is lost. 

Shift work simulation has been shown to affect the immune system. This contributes a higher risk of infection among shift workers, notably Covid-19.

Circadian disruption is also associated with disturbance of our the autonomous nervous system which controls breathing and our heart beat. This affects the connection between the brain and its surrounding tissues and their proper function.

This contributes globally to weight gain, Type II diabetes, increased blood pressure, compromised immune response and chronic musculoskeletal pain. This lost synchronicity also leads to a increased incidence of breast cancer, faster tumour growth and also exacerbates Alzheimer's disease. This is seen even in cases of low intensity light in the bedroom coming from a TV screen.

What can we do about it? The first step should be to limit rotating shift work as much as possible. It is somewhat possible to adapt to work at the "wrong" time but impossible to adapt to schedules that constantly change.

Some studies showed that bright light increases alertness during the night and helps adaptation to night work by shifting the circadian clock. However, long term impact on health is still unknown.

Controlling and limiting the time during which we eat (e.g. 10 hours during the day and not eating overnight) appears to be beneficial for heart and metabolic health (Sutton et al, 2018). This may be compatible with shift work.

There is probably no optimal solution for this unless we limit shift work to just essential hospital services. This may then help reverse the global trend towards a 24 hour society to decrease shift work for better health. 

Are we able to take that huge step? Especially when most countries are opening up again after Covid-19.


Dun A, Zhao X, Jin X et al (2020). Association Between Night-shift Work And Cancer Risk: Updated Sysyematic Review And Meta-analysis. Front Oncol. 10:1580. DOI: 10.3389/fonc.2020.010006

Manouchehri E, Taghipour A, Ghavami V et al (2021). Might-shift Work Duration And Breast Cancer Risk: An Updated Systematic Review And Meta-analysis. BMC Women's Health. 21: 8. DOI: 10.1186/s12905-021-01233-4

Matre D, Christensen JO, Mork PJ (2021). Shift Work, Inflammation And Musculoskeletal Pain -The Hunt Study. Occu Med (Lond). 71(9): 422-427. DOI: 10.1093/occmed/kqab133. 

Sutton EF, Beyi R, Early KS (2018). Early Time-restricted Feeding Improves Insulin Sensitivity, Blood Pressure, And Oxidative Stress Even Without Weight Loss In Men With Prediabetes. Cell Metab. 27(8): 1212-1221. DOI: 10.1016/j.cmet.2018.04.0