Sunday, March 26, 2017

Anatomy Trains Course

The three amigos 
Aized and Sham did the Pediatric Craniosacral Therapy course two weeks ago, while Reggie, Ting Jun (TJ) and I attended the Anatomy Trains workshop this weekend.

TJ has been at the course for the past four days and since Reggie and I did the first two days last year, we came only for the third and fourth day this year.

It was good to have done a little last year and then review some the concepts while adding on to it this time around.

Here are some pictures from the course.

More theory

TJ has the best view for this practical
At the end of the course the presenter was saying "if all of you go in to see and patients tomorrow and wonder what you need to do then I've done my job. "

He was challenging us to look at and treat our patients with a whole new perspective instead of trying to treat our patients the same way we've done.

This has been a most interesting and stimulating course. It ties in nicely with many of the things we already do with fascia while treating our patients.

Well, I'll share what I've learnt with the rest of our team and we'll all be looking to treat our patients
in a better way.

Saturday, March 18, 2017

Mirror Mirror On The Wall

Rachel training while waiting for her patients
When you go to a gym, one of the first things  you notice is there are mirrors almost everywhere. And you see lots of people training in front of the mirrors. In theory, the mirrors are there to ensure you hold correct and proper form during exercise. Can mirrors really be helpful?

Previous studies showed mixed results about using mirrors for exercise. Some studies show workout benefits, some no effects while others show negative effects depending on the specific task and experience level of subjects.

Currently, there is a lot of evidence showing that external focus leads to better performance than internal focus while performing physical tasks. Let's say you're shooting a basketball on the free throw line. Focusing on the rim rather than the movement of your wrist will get you better results. One reason is external focus (focusing on the rim) allows well-practiced movements to take place on auto pilot. This is more efficient than trying to directly control wrist action (internal focus).

A group of researchers studied the role of mirrors in attentional focus by getting subjects to do two series of tests. One involved flexing the elbow as hard as possible (single joint movement). The other test involved jumping as high as possible (multi joint movement).

In both cases, tests were done four times under the following conditions. Internal focus, external focus, neutral and finally with a mirror.

To sum up, external focus was best for both series of tests, while internal focus was worse. Using mirrors were no different (statistically) from the neutral condition.

So for both tasks, the mirror didn't really matter. Perhaps while doing resistance type training with heavier weights, mirrors may be helpful for maintaining symmetry of movement or correct form. What is important is that external focus trumps internal focus.

Runners take note that a previous study found that focusing on your form or your breathing (internal focus) results in worse running economy than if you focused on the surroundings (external focus).


Halperin I, Highes S et al (2016). The Effects Of Either A Mirror, Internal Or External Focus Instructions On Single And Multi-joint Tasks. PLOS One.

Schucker L, Hagemann H et al (2009). The Effect Of Attentional Focus On Running Economy. J of Sports Sciences. 7(12) : 1241-1248.

Saturday, March 11, 2017

Stress Fractures In Teenage Female Runners

Icing the shin
The Singapore National School's competitions are usually held between March and late May every year since 2009. And it's that time of the year again where we see many patients in our clinics with shin splints. Mostly adolescent and teenage girls and the occasional boy.

Why are girls more susceptible to shin splints and stress fractures? Well, some new data shows that if teenage female athletes don't eat enough to support their training, there will be complications regarding their subsequent training and health.

The study tracked 323 female athletes at Stanford University in 16 different sports including cross country running. Bone scans and questionnaires were used to assess the runners based on the components of the "female athlete triad" consisting of "low energy availability, with or without disordered eating, menstrual dysfunction and low bone mineral density. "

Risk status were calculated based on an article published in the British Journal of Sports Medicine  in 2014. Have a look at Figure 4 in the article if you're keen to know more about the calculations.

Looking only at the cross country runners (47 runners) data, half the runners were classified as low risk, and three of those later developed stress fractures.

Sixteen of the runners had moderate risk and 50 percent of these developed stress fractures within a year. These girls were about four times as likely to get injured compared to the low risk group.

Seven runners were in the high risk group and five of them developed stress fractures. They were nearly six times as likely as the low risk group to get injured.

Well, if you're thinking like me, not so good news for the girls if you're a runner and in the moderate to high risk group.

The researchers suggested the following guidelines for female athletes in the moderate to high risk group. The athletes need to ensure they're getting enough calories to support their training along with calcium and Vitamin D. Their menstrual function, bone health and nutrition needs to be monitored on an ongoing basis.

Higher risk athletes may have to consider using low impact cross training more often in their weekly routine. Good sleep and recovery are important too.

Stress fractures occurred mostly in the foot for the low risk athletes, probably as a consequence of biomechanics and jumping sports (due to higher forces).

In the higher risk categories, many of the stress fractures were in the sacrum, pelvis and femoral neck (where the bones tend to be softer). These areas may be due to weakened bone rather than biomechanical forces.

So all the doctors, physiotherapists, physical education teachers, coaches, heads of departments and administrators in charge of female teenage athletes reading this post, please take note.


Tenforde AS, Carlson Jl et al (2017). Association Of The Female Athlete Triad Risk Assessment Stratification To The Development Of Bone Stress Injuries In Collegiate Athletes. AJSM. 45(2): 302-310. DOI: 10.1177/0363546516676262.

Friday, March 3, 2017

Current Hydration Guidelines May Well Be Wrong

Picture by richseow from Flickr
We've been told in the past by articles, journals and research scientists that if you lose more than 2 percent of your body weight (through sweating) during endurance exercise/ racing your performance will be affected.

Moreover, advertisements from Sports drinks companies keep harping on the fact the you need to drink up or else you get dehydrated.

However, some recent studies (as well as anecdotal evidence from the world's top distance runners) suggest that it may be possible to lose more than 2 percent of your body weight (from sweating) with little or no loss in your performance.

Research scientists from New Zealand's High Performance department have suggested that previous published dehydration studies were conducted in "relatively windless environments (i.e. wind speed less than 12.9km/h) with participants being aware their hydration status." They stated that such conditions do not simulate real race conditions.

In their own (albeit) small study of 10 cyclists, they found that weight loss of up to 3 percent did not slow down the cyclists nor their power output decrease in a 25 km time trial.

Another study on elite male marathoners examined their drinking behavior during 13 major city marathons. Haile Gebreselassie was found to have lost 9.8 percent (and that's a lot) of his body weight during the 2009 Dubai Marathon and still won in 2:05:29 hrs. All drinking by the elite runners were ad libitum (or at their own time and pleasure).

Granted the above study was done on elite runners. Does that even apply to mere mortals like us?Especially in hot and super humid Singapore.

Here are my own thoughts. From the time I started running cross country as a twelve year old kid, I've noticed that I tend to drink less than my team mates and other competitors. And definitely less than what the Sports drinks companies recommend. In fact I often had a side stitch after drinking. That also deterred me from drinking too much then.

So despite what you've heard or read before, at least give it a try in your next few long bike or run sessions. Try to get through those long sessions drinking as little as you can. You'll be pleasantly surprised that you may not need as much fluid as you think.


Beis LY, Wright-Whyte M, et al (2012). Drinking Behaviours Of Elite Male Runners During Marathon Competition. Clin J Sport Med. 22(3): 254-261. DOI: 10.1097/JSM.0b013e31824a55d7.

Wall BA, Watson G et al (2015). Current Hydration Guidelines Are Erroneus: Dehydration Does Not Impair Performance In The Heat. BJSM. 49(16): 1077-1083.

Friday, February 24, 2017

Is Income Inequality Slowing Us Down Too?

"Beep" Test
A new study has found that kids from the United States are among the least fit in the world (out of 50 countries). And it may be due to their unequal income distribution as researchers found a correlation between income inequality and fitness.

Researchers pooled data from 177 previous studies conducted around the world to understand the link between a country's income inequality and youth fitness. They specifically compared a country's Gini Index (which measures how income is distributed throughout that country) with a 20 metre shuttle run test in that same country. 

When there's a large gap between the rich and poor in a country (i.e. higher Gini Index), there tend to be large sub populations of poor people within that country. And poverty is linked with a whole bunch of poor health outcomes. One of those outcomes is poor aerobic fitness in children.

The researchers found that the greater the Gini Index (i.e. the higher the number), the less likely their kids were to perform well in the shuttle run test (also know as the "beep" test or the multi-stage fitness test).

Two parallel lines are drawn 20 metres apart in the "beep" or multi-stage fitness test. The children must run back and forth between the two lines, reaching each line before a beep sounds.

The time between beeps decreases as the test goes on, forcing the kids to run faster. If a child fails to reach the opposite line before the "beep" sounds twice in a row, he / she is eliminated from the test.

This test is popular around the world as many people can be tested simultaneously and research scientists use it to draw conclusions about a country's level of fitness by pooling and comparing data.

Our Singapore readers may remember this "beep" test was highly unpopular among our "S" league footballers who had to achieved Level 13-2 before they can play in our professional league.

Now, you must be wondering what does income inequality have to do with obesity?

The data suggested that poverty tends to make people less fit primarily when they live in a relatively rich (or developed) country while the opposite is true in undeveloped countries.

Researchers suggest that for the young people in developed countries with low income, they tend to not have access to healthy food. They normally have access to cheap but very high calorie, energy-dense food. Being poor but surrounded by fast food, cars and television seems to be more detrimental than being poor in a rural environment where physical activity is a necessary part of life.

The young people in undeveloped countries differs in that they may not have access to parks, playgrounds, equipment and facilities. They tend to be physically active out of obligation as they have to walk or cycle to and from work. They may also need to walk greater distances to access fresh water or groceries.

No Singapore kids were included in this study, but our Gini coefficient is on the high side so does this mean the poorer kids are less fit in Singapore too?

Maybe it's timely that it's announced in today's Straits Times that all pre-school children will have at least one hour of physical activity a day including time spent in the sun (to reduce myopia) and also be served healthy meals including fruit.

Front page in today's Straits Times 240217

When it comes to being fit and healthy, it's good to start them young.


Lang JJ, Tremblay MS et al (2016). International Variability in 20 m Shuttle Run Performance In Children And Youth: Who Are The Fittest From A 50-country Comparison? A Systematic Literature Review With Pooling Of Aggregate Results. BJSM. Published online first :20 Sptember 2016. DOI:

Saturday, February 18, 2017

World Champion Athlete Comes To Floss Band Course

We had a Pencak Silat World Champion attend the Floss Band course today at Sports Solutions along with coaches, and sparring partners from the Singapore Silat Federation.

Yes, you read correctly, Muhammad Shakir Junda (above right) is a 2-time Pencak Silat World Champion (in the over 85-90 kg category). He was crowned World Champion in 2012 and 2016.

While I was still working at the Singapore Sports Council (now the S'pore Sports Institute), I had treated 3 Silat World Champions before and I found out today they were still involved with grooming future world champions.

Of course there were also other Physiotherapists, Personal trainers, Physical Education teachers and Occupational Therapists attending the course today. It was good to see some familiar faces in the participants today (Jocelyn and Tommy).

Hey, I thought it was the Floss band course, not foam rolling

Tommy Yau explaining how it's done

Lenis and Jacq do the cha cha?
A big thank you to Amy, Danny and Ekina for coming early and getting the place ready so I can eat a little after seeing patients in the morning. And for packing up after the course too. Please contact them at Sanctband Singapore if you want to attend the next course in April.

Thank you to all who came to the course today, glad you guys found it useful. And hopefully we'll get more World Champions in Pencak Silat too.

Thursday, February 16, 2017

Any Runners Recognise This?

Found this in my parents place. How many of you remember or recognise this? My parents are slowly clearing my stuff that I've accumulated over the years.

For those of you who don't know, these are the nails we use for the racing spikes (or shoes) on the running track.

Let me know if this brings back memories.