Health Trends For 2021

Straits Times 1/1/21

Great suggestion in today's Straits Times article on the back page (B16, under Sports section) where the author suggested having more local running events for women.

I say not just more races for women only, but men and those under 21 too. In a year where most if not all running races were cancelled, runners are starved for social interaction and a chance to clock a personal best time for some or be quick enough for that elusive Boston qualifying (or BQ) time.

Perhaps with the rollout of the vaccines making exercising in enclosed spaces safe again, people may still want to go back to gyms, yoga studios and fitness centers etc.

I'm hope I'm wrong for the sake of those businesses, but I think gyms, yoga, Pilates studios may not be totally out of the woods yet. Bike shops, cheap dumbbells and other home exercise equipment will definitely continue to be in hot demand. Since March 2020, where most the world started lockdowns, too many people have learnt how simple, cheap and safe training at home is. 

I'm predicting that running, cycling, long walks and roller blading will continue to be popular in this new year. Let's all recognize the benefits of our local parks, bike lanes, park connectors and green spaces. All these spaces definitely impact our health.

A lot of us started baking, cooking and even growing our own food since the lockdown. All are healthy trends and may we continue to do that.

Let's continue to support our own local communities, the smaller shops and restaurants as they battle to carry on. We bought all our Christmas and birthday gifts from Everyday Vegan Grocer and Le Matin.

Here's wishing all of you a safe, healthy and wonderful year ahead.

Bicycle Lanes In Singapore?

Singapore's only bike lane@ Coastal road

I last wrote about having bicycle lanes on the road way back in 2010 and 2011. No one really paid attention then. Then earlier this week, British Prime Minister Boris Johnson came out promising to build thousands of miles of new bike lanes to get the Brits moving and healthy after months of coronavirus lockdown.

His pledge came after plans to force restaurants to display calories on menus as part of a bigger battle to help the British lose weight. This is after an analysis by the Organization for Economic Development released in 2019 found that Britain was the second fattest nation in Europe, with almost a third of the population classified as overweight.

ST 1/8/2020 on page A23

Being obese makes one more vulnerable to many diseases including the coronavirus.This is especially true for Johnson himself after his own experience with Covid-19. His life was in danger and he had to be treated in intensive care largely because he was overweight. He had previously dismissed the idea of government intervention over what the public should eat, but changed his mind after being hospitalized.

When Minister Mentor Lee Kuan Yew was still alive, he did consider special bike lanes for cyclists in Singapore. He had in his younger days cycled to university in Cambridge and had to also cycle about five miles uphill to visit his girlfriend and later wife as she lived in a different hostel.

From -Hard truths to keep Singapore going

"It's better for everybody's health, it's better for the environment and it's certainly better than having the place or having the roads overcrowded with cars, taxis, buses."

From -Hard truths to keep Singapore going

During the circuit breaker/ lockdown in Singapore, it was a dream come true for cyclists, as there was so much less traffic on the roads. My sons and I went cycling almost daily as we did not have to worry about sharing the roads with the cars and buses. Throughout the world, bicycles were selling like hotcakes, including Singapore, as many people rode bikes for both transport and exercise.

Some of you reading this may say that it's too hot to ride bicycles to the office or to run errands. Yes, in our climate you will will definitely need a shower after riding to work. But it will also not to be too cold when it rains. So we will need to have toilets and parking spaces for bicycles. A small price to pay for a cleaner and greener environment.

Many drivers will not like this idea (there are many drivers who hate cyclists if you look at the online forums) of bike lanes on our roads. Well, you can't please everyone.

Newly appointed transport minister Ong Ye Kung, are you reading this?

*A big thank you to Jeffrey Keng. The very first picture right at the top and the one just above was taken from a video by Jeffrey Keng on 22/9/18 while we were cycling along Coastal road.

Do Heavy School Bags Cause Back Pain In Children?

I had a nine year old girl come to our clinic to see me this week complaining of neck pain. Her grandmother who brought her thought it may be related to her very heavy school bag that caused it. That along with the extra time on screens during home based learning recently during the circuit breaker.

After examining the little girl, I explained to her grandmother that what she thought may not be true.

You would have seen plenty of advertisements on the internet suggesting you buy your child an ergonomic bag pack for your child to avoid back and neck pain. However, when I searched the literature, there were no convincing proof in the last 20 years between heavy school bags and posture/ back pain among the young.

Many of you would have seen a young child with a big school bag on their shoulders. You would have read about it in the papers. There are many articles available online regarding this topic too. Many of the articles quoted above suggest that your child should not carry more than 20 percent of their body weight. After searching, I found out that this figure is taken from an article by Dockrell et al in 2013).

The most recent evidence published was from a systematic review in 2018 conducted by a team of Australian Physiotherapy researchers. They examined 69 eligible studies with a total of more than 72,600 children.

Many of the articles were rated as either having a moderate to high risk of bias due to high attrition rates, mixed testing methods, confounding factors and poor prognosis. As a result, most of the articles did not find an association between school bag characteristics and low back pain even though there were mixed sample sizes, different school bag weight and different definitions of back pain.

The authors suggested that due to variables in school bags, measuring instruments and timing of data collection, there were no straight "yes" or "no" answers. Hence, no strong conclusions can be formed.

An older systematic review in 2008 examined 10 qualified trials with more than 17,000 children/ teens on neck, upper back and shoulder pain. The authors found that static postures, depression, stress, psychosomatic symptoms, age and gender (girls had higher reports of pain than boys, especially those who were depressed (Prins et al, 2008).

If I may digress here, even among adult research there was insufficient evidence for association between spinal curves (e.g. scoliosis) and all other health related outcomes. This includes low back pain, disc herniation, neck pain, fractures, headaches, symptomatic degenerative lumbar disc disease and thoracic pain (Christensen et al, 2008).

Perhaps many of us (including all the online articles you read) after seeing a child hunched forward with a heavy school bag while walking home assume that heavy back packs causes neck and/or low back pain.

This may have fueled further beliefs among doctors, physiotherapists, other clinicians and the general public that heavy back packs can cause neck/ back pain.

Personally, I do get concerned whenever I see a young child carrying a heavy back pack even if the evidence does not suggest that it will hurt them permanently.

As my wife says (quoting Tom Myers), children have very elastic connective tissue and they are very resilient. Unless your child is perpetually carrying a super heavy school bag, it probably will not affect their necks and backs permanently.


References


Dockrell S, Simms C et al (2013). Schoolbag Weight Limit: Can It Be Defined? J Sch Health 83: 368-377.

Prins Y, Crous L et al (2008). A Systematic Review Of Posture And Psychosocial Factors As Contributors To Upper Quadrant Musculoskeletal Pain In Children And Adolescents. Phy Theory Pract. 24: 221-242. DOI: 10/1080/09593980701704089

Yamato TP, Maher CG et al (2018). Do Schoolbags Cause Back Pain In Children And Adolescents? A Systematic Review. BJSM. 52: 1241-1245. DOI: 10.1136/bjsports-2017-09827.

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?

Studying With Tom Myers Live Online

Looks like I've gotten myself much more screen time again during this circuit breaker period. I've signed up for a 'live' webinar taught by Tom Myers from May 15-17. Due to the unusual circumstances of the global pandemic, the course has to be taught over Zoom, of course.

This is actually the 3rd online course he's teaching since the COVID-19 started. I didn't sign up early enough for the first two and they filled up quickly. Due to high demand, they announced that Tom was teaching the same course for the third time, so I made sure I signed up straight away.

I've attended a few of the Anatomy Trains courses already, and previously one introduction course taught by Tom before. But when Tom is teaching, I just couldn't resist, even though I've learnt some of this material previously.

Tom says he misses using his hands during this pandemic

There's a slight hitch though. The course is taught from 10 pm to 12 am and from 3 to 5 am. I'll have to find a way to cope.

Picture of healthy fascia above.

Can Exercise Give You Headaches Or Migraines?

My patient rings up complaining of having a terrible migraine after going out for a run. She suffers frequently from migraines and usually exercise and/or seeing us in the clinic would help. She was hoping to come and see us since Physiotherapy has been reclassified as "essential services".

Despite Physiotherapy being reclassified as an "essential service" recently on 29/4/20, the criteria to see patients in the clinic are very strict.

The Ministry of Health (MOH) have told us that face to face sessions are only for "patients whose condition would deteriorate significantly or rapidly if treatment is not provided or performed and would potentially threaten their health and well being".

We can only open once a week seeing a maximum of 6 patients and we're told to "leverage on tele-consult/ tele-rehab as far as possible".

Many of our patients have called or messaged us asking to be seen and we've explained that we can only treat them if they meet the above criteria.

My running patient did add that she ran a lot harder and that was when her migraine started. I told her that I just read an article on runners and their calcitonin gene-related peptide (CGRP) levels.

In that study, 46% of the enlisted running subjects reported suffering from headaches/ migraines while 54% did not.

CGRP helps with making your blood vessels larger (vasodilation), which then increases blood pressure and inflammation in your nervous system. Increased CGRP levels are known to be associated with headaches and migraines.

The researchers measured CGRP levels (by drawing blood) in  runners before and after running. They then got the runners to run 21 kilometres at 75-85 VO2 max.

 CGRP levels significantly increased by one and a half times in the entire group after the run. CGRP was significantly higher for those who had prior migraines before the run and those runners reported suffering from migraines after the run.

This led the researchers to conclude that medium to long distance endurance exercise boosted CGRP levels and that high intensity exercises can heighten the reaction further. This can potentially trigger both headaches and migraines brought on by exertion.

Previous research has shown that exercise can decrease frequency of migraines and improve symptoms and reduce migraine triggers (Aristeidou et al, 2018). With this new article I have to add that migraine sufferers need not stop exercising, but they do need to watch their exercise intensity.

Low to moderate exercise intensities does not seem to be a trigger. There are also medications that helps with blocking CGRP for those of you who don't mind ingesting medication in order to exercise hard. Check with your doctor for the prescription.

Good news for those who do not suffer from headaches or migraines as an increase in CGRP levels is good for you as it has a protective effect for cardiovascular function.


References

Aristeidou S, Baraldi C et al (2018). The Association Between Migraine And Physical Exercise. J Headache Pain. 19(1): 83. DOI: 10.1186/s10194-018-0902-y.

Tarperi C, Sanchis-Gomar F et al (2020). Effects Of Endurance Exercise On Serum Concentration Of Calcitonin Gene-related Peptide (CGRP): A Potential Link Between Exercise Intensity And Headache. Clin Chem Lab Med. DOI: 10.1515/cclm-2019-1337.

To all our patients reading this and asking to be treated. Yes the government has indeed allowed some businesses to open. As you can see from the MOH circular, clinics have very strict criteria regarding who we can see even though this is not published in the news. Rightfully so since we are still in the circuit breaker period.

Please bear with us, we will inform you as soon as we are given further instructions by MOH to allow us to see more patients.

Will You Lose All Your Strength During The Circuit Breaker If You Cannot Lift Weights?

Lunging with a 10 kg bag of rice 

We are currently at the end of week 3 of the circuit breaker (or modified lock down) in Singapore. Most of my patients who strength train are not able to take part in their usual exercises and training regimes. This is true especially for my bodybuilding and avid gym going patients, since gyms and other exercise centers are closed.

Not many of them have an ideal home gym for strength training during this period. So for them, there's a real threat of detraining (loss of strength) for them and other sporting populations. Any loss in muscle strength, power, muscle atrophy may affect future performance, injury risk and self esteem.

A recently published study (Blocquiaux et al 2020) studied older male patients (58-70 years old) during a 12 week whole body resistance training program. The subjects stopped training for 12 weeks and then resumed training for another 12 weeks.

Decent strength gains were made at 8 weeks (22%), and 12 weeks (36%) in leg strength (similar for upper limb).

What was most interesting was that all the strength gains (36%) during the initial 12 weeks were not completely lost during the 12 weeks of no training. 14% was lost during this period.

When the participants resumed training for another 12 weeks, they were stronger at the end of the second 12 week period than the first. It took them 8 weeks or thereabouts to regain what they lost in 12 weeks.

So if we were to compare with our current circuit breaker period (3 weeks and counting), don't be too discouraged. You can probably gain back what you lost. Hopefully it will take less time too looking at that study (Blocquiaux et al 2020) . For those of you who bike, run, row or do other endurance sports, there is a similar pattern observed for cardiovascular fitness too.

Now, lets look at female subjects. Correa et al (2016) studied a group of older women, and this time the period of no training was a whole year. The female participants gain an increase of 75% in strength after an initial 12 week training period. Much of these gains were lost after a year, back to baseline levels. However, after another 12 weeks or training, they gained a lot of this strength back, they were just 15% off their first 12 week training period.

So, another glimmer of hope for those of you who strength train. Though I'm hoping our circuit breaker will not be a year long!

If you make do with whatever you can find at home to strength train to failure albeit with a lighter weight, you will stave off some of the losses. That's what I try to do.

Many people are dealing with all sorts of mental and motivational issues other than physical and financial ones so exercise may be way down on their list of priorities. But if you can still exercise, it will definitely lift your mood Ludyga et al (2020).


References

Blocquiaux S, Gorski T et al (2020). The Effect Of Resistance Training, Detraining And Retraining On Muscle Strength And Power, Myofibre Size, Satellite Cells And Myonuclei In Older Men. Expt Gerontology. 133: 110860. DOI: 10.1016/j.exger.2020.110860

Correa CS, Cunha G et al (2016). Effects Of Strength Training, Detraining and Retraining In Muscle Strength, Hypertrophy And Functional Tasks In Older Female Adults. Clin Physiol Funct Imaging. 6(4): 306-310. DOI: 10.1111/cpf.12230.

Luduga S, Gerber M et al (2020). Systematic Review And Meta-analysis Investigating Moderators Of Long-term Effects Of Exercise On Cognition In Healthy Individuals. Nat Human Behav. DOI: 10.1038/s41562-020-0851-8

How Much Treadmill Incline To Use?

Getting tested at the then Racers' Toolbox (now Coached)

My patient who had been running outside contacted me after reading that running outside was more dangerous. After checking the viral article she read, I reminded her that the Belgian engineers chose to bypass all standard publishing protocols so that article wasn't reliable (picture below showing the simulated spread droplets of breathing, coughing and sneezing from people who are walking, running or cycling).

Picture by ANSYS taken from here 

Despite my reassurance, she decided that she would run indoors for now since she had a treadmill at home. She was wondering what incline she should be using while running.

The hills we run or cycle up outdoors are measured as a percentage. The treadmill also displays incline as a percentage. So if you've set the incline on your treadmill to 1.5, it means you are running at a 1.5 percent incline (not level 1.5). Most treadmills allow you to adjust the incline from 0 to 12 percent. Some models even allow for a decline. Good if you want to practice running downhill.

I suggested to my patient that she should set her treadmill at the 1 percent incline as research shows that it will simulate outdoor running as it makes up the lack of wind resistance while running indoors (Jones and Doust, 1996). This is especially so if you're running between 12 to 17 km an hour. Under 12 km an hour no adjustment is necessary as the difference is small, but you can probably still set the incline at 1 percent for an extra challenge. This may also help you transition back to running outside.

I suggested running by effort rather than by than speed alone as this may reduce the risk of fatigue, injury and frustration. This will also help with pacing before she returns to running outside.

If you too have read that viral article, the article suggested staying at least 4-5 meters behind others when walking in a single file, 10 meters while running or cycling slowly and 20 meters while cycling quickly.

I definitely don't have a treadmill and I prefer to run and bike outside. My suggestion is to respect everyone's space. Don't run or pass too close, don't follow behind and don't cut in too quickly. Stay safe.

Reference

Jones AM and Doust JU (1996). A 1% Treadmill Grade Most Accurately Reflects The Energetic Cost Of Outdoor Running. J Sports Sci. 14(4): 321-327.

Today's Straits Times 13/4/2020 on page B21 under the Sports Section too mentioned the guidelines laid out in the viral article.

Today paper published it's commentary on that same article on 15/4/2020. You can read it here.