The Power Of Rereading Your Old Books

Picture by Tom Morris

I have always like reading. The Five Find Outers, The Famous Five, Moonface and The Faraway Tree  by Enid Blyton were my favorites when I was growing up. 

When competing in cross country/ track and field and triathlon, I pored over race reports, scientific articles on training, and sports biographies to help my athletic performance.

I also have this habit of rereading the books I like. Some books I've even reread a few times. I've realized that the older and wiser version of myself reads, analyses and understands things differently (and better) than the younger me.

The same applies to treatment and rehabilitation. Everyone seems enarmored with new treatment strategies, answers and solutions. Always looking for the latest flavor of the month.

Of course I do keep up with the latest updates. But do they always work better? Perhaps if we reread our older books/ articles we can better understand things we have have tried, considered or perhaps even ignored previously. You may find that most of the answers are already there. 

My family and I are currently away traveling, hence the short post this week. I am taking the time to read both old and new books. I love the feeling of paper between my fingers.

Have a safe holiday if you are traveling.

Anterior Pelvic Tilt

Picture of APT on the left by Oliver Ludwig

I had a patient come in this week saying he was told by another physiotherapist that he had an anterior pelvic tilt (APT) that was causing his low back pain. 

He was told that his poor posture while sitting for long hours caused it. Sitting for long hours is often thought to shorten the hip flexors while also weakening the core. There is no evidence that prolonged sitting causes APT. Some correlations were reported but lack consistency between left and right sides (Elliot et al, 2021).

However, even after being 'corrected' for his APT, his low back pain did not go away.

Many people will present in our clinic with a pelvic tilt. An article from Manual Therapy found that 85 percent of males and 75 percent of females (from 120 subjects) presented with an APT without any pain or disability. 6 percent of males and 7 percent of females presented with a posterior pelvic tilt without pain or disability too. So is APT really a dysfunction or is it normal?

There are also no agreement or guidelines as to what is too much or too little pelvic tilt. Moreover there is also no reliability between health professionals in clinical testing while assessing if a patient has APT (Preece et al, 2008). One health professional will assess you and say you have an APT while another may say otherwise.

APT is also not related to low back pain. Have a look at this systematic review by Chun et al (2017). In fact, patients that have low back pain had more 'neutral' pelvic (or hip) positions.

For those of you who have been told, APT is also not related to hip flexor tightness (Elliot et al, 2017) or a weak core (Walker et al, 1987). Neither does your hamstrings length or flexibility affect APT (Li et al, 1996).

So do not worry if someone or a health professional tells you that you have an anterior or posterior pelvic tilt for that matter. It may be changeable and may help reduce pain and/ or symptoms. It is not something that you need to be overly focused on. Treating the cause of the problem is much better than just treating the symptoms.

References

Boukabache A, Preece SJ, Brookes N et al (2021). Prolonged Sitting And Physical Inactivity Are Associated With Limited Hip Extension: A Cross-sectional Study. Musculosk Sci Pract. 51: 102282. DOI: 10.1016/j.musksp.2020.102282

Preece SJ, Willan P, Nester CJ et al (2008). Variation In Pelvic Morphology May Prevent The Identification Of Anterior Pelvic Tilt. J Manual Manip Therapy. 16(2): 113-117. DOI: 10.1179/106698108790818459. 

14 Day Lag Period Between Sleep Deficit And New Injury

Picture by Jeffrey Bown from his book Goodnight Darth Vader

Well, it's that time of the year again, where school has ended (for Singapore schools) and work in the office starts to wind down. Many of our patients are already traveling before the Christmas holiday.

Many of us, in this last month of the year, will experience less sleep due to travel, parties, family, children and shift work.

Though we would love to catch up with sleep when sleep is disturbed, even with training/ exercising taking a lower priority, it becomes more difficult with all the committments.

I often tell my patients (who are still training seriously) that there is up to 51 percent increased risk of injury especially for endurance athletes who get less than 7 hours of sleep per day in the last 2 weeks (Johnson et al, 2020).

The study recruited runners, triathletes, swimmers, cyclists and rowers. Subjective health complaints (SHCs) like psychological/ lifestyle factors, cardiorespiratory and gastrointestinal problems to investigated to see if they were associated with sleep quality, training load and new injury episodes.

Applying a 7 day and 14 day lag period, a shared frailty model was used to investigate new injury risk associations with total SHCs and sleep quality.

The investigators found that 7 day lag psychological/ lifestyle SHCs were significantly associated with new injury risk. This was in contrast to cardiorespiratory and gastrointesinal SHCs were not significantly associated with new injury risk. 

New injury risk had a significant increased association with a 14 day lag if there was less than 7 hours of sleep per day. There was no significant association with total SHCs, sleep quantity and training load factors.

The authors concluded that athletes need to be aware of the lag period between low sleep quality and its subsequent impact on new injury risk. In order to minimise the risk of new injuries, psychological/ lifestyle SHCs and sleep quantity should be considered.

Be mindful. Bear in mind that this end year period may be a time when we are most susceptible to new injury if we are deprived of sleep.

Reference

Johnston R, Cahalan R, Bonnett L et al (2020). General Health Complaints And Sleep Associated With New Injury Within An Endurance Sporting Population. J Sci Med Sport. 23(3): 252-257. DOI: 10.1016/j.jsams.2019.10.013

Physical Activity And Life Expectancy

Earlier this month, I came across an older article (Janssen et al, 2013) about how leisure time physical activity is associated with increases in longevity. Men are expected to gain up to 2.6 hours of life with each hour of moderate activity and 5.4 hours of life per hour of vigorous activity.

Women are estimated to gain up to 5.6 hours of life per hour of moderate activity and 11.3 hours of life for every hour of vigorous activity!

Just last night I saw another article that was published just 2 weeks ago by Veerman et al (2024). The authors investigated how physical activity (PA) levels were associated with mortality rates. Whether low PA reduces life expectancy and how much life expectancy could be improved by increasing PA levels.

Ready for the results? For individuals in the lowest activity quartile, the greatest gain in lifetime per hour of walking would gain them an extra 6.3 hours with each additional hour of walking.

If all individuals were just as active as the top 25 percent of the population, those above 40 would live an extra 5.3 years.

Picture from Veerman et al (2024)

The  authors concluded that higher PA levels will provide a substantial increase in overall population life expectancy. 

So you know what you need to do if you want to live longer.

References

Janssen I, Carson V, Lee IM et al 92013). Years Of Life Gained Due To Leisure-time Physical Activity In The US. Am J Prev Med. 4491): 23-29. DOI: 10.1016/j.amepre.2012.09.056

Veerman L, Tarp J, Wijaya R  et al (2024). Physical Activity And Life Expectancy: A Life-table Anaylysis. BJSM. DOI: 10.1136/bjsports-2024-108125.

Do You Have More Slow Or Fast Twitch Muscle Fibers?

Picture from Bodyworksprime

I always knew I had some decent fast twitch muscle fibers in me. How do I know you may ask? I could always sprint at the end of a race. That's how I won most of the track races I took part in while competing in school competitions. My strategy was always to sit and wait off the leader's shoulder until the last 80-100 m and outkick whoever was there.

So I was very surprised when a newly published paper (Lievens et al, 2024) suggested that only 50 percent of elite coaches and sports scientists (out of > 400) actually know whether their athletes have slow-twitch or fast-twitch muscle fibers. Yet 90 percent of them believe that knowing the dominant muscle fiber type of an athlete is useful for optimizing training and performance.

Humans on average have a roughly 50-50 mix of slow and fast twitch fibers. There can be a huge variation around this average as some people can be mostly slow-twitch while others can be mostly fast-twitch. I have written in more detail about the 3 different types of muscle fibers we have. 

Here is a quick recap. Type I or slow twitch muscle fibers which are the smallest and produce the least amount of forces, but once trained can go all day long without fatiguing. They also help to hold and stabilize our posture.

Type II or fast twitch muscle fibers which are further divided into Type IIa and Type IIx (also known as IIb). These are larger muscle fibers and produce a greater and quicker force (than type I), but have less mitochondria, myoglobin and capillaries (compared to Type I) and are prone to fatigue quicker.

Type IIa (also known as intermediate muscle fibers) is a mixture of Type I and IIx fibers. They use both aerobic and anaerobic energy systems and fatigue slower than Type IIx. Proper training of Type IIa fibers will increase their ability to utilize aerobic energy, translating to greater endurance.

Type IIx are the largest muscle fibers and produces the most forces but are inefficient and fatigue quickly as it has low oxidative capacity and relies on anaerobic energy.

If you have read this far, you may already know more about muscle fibers than 50 percent of the coaches in the article above.

Studies have shown that those with more fast-twitch muscles have a faster last lap sprint in the 1500 m while those with more slow-twitch fibers generally do better in races when they are more evenly paced.

Another study (Swinnen et al, 2024) showed that those with slow-twitch fibers tend to have better running economy (use less energy at a given pace) since slow-twitch fibers uses less energy than fast-twitch fibers. 

The gold standard to know your fiber type is a muscle biopsy which means taking a small piece of your muscle for analysis. It is a really painful process plus who wants to give away hard earned muscle?

That is probably why the coaches surveyed in the Lievens et al (2024) study said they do not know their athletes' fiber type, especially if they coach middle distance, team sport athletes or recreational athletes who were not active previously. 

Coaches in the Lievens (2024) study relied heavily on how high you can jump (or how long you stay in the air). It is a decent proxy for fast twitch muscle fiber testing. Men with a vertical jump in excess of 50 cm (20 inches) and women 35 cm (14 inches) have predominantly more fast-twitch fibers.

Another study found that fast-twitchers can usually do 5-8 reps at a given load (80 max in the study), while slow-twitchers did 11-15 reps. About a third in the study group did 9-10 reps and they had an even mix of fast and slow twitch fibers. Those with more fast-twitch fibers tend to be stronger but note that they fatigue more quickly too.

This has implications for strength training since the 1-rep max calculations used to find how many reps to do at a lower weight will be different for fast versus slow twitch fiber types. Slow twitchers need to do more reps to get a comparable stimulus.

Perhaps a good estimate is how you fare over long versus short distances. Note that it will be affected by factors like how you have trained. This is definitely worth considering when you are deciding what races to compete in or how many reps to do while lifting. 

What muscle fibers you have is not destiny and does not have to determine your athletic goals. It may tell you the best way to get there.

Reference

Lievens E, Van de Casteele F, De Block F et al (02024). Estimating Muscle Fiber-Type Composition In Elite Athletes: A Survey On Current Practices And Perceived Merit. Int J Sp Physiol Perform. 19(11): 1197-1208. DOI: 10.1123/ijspp.2024-0043

Our Team Building Event

Guess what we did for our team building event? What do you see? Get the answer here.

Cardio Before Or After You Lift Weights?

Picture from Diamondback Fitness

Last week's post was about weekend warriors, who did not have enough time to exercise during weekdays. My patient who read that post was asking me if she should lift weights or do cardio first if she wanted to do both back to back. I told her it depends on her athletic goals and how much time she can spare working out. 

So should you lift weights first or cardio (or aerobic training) first?

I suggested weight training first followed by cardio (or aerobic exercises). Weight training involves external loading with barbells, weights, kettlebells and resistance bands and has a more acute injury risk if already tired. Especially after a longer aerobic session, your muscles are fatigued and lifting weights after that will elevate your injury risk.

One would usually not be able to lift as much or perform that many reps compared to starting with strength training. Especially if you decide to lift heavier weights.You will definitely do a better job if your muscles are fresh.

Note that if you lift weights before your aerobic exercise it will also inhibit your aerobic performance. Research shows that there will be a reduction in speed, power and stamina. 

Actually when I used to race triathlons, I would often do weight training and then cycle and/ or run after (brick training). I'll be fatigued after the weight training which is the state I would be in after swimming and cycling before attempting the run section anyway. So that made sense for me to always run when I'm already tired to simulate race conditions. 

Lifting weights prior to aerobic exercise will not significantly increase your risk of injury compared to tackling heavy weights when you are already tired. Do aerobic training and weight training on different days to optimize both if you have time. If you are thinking of doing both, go with weight training first.

An exception to the rule for this would be the warm up. Warming up with a bit of light cardio (stationary bike or elliptical etc) prior to weight training (or any other workout) will help prime your muscles, increase blood flow, get your mental focus and nervous system ready for action. 

You can work both strength and cardio simultanesously in the same workout when you perform circuit training or HIIT as it is now commonly called. By minimizing your rest time and prioritizing your work efforts, your heart rate remains elevated while working your muscles to simulate hypertrophy. 

You do get the best of both worlds, burning calories and endurance boosting of aerobic conditioning and the muscle building and power from strength training. Just do not do them every day as your body will not have time to recover sufficiently between sessions.

Reference

Conceicao M, Cadore EL, Gonzalez-Izal M et al (2014). Strength Training Prior To Endurance Exercise: Impact On Neuromuscular System, Endurance Performance And Cardiorespiratory Responses. J Hum Kinet. 30(44) : 171-181. DOI: 10.2478/hukin-2014-0123

Are You A Weekend Warrior?

Picure from DetailingWiki

My patient and his wife were asking me about my exercise routine and they were surprised when I told them that I still exercise 6 days a week, with one total rest day. 

I'm guessing they do not know about my training routine when I was still competing. They were saying that they found it really difficult to exercise during the weekdays. They ususally only found time on the weekend to exercise.

I told them to fret not as fitting in their exercise on weekends will still reap significant health and survival benefits as well as help their brain health.

Findings from an earlier large study (64,000 subjects) showed that people who pack all of their exercise into 1 or 2 days of the week (often referred to as weekend warriors) appear to lower their risk of dying about as much as people who exercised 3 times a week or more (O' Donovan et al, 2017).

Another recent study (August 2024) showed that a weekend warrior who met physical activity guidelines had similarly lower risks of dementia, stroke, Parkinson's disease, depressive disorders and anxiety compared to a more regular activity pattern (Min et al, 2024). Physical activity guidelines are mor than 150 minutes of moderate intensity exercise per week. 

This study by Min et al (2024) included 75, 629 participants. Their findings highlight that this is an alternative for those who are unable to exercise more regularly during the week days. 

Go and be active whenever you can

For those of you are are struggling to fit in any exercise during the week, remember that any activity is worthwhile, even if it is just on the weekend.

References

Min J, Cao Z, Duan T et al (2024). Accelerometer-Derived "Weekend Warrior" Physical Activity pattern And Brain Health. Nat Aging. 4: 1394-1402. DOI: 10.1038/s43587-024-00688-y

O' Donovan G, Lee I, Hamer M et al (2017).Association Of "Weekend Warrior" And Other Time Physical Activity Patterns With Risks For All-cause, Cardiovascular Disease, And Cancer Mortality. JAMA Int Med.177(3): 335-342. DOI: 10.1001/jamainternmed.2016.8014

New Study Does Not Recommend Standing Desks

Picture from CMD

I have written previously on the ill effects of sitting and prolonged sitting. This has also led to the phrase that "sitting is the new smoking". Which subsequently led to standing desks as a 'trendy' option to offer a way to reduce sitting time.

Previously, some of my patients have also asked me to write a memo for them so they can get  their company to pay for a standing desk at work, while other patients have simply asked for my opinion.

My take on standing desks then? I've seen many of my patients go straight from sitting to a standing desk get different problems. Being unaccustomed on their feet all day long posed new risks. It can inhibit proper circulation and add additional pressure to your legs, hips and lower back. Sort of like jumping from the frying pan into the fire if you ask me.

My suggestions for these patients was not to switch to a standing desk for the full work day, especially if they have been sitting all day immediately. To make sure they gradually phase it in.

Like previous ergonomic chairs, desks etc, there hasn't been much evidence supporting the benefits of standing desks. The earlier limited studies did not comprehensively assess long term health consequences.

In a newly published study this month (Ahmadi et al, 2024), 83, 013 participants wore devices for up to 7 years to track their sitting, standing and physical activities. This was more accurate and objective than self reporting by subjects. The researchers found that sitting for more than 10 hours a day was associated with a higher risk of heart disease and stroke.

The researchers also found that standing more did not mitigate this risk of stroke and heart disease. In fact standing for extended periods was linked to a increased risk of circulatory problems. This suggested that simply changing from stationary sitting to standing will not solve the problem since our bodies respond better to movement rather than staying in static positions. Remember motion is lotion.

Workplace interventions that promote movement found that office workers who reduce sitting time by adding light walking and standing had improvements in blood sugar levels.

So, walk to your colleague to talk to them instead of calling or emailing, take the stairs often instead of elevators, walking to the pantry etc all contribute. Better still if you can do 10 bodyweight squats every 45 minutes. All these can make a significant difference.

Reference

Ahmadi MN, Coenen P, Straker L et al (2024). Device-measured Stationary Behaviour And Cardiovascular And Orthostatic Circulatory Disease Incidence.  Int J Epidemiol. 53(60: dyae136. DOI: 10.1093/ije/dyae136

*Note that the study's large population use and the use of devices to measure objective data strengthen the findings. However, observational studies may not totally establish cause and effect. Also since the average age of the subjects was about 61 years, it may not totally apply to younger popuplations.

Single Leg Versus Double Leg Training

L leg bigger

We see many cases where patients have one limb bigger than the other in our clinics. There is an imbalance or deficit between limbs e.g. healthy versus injured, left versus right or dominant versus non dominant. This is also known as interlimb asymmetry in research. 

Strength, power, reactive strength have been shown to be affected when there were interlimb asymetries, especially in sporting performances. I have seen differences of 10-15 percent in deficits for patients even 5 years after they had surgery. Hence, I often suggest that patients work on single limb exercises to reduce this deficit/ asymmetry.

Single leg and double leg strength exercises, plyometrics, balance and even core training have been investigated in a wide variety of athletic populations to understand the effects of interlimb asymmetry. The following systematic analysis was to examine if training interventions are effective in reducing interlimb asymmetries and which types of interventions were more effective in the athletic population.

The single leg counter movement jump (SLCMJ), single leg broad jump (SLBJ), single leg lateral jump (SLLJ) and change of direction (COD) speed were the most commonly used test to check for sprint performance, jump height and COD speed.

Ready for the results? The review suggested that all training interventions have a small to moderate effects on the reduction of asymetry in SLBJ, SLCMJ and COD speed from pre to post training, although no statistically significant differences were reported. This was found in the intervention groups versus the control groups.      

The researchers suggested both unilateral and bilateral training should be considered to decrease interlimb asymmetries. If you're an athlete and have any limb asymmetries and no pain, then definitely do both single and double leg exercises to reduce the asymmetry. 

Please note that the above study was done on athletic populations. I will definitely avoid single leg exercises in the recently injured/ immediate post surgery patients and get them to do bilateral leg exercises first.

What about patients who are not loading equally a year (or longer) after a knee replacement or ACL reconstruction? I always see patients who tend to compensate too much with the non injured/ painful leg. By doing single leg exercises (pictured above), I can make their weaker side work harder.

Reference

Bettariga F,Turner A, Maloney S et al (2021). The Effects Of Training Interventions On Interlimb Asymmetries: A Systematic Review With Meta-Analysis. Strength Cond J. DOI: 10.1519/SSC.0000000000000701

Your Workout Today May Trigger A bright Idea Next Week

Picture from Triana et al (2024)

What if I told you your exercise session today can trigger a bright idea next week? That's exactly what a recent study by Finnish researchers found. They tracked a person's brain and behavioural activity for 5 months using brain scans and data from smart phones and wearable devices. 

This research (Trinan et al, 2024) was unusual since few brain scan studies involve such detailed monitoring over months. Using wearable technology in this study was crucial, especially since brain scans (while being useful) only shows the subject lying still for 30 minutes. 

2 distinct patterns were identified by the researchers. A short term wave that lasted under 7 days and a long term wave by up to 15 days. The short term wave reflects rapid adaptations like how focus is affected by poor sleep although it recovers quickly. The long term wave suggests more gradual, lasting effects, especially in areas tied to our attention and memory.

The study found that our brains do not respond to our activities of daily living in immediate, isolated bursts. Our brain activity evolves in response to our sleep patterns, physical activity, mood, and respiration rate over many days. This means that your exercise session or a restless night from the previous week can still affect your brain. Hence your memory, cognition and attention can be affected well into the next week.

It is a great study linking brain activity with environmental and physiological data as tracking our brain changes in real time can help detect mental health and neurological disorders early. This allows for earlier interventions and better outcomes.

Even though this study was not focused exclusively on exercise, the results showed that we definitely need a consistent exercise routine and maintain good sleep habits for our overall well being. I find myself particularly sensitive to these as I age. 

Reference

Triana AM, Salmi J, Hayward NME et al (2024). Longitudinal Single-subject Neuroimaging Study Reveals Effects Of Daily Environmental, Physiological, And Lifestyle Factors On Functional Brain Connectivity. Plos Bio. DOI: 10.1371/journal.pbio.3002797

Something You Do Not Know About Muscles

Picture from Burke et al, 2024

This is a very interesting finding about muscles. The muscles we use while exercising can actually communicate with our adipose (fat) stores in our body.

This study was done with 32 human subjects. A single bout of resistance exercise (or strength training) releases muscle specific microRNA-1 (miR-1) from muscles that are then transported to abdominal fat tissue via extracellular vesicles or EVs to stimulate lipolysis. Lipolysis is the breakdown of fats and other lipids to release fatty acids. This means you can use fats for energy, sparing your carbohydrate and protein.

I know what some of you reading must be thinking. Is spot reduction possible? Spot reduction means selective loss of body fat in regions involved in the exercise. Meaning can we isolate the fat in the abdomen (for men) by doing cruches or sit-ups?  Or doing lunges for the buttock and thighs (for women) and get rid of the fat there first? 

Well, sorry to disappoint you. In this study, the exercises were mainly done in the lower body- squats, leg press, leg extension and also lat pulldown (for the upper body). 3 sets of 8 reps at 80 percent of 1 rep max on the aboved mentioned exercises were performed. A fourth set to failure was performed straight after.

The lipolysis or fat breakdown in the adipose tissue was in a non specific area - the abdominal region. This was confirmed by the EV's found there.

Perhaps this is an interesting consideration suggesting that our muscles can function like a secretory organ. Like a giant endocrine organ in the body, more than we realize anyway. (Note : thoughts are my own, not from the study).

We are definitely only scratching the surface of understanding how exercise has so many other unknown benefits.

The women in the study did not have as strong an effect compared to the men in the study. Also note that is is a relatively small study with only 32 subjects.

If you are not already doing any strength training, you should. Not only it can increase your bone density, helps with insulin sensitivity, promote better sleep etc, it can also break down your stored fat.

Reference

Burke BI, Ismaeel A, Long DE et al (2024). Extracellular Vesicle Transfer Of miR-1 To Adipose Tissue Modifys Lipolythic Pathways Following Resistance Exercise. JCI Insight. DOI: 10.1172/jci.insight.182589

Best Grip For Strength Training

Pronated (overhand) grip

My son and I were discussing what grips work best while performing strength training exercises that require us to hold weights when we push, pull or carry. Especially also when doing pull-ups. He was really surprised that such a small detail like the orientation of his grip can have dramatic increase in weight lifted or reps done.

The pronated (or overhand grip) is probably the most commonly used when you do a pull-up or do a strict deadlift. While a supinated (or underhand) grip is used when you do a dumbbell curl or a chin-up. 

Alternate (mixed) grip

There is also the mixed (alternated) grip (pictured above) in which one hand is pronated and the other is supinated. A neutral grip is when both palms (or fists) face each other like when doing a hammer curl. A hook grip (pictured below)is often preferred by advanced lifters when using very heavy weights. The thumb is 'hooked' between the bar and wrapping your index and middle fingers around the thumb for a more secure hold.

Hooked grip

I explained to my son when it comes to grip positions, it is all about all about anatomy. Even slight variations in hand positions during a lift will change which muscles you are using. 

Let's look at the dumbbell curl. When you use the supinated grip, your biceps are the prime movers. When you rotate your hands 90 degrees to a neutral grip, the emphasis changes to a different elbow flexor, your brachialis. If you rotate your hands 90 degrres again to a pronated grip, you will target brachioradialis, yet another elbow flexor.

Supinated (underhand) grip

How do you choose between the supinated versus the pronated grip? It usually depends on the exercise. It will be difficult to do the standard deadlift with a supinated grip since it would be more difficult to hold the bar. Other than that, the main difference between the 2 grips will be the slight difference in muscle recuitment.

Similarly doing pull-ups with the pronated grip will target your latissimus dorsi and trapezius more while the supinated grip for chin-ups will involve your biceps more.

From previous experience,  a grip change is often useful for any exercise that you have not had a significant improvement in the last 4-6 weeks. Say you have not been able to increase weight in your bicep curl, try the hammer curl as it will target your brachialis, which is the strongest of the elbow flexors.

A word of caution, do not try to change your grip for the Olympic lifts (if you do them) since they already work best within the rules of the sport.

With other lifts, a small change can get bigger gains.

Still Doing Those Pendulum Exercises For Shoulder Pain?

Quite a few patients who came to our clinic this week had frozen shoulder. Almost all of these patients had been prescribed pendulum exercises (also know as Codman pendulum exercises) by their previous healthcare provider. The intention is to move/ rehabilitate the glenohumeral (or shoulder) joint while not worsening recently injured or operated tissue.

This is done with the patient standing with a slightly bent torso with the affected arm hanging downwards, using the momentum of the torso/ trunk to move the arm without activating the muscles in the shoulder girdle. The arm can be moved side to side, forwards and backwards, or in a circular motion. Codman pendulum exercises are also always  prescribed after shoulder surgery . In fact, they are the mainstay of many shoulder rehabilitation protocols.

However, Cunningham et al (2020) demonstrated that Codman pendulum exercises involved minmial glenohumeral and scapular-thoracic movement. Movement is mainly from the trunk. They may be a safe way to start early movement/ stretching of the upper limb but may be of limited further use in restoring passive shoulder range of motion.

In fact Gurney et al (2016) found that Codman pendulum exercises induced the least muscle contraction in rotator cuff activity when they investigated several tasks, common rehabilitation exercises and ambulation. Wearing and taking off a shirt induced the highest. Even walking produced substantially higher muscle activity than the Codman exercises. 

Of course if the movement is directly generated from the shoulder rather than the trunk as well as performing larger pendulum circles, there will be increased rotator cuff muscles activity.

Personally, in our clinic, I find that teaching patients 3 basic exercises with elastic resistance bands work much better for the shoulder. Intensity, dosage and exercise position will have to be modified dependent on the surgery and condition the patient has. 

I show them the one arm shoulder frontal raise (pictured above), the lateral raise and a simple basic rowing exercise where the shoulder blade is retracted (or pulled back). In fact, the same few exercises and the single arm reverse fly (pictured below) were found to be effective for office workers to perform daily for 10 minutes to reduce neck and shoulder pain (Saterbakken et al, 2020). 

From Saterbakken et al (2020)

You can definitely stop doing those Codman pendulum exercises.

References

Cunningham G, Charbonnier C, Ladermann A et al (2020). Shoulder Motion Analysis During Codman Pendulum Exercises. Arthrosc Sp Med Rehab. 2(4): e339. DOI: 10.1016/j.asmr.2020.04.013

Gurney AB, Mermier C, LaPlante M et al (2016). Shoulder Electromyography Measurements During Activities Of Daily Living And Routine Rehabilitation. Ex J Orthop Sp Phy Ther. 46(5): 375-383. DOI: 10.2519/jospt.2016.6090.

Saterbakken AH, Makrygiannia P, Stien N et al (2020). Dose-response Of Resistance Training For Neck-and Shoulder Pain Relief: A Workplace Intervention Study. BMC Sp Sci Med Rehab. 12:8. DOI: 10.1186/s13102-020-0158-0

When Does Your Body Age The Fastest?

Picture by Steven Gregor from The Guardian

I always thought that age was just a number. How you feel is more important. Definitely being young at heart helps too. Mentioned this to my friend who's in his 60's while cycling this morning and he said that's the problem when you are young at heart. He said that he feels young at heart but the problem is that his heart is not that young.

Newly published research from Stanford University suggest that humans age very quickly in 2 periods, once around age 44 and the other around 60 (Shen et al, 2024).

Researchers in this study collected and analyzed more than 135,000 biological samples from 108 subjects ranging from 25 to 75 years. Cytokines, skin, oral, nasal microbiome, proteins, lipids, bacteria, ribonucleic acid etc were studied. They found that at around 44 years, those studied had a dramatically different mix of molecules than others just a few years younger. This indicates a spike in the risk of a heart attack, faster skin and muscle aging and slower alcohol and caffeine metabolism.

The next period of acclerated aging happened around age 60. More signs of aging for the heart, skin and muscles. Once into the 7th decade, our immune systems are weakened, kidney function reduces and decreased carbohydrate metabolism that can lead to Type II diabetes.

This shows that biological aging is not linear. It depends on our lifestyles primarily and genetics secondarily and how they interact. For many people, the early 40's and 60's tend to align with major life changes. Your children leaving for university, stopping work, downsizing your home etc.These changes may influence your diet, exercise, social exposure and other factors that affect how your bodies work.

Can we slow the biological aging? The researchers suggest adopting healthy lifestyle habits and ditching the bad ones to delay the aging in the 40's and 60's. If you are not yet 40, start paying attention to heart healthy habits, monitoring especially your cholesterol and triglycerides levels. Have a healthy diet, get enough exercise, minimise smoking and sugar.

Research suggests calorie restriction may protect health and longevity by protecting DNA from age related changes. Subjects who ate less calories by an average of 12 percent slow down their rate of aging by 2-3 percent (Waziry et al, 2023).

Bad sleep does not only make you tired, but makes you look old and haggard. Sleeping less than 6 hours each night can add about 15 months to your biological age and speed up the pace of aging (Kusters et al, 2024). Make sure you get enough shut eye.

Steven Gregor from The Guardian

Those who are yet to hit their 60's definitely need to strength train since muscle loss accelerates. Losing 1 to 2 percent of your muscle mass every year causes you to lose your ability to move freely and easily. Your health plummets as a result. A recent study by Da Silva et al (2024) showed that middle aged and older adults who did 12 weeks of progressive strength training delayed or even reversed sarcopenia (age related muscle loss). 

Now you know.

References

Da Silva AC, Mapa V, Ferreira-Junior JB et al (2024). Progressive Strength Training Can Reverse Sarcopenia Stage In Middle-aged And Older Adults Regardless Of Their Genetic Profile. Arch Geron Geriatrics. Vol 117. DOI: 10.1016/j.archger.2023.105182

Kusters CDJ, Klopack ET, Crimmins EM et al (2024). Short Sleep And Insomnia Are Associated With Accelerated Epigenetic Age. Pysch Med. 86(5): p453-462. DOI: 10.1097/PSY.0000000000001243

Shen X, Wang C, Zhou X et al 92024). Nonlinear Dynamics Of Multi-omics Profiles During Human Aging. Nat Aging. DOI: 10.1038/s43587-024-00692-2

Waziry R, Ryan CP, Corcoran DL et al (2023). Effect Of Long-term Caloric Restriction On DNA Methylation Measures Of Biological Aging In Healthy Adults From The CALERIE Trial. Nat Aging. 3(6): p249-257. DOI: 10.1038/s4357-022-00357-y

Can You Prevent Running Injuries?

We have been seeing some runners in our clinic recently. Some seasoned runners, but quite a few new, novice runners. My definition is unless the runners have been training, running and/ or racing for at least 5 years, they are still considered novice runners.

As a runner I would love to run long and hard daily, alas if we do that injury definitely beckons. How do we prevent that from happening? Can we actually prevent running injuries?

I came across an article investigating if it was possible to prevent running injuries. In this particular study (Leppanen et al, 2024), there were 325 participants who were fairly new runners (less than 2 years of running experience) and aged between 18-55 years. Interventions were completed before the actual runs. The runners attended group training twice a week with a physiotherapist for 6 months.

They were divided into 3 training groups, 2 intervention and 1 control group. All 3 groups followed a similar training program and all runners were taught about the basics of running technique. The first intervention group (108 runners) did strength and conditioning exercises for the hip and core. The 2nd group (111 runners) did exercises to strengthen the ankle and foot, while a third control group (106 runners) did static stretching.

Each training session lasted about 30 minutes twice a week with the exercises and difficulty level progressing over the course of 6 months. Each exercise had 4 different versions with different levels of difficulty and intensity. After the training session, the participants ran outdoors for 30-75 minutes. The participants reported all running related injuries each study week using a mobile application.

Results show that the group that focused  on hip and core training sustained the least injuries among the 3 groups. They had 39 percent lower prevalence of all overuse injuries and 52 percent lower prevalence of overuse injuries compared to the control group. 

I was surprised that the  ankle and foot exercise group did not prevent running related injuries compared to the stretching group. The incidence of acute injuries was lower in the control group than ankle and foot exercise group perhaps suggesting that stretching may help prevent acute running injuries. However, do take note that there were a low number of acute running injuries in this study so this observation should be approached with caution.

This study shows that beginner or novice runners injury rates can be significantly reduced by training the hip and core muscles. Overuse injuries can be cut by about half by strengthening this area compared to stretching which has always been traditionally thought to prevent injuries. And it's really easy to do with just body weight and/ or resistance bands.

Come see our physiotherapists at Physio Solutions and Sports Solutions to learn about what stregthening exercises would help prevent running injuries for you.

Reference

Leppanen M, Viiala J, Kaikkonen P et al (2024). Hip And Core Exercise Program Prevents Running-related Overuse Injuries In Adult Novice Recreational Runners: A Three-arm Randomised Controlled Trial (Run RCT). BJSM. 58: 722-732. DOI: 10.1136/bjsports-2023-107926.

Are Good Athletes Born Or Made?

Unleash the ROAR

I brought my son to football practice earlier today and noticed that some kids were really athletic, a lot quicker and stronger than most of the children of the same age. Of course some were not so. 

Which begets the question of whether good athletes are born with physical gifts or can hard work trump talent?

Here is what a recently published study (Silventoinen et al , 2024) says. This really interesting study involving 198 twins (6-18 years old) used 15 tests to assess for genetic contribution or environmental contributions. In short, the twins completed a battery of tests to analyze whether it is just talent or training that made them good or not so good athletes. Genes versus environment. 

40 percent (78) of the twins were monozygotic (or identical twins), sharing the same DNA. The rest were fraternal, meaning they share about half their DNA. This would mean that if the results of a certain test are more similar within identical twins than fraternal twins then that suggests a larger genetic influence.

The results (below) show that genes played a big role in the results. Between 52-79 percent of your flexibility, power and strength is determined by your genes. Thank your mum and dad for those of you blessed in those areas. I will definitely thank mine for what they gave me.

Picture from Silventoinen et al, 2024

See the figure above, 52 percent in the standing long jump, and a whopping 79 percent for sit and reach showing that the girls performing better than boys in flexibility. The boys performed better than girls in cardiorespiratory endurance and muscular strength. Most of the tests actually showed modest to moderate genetic correlations. 

The 3 tests that were most correlated with the rest of the tests were push-ups, standing long jump (standing broad jump for us Singaporeans) and the Beep Test. Need a simple and quick way of assessing someone's overall fitness, these 3 are the easiest. Perhaps our schools' DSA, Singapore Armed Forces and sports talent ID department should take note when assessing talent.

What about the role of the environment? We need to consider 2 components here. Shared environmental factors, like the area you grew up in, socioeconomic status, opportunities to play sports etc. There are also unique environmental factors, which reflect your own path through life. Whether you joined a sports team, broke your leg /arm or had a great physical education teacher that believed in/ motivated you.

The effects of shared environmental factors appear to be negligible in this study. This is in contrast to earlier published data. So this study's analyses focused on genetic and unique environmental factors.

From my previous readings, work and experience, I would have thought running fast (sprinting) and explosive power (jumps) were 'gifts' from your parents more so than endurance. You may have heard the saying that sprinters are born while endurance runners are made. You may also know a runner that trained loads before becoming a great marathon runner. 

The results in this study do not totally back those assumptions since standing long (or broad) jump (the best measure of explosive power in the tests) had the lowest genetic contribution. But that may be the difference between 2 facets of talent : untrained performance levels and trainability. 

The standing long jump performance may show the explosive properties in their muscles, but it does not reflect a determined and serious effort to train.

Similarly, the 12 min run results do not tell what happens when you clock 100 km of training a week. They are all estimates of 'starting points' but will not tell us how much, with sufficient hard (and smart) work, where we might end up. 

In 2001while representing Singapore

A physiotherapist that treated me after I had stress fractures in both my shins (when I was 20) told me that I would not become a good triathlete. Happy to prove that person wrong later (pictured above with Dimitry Gagg, 1999 World Triathlon Champion And Daniel Lee, 2006 Asian Games Silver medalist) and doubly so when I overheard that same physiotherapist telling another colleague that our physiotherapy department had athletes too after I joined them.

You may be blessed with the best genes, but if you do not train smart and hard enough, there will be others with less talent who will be able to be better than you because they trained smarter and harder.

Some of those ideas are not solely my own. They are discussed in detail by David Epstein in his 2013 book The Sports Gene. 

Whatever genes you have, remember to thank your parents.

Reference

Silventoinen K, Maia J, Sillanpaa E et al (2024). Genetic Regulation Of Physical Fitness In Children: A Twin Study Of 15 Tests From Eurofit And Fitness gram Test Betteries. Med Sci Sp Ex. DOI: 10.1249/MSS.0000000000003496

Is Hyrox Just A Fad?

ST 240824

Hyrox is the newest brand of fitness trend currently sweeping Singapore and the world, it seems.

I do not have an Instagram account, but my wife and colleagues tell me that their IG feed had been flooded with friends dripping with sweat as they did lunges with 24kg sandbags, pushed 152kg sleds (pictured below), did burpee broad jumps etc interspersed with 1 km runs after Singapore hosted a race on 29/6/24. Our local paper, The Straits Times, also featured an article in today's (240824) paper on page A16 (pictured above).

Picture by Kenneth Lee from CNA

Hyrox cofounder and CEO Christian Toetzke wanted to create a sport with broader appeal that could bring mass participation to the gym and running space. He partnered Moritz Furste, previous Olympic gold medalist in field hockey to start their version of exercise. The special 'ingredient' is its mix of 8 movements requiring strength, power and endurance which requires you to push, pull, run, carry and throw. Exercises that could be assessed quickly by officials on the course were chosen since the idea was to hold events with large waves of competitors.

The exercises need to be relatively safe to do under fatigue and mustn't be more difficult for women than men. Hence, box jumps were taken out (for safety) and monkey bars too (more difficult for women). And so, Hyrox was 'born' in 2017 with 8 exercises and a total of 8 km of running.

The first ever Hyrox event was held in Germany with 650 participants in November 2017. Nearly 7 years later, Hyrox is on course to host 45 events for 425,000 participants in 5 continents this year (according to the company's statistics). Singapore's event on June 29th this year drew 6,500 participants, up from 3,500 last October. Singapore will be hosting another event next week on 1/9/24. More than 70 percent of the 6,500 participants in Singapore were millennials.

My wife who goes to UBX at Holland Village tells me that it helps that participants are doing the same exercises together. That strong community element definitely helps when the chips are down and helps with training adherence. The friendships made provide a sense of belonging especially for some people who have never participated in team sports before so this gives them a chance to experience camaraderie and accountability. For Hyrox, this sense of community is global since the race follows an identical format anywhere it is organized.

Gym owners and others in the fitness industry may feel all too familar with the hype around Hyrox after previous flavors of the month have come and gone. Perhaps some gym owners are wary after a recent spate of gym closures although the Hyrox Singapore organizer said that its standardized and accessible nature sets it apart.

I have not taken part in any Hyrox event, but I have done all the different exercises before, albeit not all at once. I will say that Hyrox will definitely help strength and endurance. Unlike the higher intensity CrossFit programmes which can be technically difficult for beginners and thus sets a higher bar for entry, Hyrox fits well in the group exercise spectrum. It also allows one to gauge your own progress.

Critics (not me) have mocked such fitness events/ trends and wondered why anyone would pay to do exercises that could be performed elsewhere for free. One of my patients said with humour that he paid almost $200 to 'torture' himself with friends. Some patients that I asked also said they started because of a 'mid-life' crisis.

One can call Hyrox a fad especially if they do not see the appeal. I am just happy people are getting off their couches and desks to start any form of physical activity to improve their health. Especially when Singapore's young adults' diets and physical activities in Singapore did not comply with international health guidelines (Leu et al, 2023).

81.8 percent of the surveyed participants did not meet World Health Organization requirements of at least 150 minutes of moderate intensity aerobic exercise or 75 minutes of vigorous intensity exercise and muscle strengthening exercises at least twice a week. 

Most of those surveyed said their exercises were walking to public transport stations and while looking for food. One subject even said that the weekend is the only time to like just "collapse".

Hyrox is definitely trendy and seems glamorous now that people love to post about it on social media, which is also contributing to its popularity. I am just glad Singaporeans are more active in whatever form of exercise they choose. Plus, if they overdo it and get injured they can come see us in our clinics.

Reference

Leu J, Rebello SA, Sargent GM et al (2023). Hard Work, Long Hours, And Singaporean Young Adults' Health - A Qualitative Study. Frontiers Pub Health. Vol 11, 12th June. DOI: 10.3389/fpubh.2023.1082581.