Repetitive Strain Injury, stiff wrist, elbow, shoulder??

Repetitive Strain Injury (RSI) is a term that is commonly heard nowadays... seemingly stressless activities such as using the mouse and keyboard while typing in front of the computer have been blamed for causing wrist pain, carpal tunnel syndrome, etc. In this blog, I will share some simple movements and stretches that can help relieve stiffness in your body (typical office desk job, or long distance driving, studying at desk, etc).

A few key points
1. Posture... you can refer back to http://www.everhealth.asia

2. Even if you have *good* posture, good technique (the way you do an exercise, lift a heavy bag, etc)... you can still end up with OVERUSE problems (hence the word 'repetitive').

For example, every time you BEND your elbow/forearm to curl a dumbell, grip the steering wheel, click the mouse,  the main muscles which move actually originate from a tendon in the inner part of the elbow. If you do such movements too often, it is possible that this particular tendon may feel sore, and sometimes the inflammation is commonly called 'Golfer's elbow'.

Every time  you STRAIGHTEN your elbow/forearm to lower a dumbell, the last few inches of hitting a tennis ball, etc the muscles which move actually  originate from a tendo in the outer part of the elbow.   If you do such movements too often, it is possible that this particular tendon may feel sore, and sometimes the inflammation is commonly called 'Tennis elbow'.

In this blog, we will not focus on how to treat such conditions - please consult a physiotherapist or chiropractor.

3. Getting on your nerves!

The diagram above shows some nerves that pass through portions of the shoulder, arm, and hands. Every time you feel some tingling or numbness in the wrist and/or fingers, it could be due to the nerve being 'trapped' somewhere along this pathway (from the neck to the fingers)... let's leave it to the chiropractor or physiotherapist to handle this matter!

4. What CAN you do to reduce the chance of repetitive strain injury?
*Do 'opposite' movements. For example, since you type a lot (or SMS), hold the mouse for long periods of time, your fingers are scrunched up... So it makes sense to STRAIGHTEN them up!
You can give these exercises a try... It is NOT necessary to use force (or strength). You can try 10 repetitions or as often as you feel like it.

Tiger claw - gently open and close your fingers

Snake - basically moving the wrist in and out, with your opposite thumb to provide very slight resistance

Of course the more common stretches can also be done... Just hold the stretch for 5 to 10 seconds (do not bounce) to relieve stiffness in the wrist and forearm.

Finally, do give the wall push a try! It can relieve tension in the shoulders, neck and upper back.
Hands criss-cross on top of each other, PUSH into the wall, STRAIGHTEN your ARMS while you STEP BACK from the wall. Hold for up to 10 seconds, then switch hands

Choosing sport shoes...

There's no shortage of websites, magazine and newspaper review of sport shoes... In this regard, I find that the American Association of Podiatric Sports Medicine provides sensible and comprehensive advice... http://www.aapsm.org/runshoe.html

So rather than duplicating the wheel, do check out their website. Other key pointers - beware of marketing hype or SELECTIVE information presented ('barefoot running will lead you to less injury', wear 'minimalist shoes' to strengthen your feet). Thus far, there has not been much research in peer-reviewed journals to confirm / disconfirm every claim made by barefoot / minimalist shoes proponents. Offhand, there are people who have mentioned that they have stress fractures after running in Vibram Five Fingers (see podiatryarena's forum).

All is not lost, here are some general principles to help you.

1. What main type of  activity will you be doing?

Choose sport-specific shoes... There *is* a difference between running and walking! When you run, there is a point in time when your feet are off the ground... Not surprisingly, there is much more impact to your joints when you run than when you walk.

Other high impact activities - plyometric drills (explosive movements eg, burpee, jumping lunges, etc)... So, a minimalist shoe may not have enough cushioning for this.

2) Environment - where are you (mainly) going to do this activity?
If you frequently have access to the beach (soft sand) or park/garden with natural soft grass then barefoot or minimalist shoes will be fine because the soft ground can cushion some of the impact.

Many martial arts style like to train barefoot and do conditioning exercises such as jumps, etc... Be careful, because the impact of jumping on concrete is high compared to grass.

3) Your body and walking/running/movement patterns
As I have mentioned in one of the earlier blogs, do visit a physiotherapist/chiropractor to get a checkup. Typically, pelvis misalignments may lead to other suboptimal transfer of force to the knee, feet and ankle (thereby, predisposing you to pain and injury). Orthotics may be prescribed by the therapist.

If you have had multiple ankle injuries on the same side, then it is a warning sign that you need treatment and probably change to a less demanding activity for the time being.

What if you have flat feet, toes get tired easily, etc? I have tried Springboost shoes for about 3 years... very comfortable for walking because Springboost shoes have a negative heel (ie, heel is lower compared to the toes)... This means that when you walk, there is less pressure on your toes.. (see picture above). Unfortunately, they are not available in Malaysia (have to buy in Singapore).. so they can be pricey.

Recently, I have bought Skechers Shape-ups (see above) which is suitable for walking and some gym exercises. Never mind their claims about toning the body, I bought it mainly because of the rocker sole... this slightly unstable surface forces you to learn to balance... (Typically after multiple ankle injuries, your stability and sense of balance in one foot will decrease).. very comfortable on the feet... Price is about RM350

Paying up your $$$... After trying out the shoes in the shop and you have decided on the brand and model, do a quick quality control check...
Thanks to Dr George for the following tips:
Are the heights and lengths of both shoes the same? Put them side by side and measure (or estimate)
Is the heel crooked (if you put a pen vertically at the middle of the heel, it should be straight)

That's all folks...

So you think you know how to pushup?

It's good to vary your workout once in a while... variety makes it less boring!

In today's blog, I thougt of revisiting the pushup which everyone knows how to do... Dax Moy's personal training studio in UK put up this video that shows good alignment technique for pushups... Just three points on how to make it better
1) Breathe normally... It is not necessary to suck in your stomach as this (and many other 'core training' people) suggest... When your body needs to stabilise, your breathing will naturally adapt (ie, the sucking in happens without you consciously having to think/do it)... In the video, there is also a lot of squeezing - you only need a *slight* amount of squeeze to stiffen the torso, so don't overdo the squeezing.

2) Elbow positioning can be more comfortable if you angle the elbow slightly inward approximately 45 degrees (see photo)
3) Use pushup handles for less stress on the wrist

If you're a beginner, try easier versions - eg, stand up and do pushups by putting your palms on a sturdy table, then progress to something lower (eg, bed), and finally the floor.

We can also learn useful things from other sports... For example, in mixed martial arts they use exercises such as deck squats for conditioning. It is not that difficult to learn and is fantastic way to coordinate the whole body (this is unlike gym exercises such as leg press, leg curls where you just sit down and press/curl to move the weight). If it is your first time, ten repetitions on left, ten on right is sufficient to FRY your legs and buttocks, calves (to a lesser extent).

In this video, Steve Maxwell (a MMA champion) shows the deck squat - minute 2.37-2.41
It's basically 'fall' backwards *gently*, then use slight momentum to roll yourself forward. Thrust one leg forward and drive yourself upwards on the other leg.

How to make this exercise safer?
1. Put a mat under your body - it provides cushioning for your lower back
2.  Do not raise your legs that high when 'falling' backwards

Do NOT do this exercise if you have any of these conditions - neck/back/knee pain or injury, balance problems, dizziness, blood pressure abnormality.

With all these don'ts, you will see why I have not put these links under my recommendations in http://www.everhealth.asia

Have fun trying!

Ouch my feet! Flat feet and more...

Earlier in June, my classmates and I attended a workshop conducted by Dr. Mark Charrette. Dr Charrette is a chiropractor who has researched treated many people who suffer from foot problems. So I thought of sharing some key points:

1. Ligaments plasticly deform
Ligaments are connective tissues which function like straps to keep bones together. As you can see in the picture below (taken from Gray's Anatomy), there are *many* ligaments which keep bones in your feet together

Although flexible and quite tough, once ligaments are over-stretched or damaged, they will not return to their original shape/form... much like Cling Wrap (the plastic-like thing you wrap over a bowl of food and then put in in the fridge or microwave) which does not return to its original shape after being stretched.

2. We *develop* [over]-pronation and [over-]supination (ie, we are not born with)
Note: There are genetic factors that may make people likely to inherit flat feet (low arches), high arches, etc.

Pronation = sole out, toe up and out which creates the effect of knee and feet rolling inwards. Since, we develop this 'style', it goes without saying that even people with high arches or low arches may develop [over-]-pronation.


(Supination is the opposite)


3. It seems that tilting of pelvis occurs before feet problems
Dr Charrette gave a few reasons such as falling, sleeping or sitting in awkward postures, etc.

Due to these reasons, Dr Charrette suggests that we develop (learn and adapt) [over-]pronation (rolling inwards).

This makes perfect sense as I have mentioned elsewhere - the whole body is inter-connected. Hence, if there is dysfunction in say the pelvis (tilting, etc) then this can affect the direction or transfer of force elsewhere (knee down to the feet).

Surprise! Based on his experience and research, Dr Charrette said that 93-95% of the population are pronators.

4. Therefore, it may make sense that a lot of the population may need some form of orthotics (shoe inserts).

I went to one of the shopping centres a few years ago and they did the usual foot scan and custom-made orthotics... unfortunately they didn't really work (still had a lot of almost same amount of rolling in)... If youre going to spend $$$ on custom-made orthotics, I would now recommend that you go to a podiatrist (foot specialist) who would  be able to do a much better job at analysing how you walk, and more experience in measurements, etc. Some of the podiatrists in town also have a chiropractor to do some checks on your spine, etc. Alternatively, some manufacturers such as Foot Levelers http://www.footlevelers.com will make a pair for you after you have been for the scan, etc at some chiropractic clinics in Malaysia.


>During the tea break, I asked Dr Charrette about the current hot trend -'minimalist' shoes ('barefoot', Vibram, Nike Free, etc) and he mentioned that he has been to Kenya and the people there did not run marathons barefooted. Furthermore, he reiterated that support for our arches is mainly from the ligaments, and not from muscles.

>So there you go, don't believe everything sport shoe manufacturers tell you!

Last point for this blog... gleaned during one of our class visits to an integrated (muscle / joints) healthcare  centre at HSC, Cheras. One of the chiropractors there (I think it's Dr Hayden Pooke) mentioned that:

5. [Asian] people don't wear shoes in the house, unlike European people. So, basically there is no arch support...

>Hmm, maybe it's time that children wore shoes in the house so that they get sufficient arch support and wear slippers less often.

K-pop and picture perfect!

Just the other day I was reading the newspaper and this news report caught my attention "Make me a K-pop star". http://www.asianewsnet.net/home/news.php?id=19600&sec=48

According to the news, Singaporeans Ferlyn Wong (age 19) and Elaine Yuki Wong (age 23) passes an audition and sent to Korea for training (dance, language, etc)... Here is the exercise regime they were put on five days a week:

"Get up at 7am. Eat breakfast consisting of a few low-fat biscuits and lettuce.
Go for 21/2-hour gym session.
Swim for two hours.
Lunch, well, no lunch actually. Must count those calories.
Snacks (if the girls complain of hunger) - a banana or a few low-fat biscuits.
Dance class after lunch, for up to four hours.
Dinner - boiled chicken breast and salad.
Finish dinner by 7pm. After that, they are not allowed to eat or drink anything; apparently drinking will make them look bloated in the morning."

 Sounds CRAZY to me!

Why is this crazy?
1) Water intake may be insufficient - "After that [dinner], they are not allowed to eat or drink anything"

2) Food intake may not match energy expenditure
Conservative estimates assuming
*Leisurely swimming = 200 calories per hour
*Treadmill / stationary bike (depends on resistance level, etc) = 300 calories per 30 minutes
*Weight training =?

If these exercises were done on *separate* days, you can see that the exercise alone consumes about 300-400 calories...now add on dance class (presumably those with fast moves), and the energy expenditure continues...

Food intake - will the chicken breast, lettuce, salad, and biscuits provide sufficient energy intake? I really doubt it

3) Potential nutritional deficiency... As you can see, they are eating calorie-controlled diets, hence it is likely that some vitamin and mineral deficiency could occur.
Remember, when we eat food, we need to consider that we need nutrients and also for energy, repair of tissues (definitely need it if you exercise), other functions (brain power, organs to function, etc)...

I know bodybuilders have the habit of going on low calories, low carb, high protein *once in a while* to shock the body and get ripped (such as the advertisement above), but how long are  these two  persons going on such a regime? Their health will suffer and it is irresponsible if their gym trainers put them on this type of routine. Beware the curse of picture perfect!

Core training

You have probably heard about "core training", train the abs (abdominals), etc... But what exactly is the core? Bearing in mind that the body is three-dimensional, we can see that the internal organs (heart, lungs, viscera, etc) are seemingly protected by a cage - one for the upper body (thorax) and one for the lower part. Muscles wrap around from various directions - diagonal, back to front, etc... much like a parcel you receive in the mail. this gives strength and protection to the internal organs.

So, when we talk about core, we are NOT just talking about the six-pack, but also many other muscles that run across the abdominal area (obliques, hip flexors), lower back and even pelvic floor... the human body is one amazing inter-linked unit!

Is core training something new? While the concept of training the core may be popular nowadays, it may not be exactly new as some ancient exercises such as yoga and kungfu have exercises that also train the core, but were not called core exercises. Take the example above taken from a wushu book written by Wang xinde.

The top picture shows 'Iron ox tills the land'... Seems to have some overlap with dive bomber, hindu pushup, and even the downward dog posture in yoga!

The bottom picture shows 'Leopard crouches in the cave'... It seems similar to T-pushups.

Does core training prevent lower back pain? Thus far, there has not been much published research (peer-review journals), but certainly any exercise program that ingrains proper posture should be encouraged. Key points:

*Since we SIT a lot everyday (or some frequently need to drive long-distance), we should select exercises that somewhat "lengthens" the muscles. This is a figure-of-speech meaning that since we sit a lot, our joints are in a bent (or worse, srcunched) position.... so it makes sense to choose exercises that do the opposite - ie, "lengthen". Hence, we hear a lot about this keyword in pilates, Yoga, Body Balance, etc.

As a side note, Dr Michael Yessis, exercise physiologist, suggests that excessive crunches can lead to hunchback conditions. Perhaps it's a matter of poor technique (neck to chest) which drives the dysfunction... Even if you do use good technique for crunches, it makes sense to do other exercises too such as the...

*Suggested exercises - plank and quadriped... Looks simple, but don't be fooled, keeping the alignment difficult... in fact, you may find your muscles trembling as they (and your brain) struggle so stabilise - pelvis in one level, neck neither sticking up nor down, etc. Inhale, and try to keep the position for five seconds, then stop and rest a few seconds before trying again.

Top photo - Plank. Let elbows and forearms support most of your weight. Shoulder aligned directly above the elbows.There should be no sagging in the mid or lower back... very challenging if it's your first time trying it.

Bottom photo - Quadriped. Starting position - face toward the ground, kneel with knees and  toes on the ground, hands are put directly under the shoulder. Now attempt to straighten one arm and *opposite* leg at the same time.

Of herbs and worms??

Aah the wonderful world of herbs and alternative medicine.. and herbs. While English dictionaries frequently define herbs as plants, it is interesting to note that in alternative treatments such as Traditional Chinese Medicine, treatment could include the use of plants and non-plant materials... One interesting herb used is cordyceps, called 'dong chong xia cao' (literally winter worm, summer plant)... It's actually a fungus that attacks a type of caterpillar... You can read more here...  http://www.raonline.ch/pages/np/nat/np_yarcha01.html

Diet

The slimming and dieting industry is worth millions of dollars. Every year, newspapers, magazines and books present consumers with the latest diet for losing weight and fat. Of course bodybuilders are not spared too, with practically every bodybuilding magazine promoting the latest supplement to build muscle, lose fat, and gain strength.

What's the secret? There is no secret... At the end of the day, whether your goal is to gain size or lose fat, you are only left with two factors within your control:
*Exercise dosage
*Food intake - calories, carbs, protein, fat

Recognise that the body is more concerned about survival (hence, fat storage) rather than aesthetics (six-pack abs, slim waist).

Does eating salad as your main meal everyday help you lose weight? Not necessarily, as this low calorie intake may be interpreted by the body as 'danger'... So, the body continues to keep the fat storage for survival.

What about the popular Atkins diet and other variations - low carb, high protein, medium to high fat?
The typical low carb intake would be about 40 grams of carbs per day - eg, 4 pieces of bread, or one cup of cooked rice per day

Bear in mind that the brain needs a steady supply of glucose... and you do use brain power for office jobs, studying, etc. Hence, long-term low carb can lead people to feel cranky, or difficult to concentrate, etc.

Gary et. al conducted a one-year study on 63 obese people. It was published in the New England Journal of Medicine (2003). Participants were randomly assigned to either
Low carb, high protein, high fat
or
Low calorie, high carb, low fat

Results showed that more people lost weight following the Atkins diet compared to the other diet for the first six months. However, at one year the differences were not significant (ie, statistically, one would not be confident that the results were trustworthy). 

For details, read here http://www.nejm.org/doi/full/10.1056/NEJMoa022207
 
Bottom line - it's complicated...

If aesthetics is your concern, you can try cycling your levels of nutrients -
eg, three days moderate / high carb, medium protein
one day all fruit, no protein
two days low carb, high protein

Other considerations:
-What's beyond your control? Genetics... try as some people may, they may have some inherited conditions that make weight gain (or weight loss) difficult... Then there are other factors to consider - eg, your level of thyroid hormones.
-HEALTH or nice body (six-pack abs, slim waist)? You have to think carefully...

I would like to conclude by quoting one of the sentences in Gary's et al's study:

"We did not evaluate the effect of the low-carbohydrate diet on other important clinical end points, such as renal function, bone health, cardiovascular function, and exercise tolerance."
ie, was there any impact of low-carb diet on
-exercise tolerance? (anybody fainted while exercising?)
-renal function? (kidney function?)
etc...

The BEST exercise

Yoga. Pilates. Mixed martial art. Qigong. Turbulence training. Cardio. Racket sports. Boxing.

The list is endless... every year or so, "new" discoveries pop up and are touted as the BEST form of exercise. Is there such a thing as BEST???

I don't think so... Let's look at what your goal is...

Strength? Flexibility? Stability / balance? Endurance? Fat loss? Bulk? Toning? Stress release?
etc

At the risk of simplifying, exercise routines can probably be boiled down to

Strength ---------------------- Stability and balance
eg, weights                               yoga, pilates, taichi

Somewhere in between is people who do "functional" or "core" movements with weights - eg, woodchopper, etc

Can ONE exercise meet ALL the goals?
It is quite unlikely... although it must be said that yoga although typically classified as stability and balance exercise, can also build strength. In fact, some advanced yoga movements are challenging even for those who can lift heavy weights.

Since it is difficult for ONE exercise to meet ALL the goals, it is perhaps wise to choose several physical activities.
For example, those who lift weights should not neglect stretching and mobility movements to reduce stiffness.

Another point is - don't forget your immune system too. Rigorous exercise (running, swimming, lifting weights, etc) without sufficient rest  and proper food can be detrimental to your immune system, and make you more susceptible to colds, etc.