Can Frozen Shoulder Be Caused By Covid-19?

Aized was looking at her FB feed (pictured above) earlier this week when someone asked what else could be done for her frozen shoulder (or adhesive capsulitis). This lady was told by her doctor at Tan Tock Seng hospital that her frozen shoulder was possibly caused by her vaccination injections.

Then I recall reading a paper published last July 2021 that it may be Covid-19 that can cause frozen shoulder (rather than the vaccination injections). 

In that published paper (Ascani et al, 2021), 1120 patients were evaluated at the shoulder surgery unit. Of these, 146 were found to have frozen shoulder or adhesive capsulitis (AC). Of these 146 subjects, 12 had AC after contracting Covid-19, 8 female and 4 male. The patients were between 42-73 years. Frozen shoulder in the patients started 1.5 to 3 months after the Covid-19 diagnosis (mean onset was 2 months after Covid-19). 

Covid-19 symptoms were mild in 5 of the patients, were the other 7 were asymptomatic. None of the patients were severely or critically ill. 2 of the patients had diabetes that were well controlled. You can read more about that study and how the authors suggested AC can be caused by Covid-19 here.  

Can't do L hand on hip

With AC, there is pain and later lots of stiffness in the affected shoulder. First clue if you have AC, you cannot put your hands on your hips (the affected side of course, pictured above). That hand behind your back is definitely out of the question. You have difficulty bringing your arms overhead from the front and side (when your elbows are straight). The pain seems to worsen at night, disrupting sleep. Quality of life is definitely affected.

We really do not know what causes AC. Even doctors and research scientists are not sure either. However, we do know that AC afflicts women more commonly than men. Especially women above 50, more so if they are diabetic, had a prior stroke or thyroid disorders. Sometimes, it occurs after a recent shoulder surgery as well.

There seems to be some recent evidence that AC is a metabolic condition. Meaning if you're hypertensive, overweight, you drink, smoke, you have a poor diet and do little or no exercise, then you have a higher chance of getting AC.

There are usually 3 stages with AC. The first stage is the 'freezing' stage where pain is increasing with most shoulder movements. End range of motion in the shoulder starts to be limited. This stage can last from 3 to 6 months. 

The next stage is the 'frozen' stage. There usually isn't as much pain as the first stage but shoulder range is definitely more limited. Patients often complain of increasing 'stiffness' in this stage.

The last stage is known as the 'thawing' state where shoulder range starts to improve. There is usually much less pain during this stage.

AC can last between 9 to 18 months. I've seen some patients get a whole better after 6 months although it can drag for up to 24 months in other patients. 

I will write how we can help with AC in my next post. Stay tuned.

Reference 

Ascani C, Passaretti D, Scacchi M et al (2021). Can Adhesive Capsulitis Of The Shoulder Be A Consequence Of Covid-19? Case Series Of 12 Patients. 30(7): E409-413. DOI: 10.1016/j.jse.2021.04.024

Where The Streets Have Allyson Felix

I've written about Allyson Felix before previously and I hope she will still be a force to reckon with at the Tokyo Olympics. Being Nike's poster girl previously, I admired how she spoke up when Nike were unfair to their sponsored pregnant athletes.

As you can see from the article above, she still found a way to train when stadiums were closed during the lockdown after getting her coach to use a measuring wheel to mark out distances "on literally the street in front of her door". 

What a sight it must have been for her neighbors to behold when a six-time Olympic Olympic gold medalist, 13 times World Champion comes sprinting down the road at full speed. Along with her coach yelling encouragement at the top of his voice. 

Instead of complaining about what she can't do, I love the way she and other athletes resorted to unorthodox ways to train so they can be ready to compete when they can. 

I know too, that our Team Singapore athletes have resorted to ingenious ways to train too, chapeau to them. 

Let's see how she fares if the Olympics does go on.

Dealing With Defensive Medicine During COVID

I had a patient recently who injured his knee while playing badminton. The surgeon sent him for an MRI and wanted to operate after the scan showed that he had tore his lateral meniscus.

He decided to have the operation but the procedure was postponed after he got sick. The good news was that he got so much better after the wait that he decided that surgery was not needed anymore.

This reminded me of an British Medical Journal opinion article I read this morning. The article cited examples as a direct result of the lockdown/ circuit breaker period where patients got better as fear of catching Covid-19 in hospitals prevented them from seeking help.

Of course there were also tragic cases when patients cannot receive essential care and eventually dying as a result. Depression and mental health cases come to mind too.

There was an outcry in Singapore recently when it was announced that Medishield Life plans premiums were going up. Healthcare costs are definitely rising all over the world. Patients are often referred for unnecessary tests and treatment when costs are covered by insurance. Overuse and over-diagnosis consume resources and insurance premiums subsequently increase.

This is in part due to doctors practicing defensive medicine. Previously, I had written that some doctors actually charged more for steroid injections after a court case against an orthopaedic surgeon after his patient complained to the Singapore Medical Council after she developed side effects. 

The article suggested that this may be due to multifaceted reasons with vested interests playing a crucial role. Quoting the article, "medicine is permeated by a bias towards doing something rather than doing nothing, even when it may do more harm than good to our patients. Doctors failing to diagnose are resented and sometimes punished, while doctors who cause suffering through over diagnosis and over-treatment are not".

Practicing defensive medicine may also be due to expectations from patients and a fear of being sued.

While not all my esteemed physiotherapists may not agree with me, I would suggest that physiotherapy probably has the same problem. We are often quick to diagnose a 'syndrome', 'an inflammation' or a 'knot'. Perhaps it should be "I don't know for sure" now, but I can do my best to come up with a plan to treat this. If it still doesn't settle, we will definitely investigate further.

Covid-19 has definitely made us more aware of our priorities and actions. Let us use this opportunity to understand and contribute to shift away from defensive medicine and physiotherapy.

You can read the article by Minna Johansson and Iona Heath here.

Picture above taken from Joee Denis.

The Gaiter Controversy In Today's Straits Times Article

ST 290820

I read with interest earlier last week regarding the dispute between an SBS bus driver and his refusal to allow a passenger who was wearing a gaiter. The bus driver obviously felt that gaiters are not masks.

ST 240820 on page B9

A gaiter is a tube of fabric worn around the neck to keep skiers or runners warm in cold weather. They are currently popular with runners, cyclists etc in other countries because they can be pulled up to cover the nose and mouth and used as a mask.
Then in today's Straits Times (page A10, under Top of the news), the writer questioned if all masks are created equal when it comes to protection from Covid-19.

The author quoted a study (listed in my reference list) from Duke University that looked at all different kinds of face masks and measured how many droplets of saliva made it through each mask.

When the neck gaiter was tested, they found more droplets than if the person was wearing no mask or other face covering. This single layer neck gaiter was made of 92 percent polyester and 8 percent spandex.

She wrote that the researchers said the neck gaiter "seemed to disperse the largest droplets into a multitude of smaller droplets which explains the apparent increase in droplet count relative to no mask in that case".

What the Straits Times writer did not mention was that the Duke University study was done with just one person. Yes, you read correctly. N = 1. More like a case study really. Next, the way the researchers did measurements was with a phone camera and lasers. Surely, that's not a reliable way to measure particles of droplets.

I'm not sure if the Straits Times writer  even read the article. Even the authors of the Duke University study said that people are "drawing too much" from the article. The authors' intent was not to say this mask does not work or never use gaiters. That's not even the main part of the article.

If you search further, you will find that researchers from Virginia Tech did a neck gaiter study and found that gaiters "perform similarly to cloth masks and very well if doubled over." You can see the PDF document by authors Jin Pan and Linsey Marr on neck gaiters right here.


Reference

Fischer EP, Fischer MC, Grass D et al (2020). Low-cost Measurement Of Facemask Efficacy For Filtering Expelled Droplets During Speech. Sci Advances. DOIL 10.1126/sciadvabd3083. Read the article here.

Images when I googled "neck gaiter" above.

*As reported by another journalist in today's Sunday Times (page A2, Top of the news), MOH has since reiterated that makeshift face coverings such as bandanas, scarves and neck gaiters should not be used. This is under recommendations of the multi-ministry task force tackling the pandemic.

Again the Duke University case study was quoted. Again I'm wondering if the journalist even bothered to read the study itself ......

ST 300820 on page A2

How Are Restaurants And Physiotherapy Clinics Similar?

ST 230820

The inspiration for this week's post came from a few unlikely sources. First was a patient telling me yesterday of how a friend on Facebook shared that a physiotherapy practice was in the red and that they needed patients to ensure the practice's survival. So if anyone needed physiotherapy to please go support that particular clinic.

Then in today's Sunday Times article, the author wrote about diners who make and confirmed bookings at restaurants but do not show up. A restaurant founder (of six restaurants/ nightspots) who was interviewed said that irresponsible behavior by diners have always existed and is now becoming social norm. To quote her, "diners feel more entitled now by the fact that the restaurants need them more than they need us".

That we definitely understand. We have our fair share of patients who make appointments and after confirming, and reminders by our staff, fail to turn up.

Some jobs need us to show up in person. For the time being, restaurant staff, surgeons and physiotherapists are definitely in that category. With artificial intelligence and robot controlled arms who knows how long our jobs as physiotherapists are safe .....

Many other jobs or services are currently done with a combination of asynchronous work, video calls and others. A big thank you to all our patients who still despite a long and/ or a risky commute, come to see us.

We will strive to be totally switched on 100% and do our best all the time when treating you. This is our promise.

*Keeping rogue diners in check. This Sunday Times article is on page C17 under the Life section today.

This Is What Our Physiotherapists Can Do

2:08 pm - wearing socks

Here's a patient I saw this past Thursday in our clinic. He was complaining of right sided low back pain after sitting at home all day long during the circuit breaker working on his laptop. You can see from the picture above that the picture was time stamped at 2:08 pm this past Thursday.

After a quick assessment, I treated his feet. Yes, you read correctly. I didn't go anywhere near his back. Have a look at the picture at 2:31 pm. Since he wasn't a new patient, my receptionist only book a 30 minute follow up session for him. New patients get 60 minutes in our clinics.

2:31 pm - took off socks

You can see he's wearing blue socks in the first picture while I was assessing him. He took off his socks as I was treating his feet. You think his socks caused all the difference? Nah, I was pulling your leg.

Have a closer look when I put the two pictures side by side below. Click on the pictures for a bigger version.

Before and after

How's that after just 23 minutes of treatment (including assessment)? Notice his feet are not pointing outwards as much. His knees are also not as hyper extended. His pelvis is level and and not tilted forward like before. His upper body is more upright with respect to his hip as compared to earlier. And his neck is not poking forward as much with respect to his upper body.

My patient was shocked when I showed him the pictures I posted here. And by the way, his back wasn't hurting anymore when I was done treating his feet.

This is what our physiotherapists in our clinics can do with our hands when we treat patients. Not a chance that video/ tele consults can do this.

Exercise As A Remedy For COVID Stress

Today is the last day of the circuit breaker (CB) or lockdown period in Singapore. Finally, light at the end of the tunnel.

During the CB, I've noticed a lot more people in my neighborhood running than before, and many you can tell, never really exercised regularly previously. But good for them, at least they are exercising now. I guess with all the free time, gyms closed and not wanting to lose their sanity, many people go walking and running.

You can probably guess that quarantines and lockdowns or similar measures to combat plagues are associated with poor mental health. Past quarantines resulted in lingering stress levels, confusion and mounting anger (Brooks et al, 2020).

A recently published study (though not peer reviewed) done in the early stages of the lockdown (in USA) suggested that benefits of exercising extended beyond just physical benefits and help us mentally too (McDowell et al, 2020).

The study found that people who managed to keep exercising during the lockdown were less depressed and more mentally resilient compared to those whose activity levels declined.

Data from manufacturers of activity trackers showed that most people's daily step count decreased from March since most countries were under lockdown during that period.

In that study, researchers asked about 3000 non smoking subjects probing questions about their personal lives. Multiple questionnaires about how often they exercised and how many hours were spent sitting before the pandemic began.

This was compared to the lockdown period in April. Subjects were asked if they were fully self quarantined at home or did they get a chance to go outside while following social distancing rules.

They were also asked about their current mental health, whether they had symptoms of depression, anxiety, loneliness or if they were generally happy.

After collating the replies, the researches split the subjects into groups based on whether they previously had or had not met the standard exercise guidelines of 150 minutes per week of moderate exercise now compared to before the lockdown. The researchers then compared exercise routines and moods.

No surprises that the researchers found that those who managed to exercise were more cheerful and vice versa. The people  who previously had been active but because of the lockdown rarely exercised were more likely to be depressed, anxious, lonely and worried compared those who still managed get in 150 minutes of exercise a week.

Those subjects in full quarantine were the most affected as few managed to maintain any exercise routine and they reported feeling sad, depressed and solitary.

After looking at the study in detail, I noticed that most of the respondents were middle class well educated whites. Not many of other races were represented.

Because this study relied on their memories of the exercise routines, the findings may not be totally reliable as it covers separate but temporary parts of their lives during the lockdown. We can perhaps infer that exercise and their moods were linked.

I can definitely testify that exercise can improve moods and well being. If you haven't been able to exercise and get out much during the CB, bear in mind that we still have to exit the CB in stages.

Stay safe.


References

Brooks SK, Webster RK et al (20120). The Psychological Impact Of Quarantine And How To Reduce It: Rapid Review Of The Evidence. 395: 912-920. DOI: 10.1016/S0140-6736(20)30460.

McDowell C, Lansing J et al (2020). Changes In Physical Activity And Sedentary Behaviour Due To COVID-19 Outbreak And Associations With Mental Health in 3,052 Adults. Cambridge Open Engage. DOI:10.33774/coe-2020-h0b8g.

See if you can guess where I took the following pictures during my solo CB rides.

Guess where this tank is?

Abandoned guard tower

Not in use water tank?

Boosting Your Immune System While Exercising During The Coronavirus Outbreak

My cycling group has been discussing how to do our regular Saturday group ride after new restrictions by the government to restrict groups to not more than 10 people together. Or risk a $10,000 fine and a stint in jail for six months or both.

With non stop news regarding the coronavirus alerts, we definitely still need to exercise as we need a break from all the stress and anxieties that have come up daily. Don't know about you, I do definitely.

Beautiful morning

Personally, I feel that running or cycling outside is great for clearing my mind and releasing all that pent up energy. Getting out early in the morning, seeing the sun come up, hearing the birds and smelling the morning air is really nice for me. Both our minds and bodies need that.

So how do we stay safe and ensure that our exercise/ workouts now helps rather than suppress our immune system?

For those of you who are like me and need to keep on exercising, here are some basic guidelines. Do watch your intensity and duration of your exercise. Evidence suggests that being physically active makes you less vulnerable to falling sick. Data by researchers show that physically active people are 40-50 percent less likely to have days ill with acute respiratory infections.

Evidence suggests limiting sustained efforts greater than 60 percent heart rate max to not more than 60 minutes at a time. To get more bang for your buck, you can mix some high intensity efforts with rest or periods of lower intensity. That happens during our group bike rides. After riding hard for a while, we do slow down to recover. I guess stopping at the traffic lights counts too.

However, before you go out and train/ exercise harder with all the time you have now, take note that more is not always better. If you train too hard (a hard long run or a few hours of training), it actually leads to an increase in stress hormones, inflammatory changes and an increase in free radicals that will be harmful to your body.

Though this is a temporary effect, if you are under mental or emotional stress, not sleeping enough and eating poorly, it can make you more susceptible to falling sick.

In their laboratory, the researchers found that the stress starts when your intense efforts exceeds 60 minutes. It gets really bad after 90 minutes.

This is not the time to push your limits. Even for elite athletes, it's more about your health than your fitness levels.

There is plenty of data supporting regular, moderate exercise being protective of your health. You will get the most out of your exercise when you allow time for sufficient recovery. If you're tired, take a rest day, especially if you feel a slight hint of an illness coming. Do get enough sleep, eat well and manage your stress.

In this time of fear, danger and uncertainty, please take care of yourself and stay safe.

Gino


References

Nieman DC and Wentz LM (2019). The Compelling Link Between Physical Activity And The body's Defense System. J Sp Health Sci. 8(3): 201-217 DOI: 10.106/j.jshs.2018.09.009.

Nieman DC, Lila MA and Gillitt ND (2019). Immunometabolism: A Multi-omics Approach To Interpreting The Influence Of Exercise And Diet On The Immune System. Ann Rev Food Sci Tech. 10: 341-363. DOI: 10.1146/annurev-food-032818-121316.

Coronavirus And Running

My patient who saw me yesterday was complaining that the Boston Marathon originally scheduled on 20th April next month has been postponed to 19th September. She had also planned to run Berlin originally, but with the change in dates that may not pan out.

This is the first time in the race's 124 year history that the race will not take place in April. Other than the Boston marathon, new reports of other international race cancellations are coming in on a regular basis.

In sunny Singapore, The Sunday Times today reported that the Sundown Marathon on May 23rd has been cancelled. This race had 23,000 runners last year. Other local postponed races this year includes next month's JP Morgan Corporate Challenge and the 2XU Compression Run (picture above).

I can understand how runners are disappointed that all their training may have come to waste. After all the sacrifices, preparation and training done, it must be terrible not to be able to race.

The Singapore government has rolled out "social distancing" guidelines to further limit the spread of COVID-19. As many of my patients who run have commented, running is the optimal sport now since everyone is encouraged to avoid crowded, enclosed spaces whenever possible. All of us who run or cycle alone sometimes are already practicing a form of "social distancing" unprompted.

Of course we are not running away from others when we go running alone. We run or cycle alone to preserve our sanity, to analyze and solve problems that crop up.

With so many races in limbo, some of you may question why you train hard when there seems to be nothing to train for. To run hard means to subject yourself voluntarily to varying degrees of discomfort. And pushing yourself hard in a workout means you're resisting the urge to stop.

Yes, because of the coronavirus, many races have been and will be cancelled. But we have other reasons to run, we can run for the satisfaction that comes from confirming our resilience to no one else but ourselves, our ability to endure, to not stop.

I don't race anymore, but I'm definitely still running to get my adrenaline rush.

If you have to self quarantine and cannot go out for a run, maybe you can try emulating Pan Shancu who ran 6,250 laps around two large tables set up inside his apartment. One lap around the tables measured about 8 meters and he ran 50 km in 4:48:44 hours!!