Is This You?

Who thinks that the above and below postures lead to neck pain or discomfort? They are a common sight now since smart phones have become widely available.

There is a general consensus that the flexed (or forward bending) posture of the neck and head while reading and typing, also known as text neck is harmful, and is related to neck pain and other physical discomfort.

This impression that neck pain is caused by excessive smartphone use started after one computational model study in 2017 suggested that the greater the neck bending forward, the greater the overload. The theory is based purely on biomechanics and does not consider that pain is multifactorial and modulated by several factors.

Previous studies did not find an association between text neck and neck pain. Bertozzi et al (2023) also did not find an association between neck posture and time spent on smartphones with neck pain or disability.

The present study aims to investigate whether text neck is a risk factor for neck pain, while considering the influence of psychosocial and lifestyle factors. This longitudinal study with a 12 month follow-up using a self reported questionnaire and objective assessment of posture while sending messages on a smartphone. 

396 participants (87 percent) completed the 1-year follow-up. Average age of the participants was 27 years. 319 (70 percent) were female. The average neck flexion angle using the smartphone was 34 degrees. Only 4 subjects (1 percent) had neck pain "very often", 20 subjects (5 percent) had neck pain "often". 129 subjects 33 percent) had neck pain "occasionally", 158 subjects (40 percent) rarely had neck pain 85 subjects (21 percent) "never" had neck pain.

The researchers concluded that neck flexion posture was not a risk factor for neck pain or frequency of neck pain. They found that psychosocial factors like low sleep quality and insufficient levels of physical activity were contributing factors of neck pain.

So it's not really just what position you neck is in or how long you spend on your phone that can cause your neck to hurt. However, if you spend a lot of your time on your phone, please make sure you get in enough exercise and sleep well to avoid neck pain.

Reference

Correia IMT, Ferreira ADS, Gomes JFM et al (2025). Cervical Flexion Posture During Smartphone Use Was Not A Risk Factor For Neck Pain, But Low Sleep Quality And Insufficient Levels Of Physical Activity Were. A Longitudinal Investigation. Braz J PT. 29(6): 101258. DOI: 10.1016j.bjpt.2025.101258

Exercises Or Manual Therapy Better For Persistent Neck Pain?

Neck exercise

Assuming you have persistent neck pain, would you prefer to very diligently do 13 exercises (pictured above) or would you prefer to have a physiotherapist treat you with hands on manual therapy? 

Manual therapy

Research by (Villanueva-Ruiz et al, 2025) shows that both help patients with chronic neck pain. Manual therapy in this case refers to both myofascial and joint mobilization techniques (Guo et al, 2022 and Zabala-Mata et al, 2024). Please read on for a twist at the end. 

The authors randomly allocated 65 patients with non specific chronic neck pain into a manual therapy or exercise group. They received 4 treatment sessions of either performing 13 specific neck exercises with supervision (plus home exercises) or manual therapy once a week for 4 weeks.

The following outcomes were measured at baseline, 2, 4 and 12 weeks post treatment. Pain intensity, disability, quality of life, patient-perceived improvement, fear of movement and also the cranio-cervical flexion test (CCFT). 

Patients were also categorized into responders or non-responders according to their pain intensity, disability and their perceived improvement at 4 and 12 weeks post treatment. Commitment to exercise was also recorded.

After reading so far, which group do you think fared better? Note that both groups of patients had 'general physio' before and not gotten better.

Ready for the results? The manual therapy group had much more responders than the exercise group at all follow up periods. Treatment outcome in the exercise group was linked to exercise adherence. So manual therapy is more effective? Here's the twist.

When the researchers looked only at patients who were ≥ 95 percent diligent at doing their home exercises (60 percent of the exercise group), the treatments were equal. 

So, a 4 week manual therapy intervention was more effective than exercises for chronic neck pain patients. However, when exercise adherence was ≥ 95 percent, both interventions were equally effective.

Manual therapy may be superior to doing strengthening exercises for chronic neck pain when patients are not able or not motivated to do their home exercises.

For healthcare professionals whose patients are motivated and are likely to do their strengthening exercises then you can dole out the exercises out and send videos to aid them. For patients who are not compliant with the exercises perhaps due to challenging home or work situations, then manual therapy is evidenced based and effective.

References

Villanueva-Ruiz I, Falla D, Saez M et al (2025). Manual Therapy And Neck-Specific Exercise Are Equally effective For Non-Specific Neck Pain But Only When Exercise Adherence Is Maximized: A Randomized Controlled Trial. Musc Sci Pract.77: 103319. DOI: 10.1016/j.msksp.2025.103319

Year End Musings

Time flies, we are already at the last weekend of the year. My family and I climbed Mount Iron (pictured above) in Wanaka, New Zealand last week.

Mount Iron is a popular yet accessible hike of about 4.5 km that shows panoramic 360 degree views over lake Wanaka and the surrounding town and mountains. It is an impressive, yet rocky knoll that rises above the surrounding area.

It is a relatively easy walk for most people albeit with some very steep sections. Named for it's iron like shape, it's a glacier-carved knoll with stunning views.

There were many other people along the walk too. I overheard some conversations that were pretty extreme that seemed to mirror scrolling through social media. No sugar, no rest days, extreme diets etc. Super strict and crazy routines that claim to be the secret to longevity or high performance.

Just like our walk last week, it is impossible to live your life with absolutes. Every high performing athlete I have worked with eats candy, potato chips and drinks alcohol occasionally. Every banker, tycoon, high performing person in their field is flexible with their routines. 

Reason? Being too pedantic and/ or neurotic gets in they way of performance. 

So remember to be flexible, thank yourself and not listen to the nay sayers nor follow those crazy and strict routines. 

Happy New Year!

Lookout point in Oamaru

Time To Be Thankful

 Lake Tekapo

Christmas is just a few sleeps away and normally at this time of the year many of us are reflecting on the people and experiences that we are thankful for. 

However we also need to be grateful to ourselves. This is fairly uncommon since we are more comfortable expressing gratefulness to others. Research shows that taking the time to thank ourselves  for the qualities that have carried us through life is healthy and important. Even if doing so seems egotistical and can make one feel awkward.

Psychologists say that self gratititude does not come naturally since the human brain has evolved to look for problems as a way of staying safe since everyday life requires an awareness of immediate dangers. Our ancestors who sat down and relaxed were more likely to be eaten by lions. Those who dwelled on where the dangers may be were more likely to stay alive.

We also need to teach this skill to our children too as research shows that low self esteem in children and teens are linked to alcohol use, drunk driving and self harm (Gartland et al, 2019).

So especially during this year end holiday season (and beyond), spend at least 5 minutes a day looking at yourself with compassion and thanking yourself.

Acknowlegde your own positive qualities, efforts and resilience. Recognize your achivements, forgive your own mistakes, appreciate your own growth and consciously give yourself credit for who you are and what you do.

Reference

Gartland D, Riggs E, Muyeen S et al (2019). What factors Are Associated With Resilient Outcomes In Children Exposed To Social Adversity? A Systematic Review. BMJ Open. 9: e024870. DOI: 10.1136/bmcopen-2018-024870

Running Injuries Recovery Time Lines

Picture from Interplay

I feel that we live in an instantaneous society now where you snap your fingers and you want things done. Fast food, fast internet and fast access to pretty much everything. 

I have many patients who are new to running and want to be a great runner, fast. Many runners expect to improve their times with short periods of training and end up doing too much too soon.

Then there are those who are injured and try to accelerate rehabilitation and recovery beyond normal time lines. I would like to caution that effective recovery will take time and cannot be rushed or forced. 

The 2 times that I fractured my spine, I too hoped to heal faster. However, I cannot accelerate healing and rehabilitation beyond what biology will allow. I can only optimize it.

Back to running injuries. I looked at a study that studied average recovery times for common running injuries. When you look at the study the numbers may surprise you and many of the healthcare professionals that read this.

140 runners out of 839 sustained a running injury in this 24 week study (Mulvad et al, 2018). Runners in the study reported levels of pain in different body parts on a weekly basis. The injured runners attended a physical examination by a physiotherapist who provided a diagnosis. Examples are medial tibial stress syndrome (MTSS or shin splints), Achilles tendinopathy (AT), patellofemoral pain (PFP), Iliotibial band syndrome (ITBS) and plantar fascia pain (PF).

The median time to recovery for ALL types of injuries was 56 days. Yes, you read correctly. Actually let me show you the average recovery times the study found.

Plantar fascia - 35 days

Calf injury - 49 days

PFP - 49 days

AT - 56 days

ITB - 56 days

Gluteus medius tendinopathy - 56 days

Shin splints - 70 days

Hamstring - 74 days

Medial meniscus - 89 days

Surprised or shocked? You should know that effective recovery takes time. Tendons, cartilage, muscle  and especially bone will nor respond to any "magic recovery hacks" or when you try do more. They will respond to patience and appropriate loading. 

When you try to rush your rehab, it usually does not shorten the time line. It will increase the risk of flare ups, setbacks and recurrence.

Now please take note that good and correct rehab is not slow, just appropriately paced. Not everyone will take the same time to recover like those quoted in the study. Recovery is not passive, you can still train. Can't run, stationary cycling should be fine. The healthcare professional treating you should be able to give you alternatives, otherwise you should find another. It is definitely not one size fits all. 

The devil is always in the details. Only 140 out of 839 runners got injured. "Recovery" was self reported by the runners based on return to running without symptoms not performance goals.

The study did not review load management, rehab quality or whether the injuries presented early or late. Neither was training age, sleep, stress levels, nutrition nor psychology taken into account.

The goal is to work within and with the time line, not to beat it. You want the recovery to be boring but steady.

Do not believe anyone who tells you they can give you a short cut.

Reference

Mulvad B, Nielsen RO, Lind M et al (2018). Diagnoses And Time To Recovery Among Injured Recreational Runners In The RUN CLEVER Trial. PLoS One. 13(10): e0204742. DOI: 10.1371/journal.pone.0204742

An Alarming Health Trend In Our Children

Picture from QMHC

I have noticed an alarming trend. Quite a few young patients I have seen in our clinic recently have hypertension (or high blood pressure). This is supported by a recent study showing that childhood hypertension rates are rising significantly around the world. 

The researchers analyzed 443, 914 young subjects aged 1-19 from 21 different countries from 96 studies. Sub-group analyses were performed by sex, age, urban versus rural settings, investigation period, BMI group. Ready for the results?

High blood pressure nearly doubled between 2000 and 2020 in children, rising from just over 3 percent to more than 6 percent. Many young children show early warning signs. Around 8 percent had blood pressure levels that suggest they may be at risk of developing hypertension in the future. 

Some children had 'masked' high blood pressure. 9 percent of children and teenagers had normal reading when tested in a clinic. They however, had higher levels when measured at home or when tested with specialized monitors suggesting that they can be overlooked.

They also found that blood pressure increased during early teenage years. Levels tend to peak at around 14 years, especially in boys. Weight plays a major role. Almost 1 in 5 children with obesity had high blood pressure compared to less than 1 in 40 children with normal weight.

This matters since the increase in blood pressure can continue when they become adults leading to a risk of heart and kidney problems. The study also highlights the fact that this condition is more common than realized and more must be done to to detect the 'masked' cases since early detection can lead to early treatment. Preventative action can be implemented in countries where childhood obesity is increasing.

Picture from Nature

The need for reliable detection, consistent measurement and effective prevention needs to standardized as high blood pressure increases among children and adolescents under 19, now that we know the scale of the problem. They are after all our future.

Reference

Zhou J, Shan S, Wu J et al (2025). Global Prevalence Of Hypertension Among Children And Adolescents Aged 19 Years Or Younger: An Updated Systematic Review And Meta-Analysis. The Lancet Child & Adoles. 10(1): 11-21. DOI: 10.1016/S2352-4642(25)00281-0

New Research On How To Heal Your Tendons

Loading both quads and Achilles tendon

We have been doing it all wrong. Yes, whatever I written previously in this blog about tendon healing is mostly outdated, except maybe this post on collagen.

We have known about this in our clinics since March this year. Having tried it myself plus teaching our patients with good results, the time is right for me to share this information.

If you have tennis or golfer's elbow pain, jumper's knee or pain in your Achilles tendon, this post will definitely interest you. Before you read further, you need to know that almost all common advise regarding tendons that we knew previously are now mostly inaccurate.

Remember Professor Keith Barr? I wrote about his gelatin collagen research back in 2019. His latest research shows us it's time to ditch outdated treatment and start using a research backed approach to healing tendons. He shared his research in an interview with Tim Ferris. You can also listen to the podcast.

Keith Barr shared that the key to tendon repair is not rest or doing eccentric exercises like we have been taught for the past 20 years. It is targeted low load isometric training.

What tendons need is mechanical load and not rest from injury. Not extreme weight to load it but gentle controlled tension to stimulate and rebuild and realign the collagen fibers correctly. Tendons do not respond well to high reps or dynamic loading especially after injury.

With chronic injuries, tendons develop strong areas to shield (or protect) the damaged areas, so longer isometric holds will make the stronger parts fatigue, redistributing load to the weaker, injured parts to be loaded and get stronger.

With isometric contractions, you are simply holding a contraction without movement, for example like a wall sit to train the quadriceps tendon. This gives the tendon just enough stimulus without wearing it out.

Loading R patella tendon and L Achilles

The effective dose to load your tendon is 10 minutes of your time, according to Dr Barr's research.  You just need to feel tension through the tendon, not necessary to be very heavy. 

Remember it's a contraction of the tendon and not a stretch. Done too long, the tendon fatigues and it's not helpful anymore. Here are the specifics. Hold the contraction for 30 seconds. Rest 2 minutes and repeat 4 times. Total of 10 minutes. You can repeat this again 6-8 hours later to make it twice a day.

The isometric holds provide the stimulus and you can help by taking collagen to help rebuild tendon tissue. Barr's recommendations to double collagen synthesis are 15 grams of hydrolyzed collagen taken with 200-250 mg of vitamin C, 30-60 mins before your isometric holds. Choose collagen from skin sources (bovine hide of fish skin) as bone can contain heavy metals.

If you're injured or have just had surgery, you can start loading immediately after injury or surgery. Dr Barr explained how patients that had correct loading 2 days after injury recovered 25 percent faster compared to those who started at 9 days after injury (Bayer et al, 2018).

Please watch the almost 2 hour video here if you want to find out more. It's really interesting. Or you can listen to the podcast on the Tim Ferris show. I listened to the whole podcast first before watching it.

Reference

Bayer M, Hoegberget-Kalisz M, Jensen M et al (2018). Role Of Tissue Perfusion, Muscle Strength Recovery And Pain In Rehabilitation After Acute Muscle Strain Injury: A Randomized Controlled Trial Comparing Early And Delayed Rehabilitation. Scand J Med Sci Sports. 28. DOI: 10.1111/sms.13269