Obesity and Pain


Obesity is a condition of abnormal or excessive fat accumulation in adipose tissue. A body mass index (BMI) over 25 is considered overweight, and over 30 is obese.

The issue has grown to epidemic proportions, with over 4 million people dying each year as a result of being overweight or obese in 2017 according to the global burden of disease (GBD).

Some numbers… (3)

  • Worldwide obesity has nearly tripled since 1975.
  • 39% of adults aged 18 years and over were overweight in 2016, and 13% were obese.
  • Most of the world’s population live in countries where overweight and obesity kills more people than underweight.
  • Obesity is preventable.

Overweight children are more prone to becoming overweight adults, especially at higher BMIs (body mass index) or if they have an obese parent (4).

Almost half of overweight adults were overweight as children (4).


What causes obesity? (3)

The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended.

  • an increased intake of energy-dense foods that are high in fat and sugars.
  • an increase in physical inactivity.


Adipose (fat) tissue mass increases in two ways: (6)

1. Fat cell hypertrophy: Existing adipocytes enlarge or fill with fat
2. Fat cell hyperplasia: Total adipocyte number increases


The process of weight gain seems to be different in adults and in children (5).

Adults who gain or lose weight may do so through changes in the size of the fat cells (a process known as hypertrophy) . Children, on the other hand, may put on extra fat by increasing the overall number of these cells in the body (a process known as hyperplasia). This may mean that people who got fat during childhood may find it more difficult to shift the weight later in life, compared to those who piled on the pounds as adults.

The average number of fat cells (adipocytes ) rises until the age of about 20, and then remains relatively constant.

An average-sized person has between 25 and 30 billion adipocytes (fat cells), whereas the obese may have more than three to five times this number, particularly when obesity occurs in childhood or adolescence (6).

In adults, the major change in adipose cellularity in weight loss is shrinkage of adipocytes with no change in cell number.


Obesity and Pain (2)

The prevalence of pain is 33% in obesity people. It seems that people with obesity are more pain sensitive, due to a lower pain threshold and pain tolerance. Let’s have a look at several potential mechanisms that may link the two phenomena.


Mechanisms of obesity-related pain

Mechanical mechanism

Direct contribution of weight

  • Excess weight on weight-bearing joints and skeletal muscle tissue causes tissue and joint damage

Indirect contribution of weight

  • The compression forces on the lumbar spine during the lifting tasks is greater in people with obesity compared to people with normal weight.



  • Sleep disturbance can increase pain

Physical activity

  • Low physical activity levels are associated with low-back pain in a population with obesity


People with overweight and obesity demonstrate significantly lower pain threshold and pain tolerance compared with non-obese controls.

Degree of overweight is associated with higher pain sensitivity.

Inflammation theory

  • Obesity is a low-grade inflammatory disease. Pro-inflammatory immune cells and adipocytes (fat cells) secrete pro-inflammatory proteins (cytokines).


Factors influencing pain sensation


  • Women seem to have higher pain prevalence and higher pain sensitivity compared with men

Body fat distribution

  • Body regions with more excess body fat (e.g., abdominal area) may also have a higher level of inflammation. Therefore, they are more pain sensitive compared to body regions with less body fat (e.g., hands and forehead).

Dietary factors

Vitamin D

  • The prevalence of vitamin D deficiency is higher among people with obesity.
  • Greater osteoarthritis pain ratings were reported in people with vitamin D deficiency in both obese and non-obese groups.

Dietary quality

  • An animal study suggested that lower diet quality increased pain sensitivity and susceptibility to chronic pain.


Take home message

It is crucial to keep undercontrol your weight in your youth. Obesity is preventable.

Obesity seems to lead to PAIN, despite the interrelationships between Pain and Obesity is complex and still in its infancy.

It is important that you tackle this pathology. Dietary changes, increased physical activity and behavior changes can help you lose weight.




  1. The association between chronic pain and obesity, 2015;
  2. Obesity and pain: a systematic review, 2019;
  3. Obesity, WHO;
  4. Childhood obesity and adult morbidities, 2010  – The American Journal of Clinical Nutrition;
  5. Fat cell numbers stay constant through adult life, Nature – 2008;
  6. Exercise Physiology: Nutrition, Energy and Human Performance, William D. McArdle, 2009.




Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome (CTS) is a condition involving a nerve (the median nerve), which runs down the front of the forearm and through a tunnel in the wrist where it is being compressed.

CTS is the most common entrapment neuropathies, accounting for 90% of all neuropathies (9). The compression of the median nerve results in pain, tingling and/or numbness in the  thumb, index finger, middle finger, and the radial half (thumb side) of the ring finger. Pain also can radiate up the affected arm. With further progression, hand weakness, decreased fine motor coordination, clumsiness, and atrophy at the base of  thumb can occur.

In the early presentation of the disease, symptoms most often present at night when lying down and are relieved during the day. With further progression of the disease, symptoms will also be present during the day, especially with certain repetitive activities, such as when drawing, typing, or playing video games. Typical occupations of people with carpal tunnel syndrome include those who use computers for extended periods of time, those who use equipment that has vibration such as construction workers, and any other occupation requiring frequent, repetitive movement (9).  

CTS has a prevalence of 5.8% for men and 10% for women. There is a marked increase in prevalence with increasing age: 3.7% in those younger than 30 years of age compared to 11.9% in those over 50 years of age (3).


Risk factors (3)

  • Obesity
  • Age: the risk for CTS appears to increase linearly with age and more than doubles in those over the age of 50.
  • Female sex: increases the risk between 1.5 and 4 times compared to male counterparts
  • Diabetes
  • Osteoarthritis
  • Previous Musculoskeletal Disorders (e.g. chronic back pain, osteoarthritis, fibromyalgia, tendinopaties, rheumatoid arthritis, etc.)
  • Cardiovascular Risk Factors: hypercholesterolemia (high cholesterol), hypertension, high triglycerides (fat in your blood)
  • Hypothyroidism
  • Family history of CTS
  • Lack of physical activity


Classification of Carpal Tunnel Syndrome (2)

  • Mild: intermittent symptoms
  • Moderate: constant symptoms
  • Severe: atrophy at the base of  thumb (Thenar muscle atrophy)


What can help my Carpal Tunnel Syndrome?

Primary interventions  (moderate evidence that it works) (3)

Night splinting

Corticosteroid injection (4)


Secondary interventions (weak evidence that it works)

Assistive techology: keyboards with reduced strike force for patients with CTS who report pain with keyboard use. Develop alternate strategies, including the use of arrow keys, touch screens, or alternating the mouse hand.

Thermotherapy: use of heat for short-term symptom relief.

Electrotherapy: application of microwave or shortwave diathermy for short-term pain and symptom relief.

Phonophoresis (a procedure that delivers drugs through the skin through the use of ultrasound): use for patients with mild to moderate CTS.

Manual therapy: performed directed at the cervical spine and upper extremity, for individuals with mild to moderate CTS in the short term.

Stretching: a combined orthotic/stretching program in individuals with mild to moderate CTS.

Conservative treatment Vs Surgery?

  • Conservative treatment should be preferred for mild and short-term CTS. Surgery (usually carpal tunnel decompression) is more effective than conservative in CTS, and should be considered in persisting symptoms . Surgical treatment leads to a greater improvement of symptoms at six months. At 3 months and 12 months, the results were not significant in favor of surgery or conservative treatment (1).
  • In the long term surgery is superior to conservative treatment (5).


  • Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm (6).


The Goal of the surgery  is to relieve pressure by cutting the ligament pressing on the median nerve.


Surgery complications

Carpal tunnel decompression appears to be a safe operation in most patients, with an overall serious complication rate (requiring admission to hospital or further surgery) of less than 0·1% (7).


Take home message

If a period of conservative treatment causes little to no improvement and/or you have a severe diagnosis of CTS, then surgery may be appropriate. Take into account that in some cases CTS may be resolved spontaneously.

Treat CTS as early as possible after symptoms start. In the early stages, simple things that you can do for yourself may make the problem go away. For example (8):

  • Take more-frequent breaks to rest your hands.
  • Avoid activities that make symptoms worse.
  • Apply cold packs to reduce swelling.




  1. Effectiveness of surgical versus conservative treatment for carpal tunnel syndrome: A systematic review, meta-analysis and qualitative analysis, 2018;
  2. Carpal Tunnel Syndrome: A Summary of Clinical Practice Guideline Recommendations, JOSPT 2019;
  3. Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome, JOSPT 2019;
  4. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial, 2018;
  5. Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome, 2006;
  6. Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome: A Systematic Review, 2017;
  7. Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis, 2020;
  9. Carpal Tunnel Syndrome, Justin O. Sevy et al. 2020.






Should children lift weights?

Don’t worry Mum and Dad. Your kids can lift weights.

Let’s start with some common Myths .

Resistance training will stunt the growth of children

No scientific evidence indicates that participation in a supervised resistance training program will stunt the growth of children or damage developing growth plates (the areas of new bone growth in children and teenegers) BMJ 2014. In all likelihood, regular participation in a well-designed resistance training program during the growing years will have a favorable influence on bone growth and development.

Resistance training is unsafe for children

The risks associated with youth resistance training are not greater than other recreational and sport activities in which youth regularly participate (A D Faigenbaum et al. , BMJ 2014).

Youth need to be at least 12 years old to life weights

Although there is no evidence-based minimum age for participation in a youth resistance training program, all participants should be able to accept directions and follow safety rules. Boys and girls younger than 12 years old have participated safely in supervised resistance training programs (A D Faigenbaum et al). Generally, when youth are ready for sport participation, approximately ages 7 or 8, they are ready for some type of resistance training as part of a well-rounded fitness program.

Girls will develop bulky muscles if they lift weights

Training-induced gains in muscular strength during childhood are primarily due to neuromuscular adaptations and skill development. Although boys may develop bigger muscles during the growing years because the effects of anabolic hormones would be operant, girls can get stronger throughout childhood and adolescence while gaining all the benefits from resistance training without developing bulky muscles (BMJ 2014).

Resistance training is only for young athletes

Regular participation in a well-designed resistance training program offers observable health and fitness value for all children and adolescents (BMJ 2014). In addition to performance enhancement and injury reduction, resistance training can improve musculoskeletal health, enhance metabolic function, and increase daily physical activity. Resistance training may be particularly beneficial for overweight youth who often are unwilling and unable to perform prolonged periods of aerobic exercise (Jordan J Smith, 2014).


It is important that youth resistance training programs should be supervised by qualified fitness professionals and consistent with the needs, interests, and abilities of younger populations. Fitness professionals should provide an opportunity for all participants to have fun, make friends, and learn something new, with the goal of improving muscular fitness (i.e., muscular strength, muscular power, and muscular endurance) ACSM 2016 .


Youth resistance training guidelines with progression based on each participant’s resistance training skill competency and muscular strength:

Resistance training skill competency and muscular strength (ACSM 2016).


  • Set: 1-2                                   Repetitions: varied           Intensity: < 60% 1 RM (Repetition Maximum)
  • Exercises: Basic                    Frequency: 2/week


  • Set: 2-4                                   Repetitions: 6-12              Intensity: < 80% 1 RM
  • Exercises: Intermediate      Frequency: 2-3 / week


  • Set: Multiple                        Repetitions: < 6                 Intensity: > 85% 1 RM
  • Exercises: Advanced          Frequency: 2-4 /week


Despite traditional fears and misinformed concerns associated with youth resistance training, new insights into the design of youth fitness programs have highlighted the importance of enhancing muscular fitness during childhood and continuing participation in strength-building activities throughout adolescence. Although factors such as heredity, training experience, and health habits (e.g., nutrition and sleep) will influence the rate and magnitude of adaptation, seven principles that determine the effectiveness of youth resistance training are the principles of (a) Progression, (b) Regularity, (c) Overload, (d) Creativity, (e) Enjoyment, (f) Socialization, and (g) Supervision (ACSM 2016).



Since today’s youth are weaker and slower than previous generations, the time is ripe to incorporate strength-building exercises into youth fitness programs (Mythbusting – ACSM 2020).

Strength training, when performed in a controlled, supervised environment, can help children and adolescents of all athletic abilities safely improve their strength and overall health and well-being. The health benefits of strength training far outweigh the potential risks, especially in today’s society where childhood obesity continues to rise (Sport Health, 2009).




RESISTANCE TRAINING FOR KIDS, Right from the Start – ACSM, 2016;

Position statement on youth resistance training: the 2014 International Consensus, BMJ;

Resistance training among young athletes: safety, efficacy and injury prevention effects, Br J Sport Med, 2010;

The health benefits of muscular fitness for children and adolescents: a systematic review and meta-analysis, Sports Med – 2014;

World Health Organization. Global Recommendations on Physical Activity for Health. Geneva: WHO Press, 2010. 58 p;

Strength Training in Children and Adolescents. Raising the Bar for Young Athletes? Sports Health, 2009.






What is Fibromyalgia?

Fibromyalgia is a chronic pain syndrome diagnosed by the presence of widespread body pain. The disease is characterised by generalized body pain, fatigue, sleep disturbance, memory and mood difficulties. The prevalence of fibromyalgia is estimated at 2%–4% in the general population, being more frequent in women than in men, with age between 30 and 50 (American College of Rheumatology).

What causes Fibromyalgia?

Fibromyalgia is a condition with unknown aetiology (the causes or origin of disease). The pathophysiology of the disease is not clearly understood, although abnormality in pain processing at various levels, sleep impairment, and abnormalities of the autonomic nervous system (a component of the nervous system that regulates heart rate, blood pressure, respiration, etc.)  have been identified as contributory factors.


How is Fibromyalgia diagnosed?

Despite our increased understanding of the condition, there are no objective diagnostic tests. Diagnosis is often made by exclusion of other conditions such as neurological syndromes and depression. Usually, the diagnosis of fibromyalgia may take years to be completed, with people visiting several medical specialists in that time.

Diagnostic Criteria for Fibromyalgia (AAPT 2019):

  • 6 or more pain sites from a total of 9 possible sites: head, left arm, right arm, chest, abdomen, upper back & spine, lower back & spine (including buttocks), left leg and right leg;
  • Moderate to severe sleep problems or fatigue;
  • Fibromyalgia plus fatigue or sleep problems must have been present for at least 3 months;
  • trouble concentrating, forgetfulness, and disorganized or slow thinking;
  • muscle stiffness, typically more severe in the early morning and improves as the day goes on. It is not responsive to corticosteroids;
  • Environmental sensitivity or hypervigilance, manifesting as intolerance to bright lights, loud noises, perfumes and cold.


How is Fibromyalgia treated?

In general, the treatment of fibromyalgia should take the form of a graduated approach. . Initially, we should focus on non-pharmacological therapies. There is a strong recommendation for the use of exercise, particularly given its effect on pain, physical function and well-being, availability, relatively low cost and lack of safety concerns. We don’t know which type of exercise is more effective: strength and/or aerobic training (e.g. walking, running, cycling).

There is a weak recommendation for other non-pharmacological therapies, such as cognitive behavioural therapies (CBT), acupuncture, hydrotherapy, yoga, and tai chi.

Fibromyalgia often requires a multidisciplinary approach with a combination of non pharmacological and pharmacological treatment, even though, there is a weak recommendation for the latter.

Pharmacological therapies should be considered for those with severe pain (duloxetine, pregabalin, tramadol) or sleep disturbance (amitriptyline, cyclobenzaprine, pregabalin).

Pharmacological therapies which are not recommended are NSAIDs (e.g. Ibuprofen), MAOIs (antidepressants), SSRIs (antidepressants), o growth hormone, sodium oxybate, strong opioids and corticosteroids. (EULAR 2016)

Living with Fibromyalgia

With proper treatment and self-care, you can get better and live a more normal life. Here are some self-care tips for living with fibromyalgia (American College of Rheumatology):

  • Make time to relax each day. Deep-breathing exercises and meditation will help reduce the stress that can bring on symptoms.
  • Set a regular sleep pattern. Go to bed and wake up at the same time each day. Getting enough sleep lets your body repair itself, physically and mentally. Also, limit caffeine intake, which can disrupt sleep. Nicotine is a stimulant, so those fibromyalgia people with sleep problems should stop smoking.
  • Exercise often. This is a very important part of fibromyalgia treatment. Regular exercise often reduces pain symptoms and fatigue. You should follow the saying, “Start low, go slow.” Slowly add daily fitness into your routine. It takes time to create a comfortable routine. Just get moving, stay active and don’t give up!
  • Educate yourself. Nationally recognized organizations like the Arthritis Foundation and the National Fibromyalgia Association are great resources for information. Share this information with family, friends and co-workers.
  • Look forward, not backward. Focus on what you need to do to get better, not what caused your illness.



  • American College of Rheumatology website;
  • EULAR revised recommendations for the management of fibromyalgia, 2016;
  • AAPT Diagnostic Criteria for Fibromyalgia, 2019.



How to burn FAT faster?

In order to use fat (Free Fatty Acids –  FFA) as your main fuel, you need to exercise at low intensity (e.g. cycling, walking) so the body has the capacity to mobilize and oxidize fat (break down fat). Remember, the complete oxidation of one molecole of stearic acid (fat)  requires 26 molecules of oxygen, while the complete oxidation of one molecule of glucose (carbohydrate) requires only 6 molecules of oxygen. In other words, if you want to burn fat you need more oxygen and this is the reason why you should exercise at low intensity (in theory).

Fat combustion almost totally powers exercise at 25% of aerobic capacity (it is the highest amount of oxygen consumed during maximal exercise). If you walk or cycle, at 1 hour you use 70% of carbohydrate and 30% of fat, at 2 hours 60% of carbohydrate and 40% of fat, at 3 hours 40% of carbohydrate and 60% of fat, and at 4 hours 20% of carbohydrate and 80% of fat (Generalized percentage contribution of macronutrient catabolism in relation to oxygen consumption of the leg muscles during prolonged exercise, e.g. cycling  figure 2.9, page 46 – William D McArdle, Frank I Katch – Essentials of Exercise Physiology 4th edition, 2011).

As you can see exercise intensity and duration affect Fat Oxidation. You need to walk or cycle for more than 3 hours if you want to use fat as your main fuel. That’s boring and unfeasible.

Don’t worry, there is another way…

You need to increase your metabolism! The only way to increase your metabolism is resistance training ( weight lifting) in order to build up your fat-free mass (muscles). More muscles = higher metabolism at rest = more calories to burn.

Endurance training (running, cycling, rowing, etc) has a lot of beneficial effects on your heart health, cardiorespiratory function, endurance fitness, and physical well-being. However, it is important to realize that muscles are the engines of our bodies. If the engine is bigger, we burn more calories. For this reason, the only option you have to keep a big engine is …. weight lifting.

ACSM (The American College of Sports Medicine) Resistance training recommendations:

  • 2-4 sets x 8-12 reps each for the major muscle groups;
  • 70% – 80% of maximum resistance (8-12 reps);
  • performing 8 to 10 multi joint exercises;
  • two or three nonconsecutive days per week

Another option if you don’t have time to go to the gym or like now you are stuck at home due to covid19, it is high-intensity circuit training (HICT) using body weight as resistance.

HICT can be a fast and efficient way to lose excess body weight and body fat. When resistance training exercises using multiple large muscles are used with very little rest between sets, they can elicit aerobic and metabolic benefits. Research has found that these metabolic benefits can be present for up to 72 hours after a high-intensity exercise bout has been completed.

  • Number of exercises 9-12
  • A 30-second exercise bout
  • Rest Between Exercise Bouts 30″ (6)
  • Total exercise time at least 20 min  ACSM guidelines (3)

HICT SAMPLE PROGRAM: The following is an example of a 12-station HICT program. Exercises are performed for 30 seconds, with 10 seconds of transition time between bouts. Total time for the entire circuit workout is approximately 7 minutes. The circuit can be repeated 2 to 3 times.

  1. Jumping jacks Total body
  2. Wall sit Lower body
  3. Push-up Upper body
  4. Abdominal crunch Core
  5. Step-up onto chair Total body
  6. Squat Lower body
  7. Triceps dip on chair Upper body
  8. Plank Core
  9. High knees/running in place Total body
  10. Lunge Lower body
  11. Push-up and rotation Upper body
  12. Side plank Core



You don’t need to walk or cycle for hours, in order to start burning fat. Everyone will give up at one point. There is a much better and quicker way. You need to do resistance training, because the secret to burn fat faster is to increase your metabolism. 



  • Carbohydrate and fat utilization during rest and physical activity, the European e-Journal of
    Clinical Nutrition and Metabolism, 2010;
  • Skeletal muscle energy metabolism during exercise, Nature metabolism, 2020;
  • HIGH-INTENSITY CIRCUIT TRAINING USING BODY WEIGHT: Maximum Results With Minimal Investment, ACSM, 2013;

  • Intramuscular and extramuscular fuel sources (fig.2 – Skeletal muscle energy metabolism during exercise, Nature metabolism, 2020);
  • William D McArdle, Frank I Katch – Essentials of Exercise Physiology 4th edition, 2011, page 46, figure 2.9



Frozen Shoulder

What is Frozen Shoulder?

Frozen Shoulder, also known as Adhesive Capsulitis, is a condition where the capsule, a membrane which encloses the shoulder joint, becomes thickened and tight. This process leads to stiffness and pain in your shoulder, and affects 2 to 5% of the general population.

Frozen shoulder can be classified as primary (idiopathic = cause is unknown) or secondary (typically present after shoulder injury or surgery).

Today we are talking about the primary frozen shoulder…


Risk Factors

Diabetes, Thyroid disease, age 40-65, female, and a previous episode of adhesive capsulitis in the contralateral arm.



There is a gradual and progressive onset of pain and restricted active and passive ROM (range of movement) in both elevation and rotation of the shoulder. Functional activities such as reaching overhead, behind the back, or out to the side become increasingly difficult due to pain and/or stiffness.

Diagnostic Classification Criteria

Age is between 40 and 65 years old;

Pain and stiffness limit sleeping, grooming, dressing, and reaching activities;

Shoulder rotation movement (internal or external) decreases;

Imaging (x-ray) are usually normal.


Clinical Course 

What should you expect?

  • At first, pain is the main problem. It can spread down the arm and is often worse in bed, especially if lying on the affected side, disturbing sleep.
  • The pain slowly eases, but stiffness increases, becoming the main problem, before gradually resolving.
  • The whole process may last from a few months to two to three years, but the pain does not last for the whole time.

How can you help yourself?

  • When in pain, the emphasis is on pain relief and gentle use of your arm to ease spasm and maintain movement.
  • Using your arm will not do any harm, but avoid aggravating your pain by doing too much. Take pain medication as advised. You may find hot packs helpful.
  • In bed, support the arm with pillows as a reminder not to roll onto it.
  • As time passes you will feel less need for pain relief.



Radiographs are not routinely required, but if obtained, are typically normal with adhesive capsulitis.



Conservative treatment

Intra-articular corticosteroid injections combined with physiotherapy (shoulder mobility and stretching exercises) are effective in providing short-term (4-6 weeks) pain relief and improved function. This article shows some exercises you can do.

If symptoms fail to resolve with conservative treatment, then surgery may be considered.

Surgical treatment options:

  • Manipulation under anaesthesia (MUA): manipulation of the shoulder joint under general anaesthesia.
  • Arthroscopic capsular release (ACR): surgical procedure to release contracted tissue.
  • Hydrodilatation: injection of sterile saline solution, usually with corticosteroid, to distend the shoulder capsule.

A study from The Lancet in 2020, showed that both treatments (conservative and surgical) led to substantial improvements in shoulder pain and function. None of the treatments were clearly superior.

A study from The BMJ (British Medical Journal) in 2016, reported that treatments other than pain medication are not always needed; but steroid injections are often used to reduce inflammation and pain in the shoulder, and physiotherapy may help to diminish pain and restore movement.

A minority of people are referred to hospital with frozen shoulder, where additional options include release of the tight tissues by an injection or by keyhole surgery.

It remains unclear which options are most effective. You should discuss treatment options with your clinician, based on your needs and preferences.

Another study from JAMA (The Journal of the American Medical Association) in 2020, showed that steroid injections was associated with increased short-term  (< 12 weeks) benefits compared with other nonsurgical treatments, and its superiority appeared to last for as long as 6 months. The addiction of  a home exercise program with simple ROM (range of movement) exercises and stretches, it may be associated with added benefits. The results of this study suggest that steroid injection should be offered to people with frozen shoulder at first contact.



Frozen shoulder is a condition that can be quite debilitating and it could take over 2-3 years to recover. It is important that you find the right balance between rest and activity to prevent your shoulder from stiffening. Try to avoid the movements that are most painful and remain generally active, even if you have to limit how much you do. It remains unclear which treatment options are most effective in the long-term (conservative or surgical), but in the short-term, steroid injection is the best option; which should be accompanied by exercises to maximize the chance of recovery.



  • Shoulder Pain and Mobility Deficits: Adhesive Capsulitis, JOSPT 2013;
  • Physical therapy in the management of frozen shoulder, SMJ 2017;

  • Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial, The Lancet 2020;
  • What is the most effective treatment for frozen shoulder? BMJ, 2016.
  • Comparison of Treatments for Frozen Shoulder A Systematic Review and Meta-analysis, JAMA, 2020.



Osteoarthritis (OA) is the most common form of arthritis, affecting an estimated 302 million people worldwide, and is a leading cause of disability among older adults. The knees, and hips, are the most commonly affected joints. OA leads to pain, stiffness, swelling, and loss of normal joint function (article). 

X-Ray has showed severe osteoarthritis in my knee / hip. What should I do? 

Do not panic. Imagings quite often show some abnormalities, but  it doesn’t mean that those findings are the cause of your pain. Let’s have a look at the poor correlation between knee pain and imagings, for example.

Knee X-ray and Pain

Radiographs have long been considered as the reference standard for the assessment of OA, for more than four decades. To date, the majority of studies have reported that radiographic OA (ROA) is poorly correlated with knee symptoms, and most risk factors for ROA are not strong predictors of knee pain. Pain perception is complex, however, and knee pain is frequently associated with non-OA variables, such as psychosocial factors, education, economic status as well as local pathology (article).

Knee MRI and cartilage damage

Arthritic change within knee joints is very common even in those without pain, for example a study from Geurmazi et al. 2012, found 69% of people with no pain had evidence of cartilage damage on MRI.


Now, you know that you shouldn’t completely believe to your imaging findings, because there are people with asymptomatic knee osteoarthritis and other people with symptomatic knee osteoarthritis. If you are part of the second group, there are two things you can start doing:

Exercise and Weight loss

The Key Factor  is to listen to your knee. You know what type of exercises your knee likes and doesn’t like to do. It is important that you keep the intensity of the pain below 5/10 (0= no pain; 10 = the worst pain), to avoid flare ups.

Exercises: Tai Chi, Yoga, Walking, Cycling, Balance Training, Running?

Running does not increase symptoms or structural progression in people with knee osteoarthritis – Grace H. et al. 2018

Key points from the article:

  • Running doesn’t appear to increase the risk of developing hip or knee arthritis;
  • Running with knee OA doesn’t seem to speed up disease progression or worsen symptoms over a period of time.

Avoid: TENS (transcutaneous electrical nerve stimulation), Modified Shoes, Wedged Insoles, Massage, Manual Therapy, Pulsed Vibration Therapy. The scientific evidence behind these treatments and tools is weak.



Bear in mind that it is crucial to exercise and keep your weight under control. These are the only two tools we can use to slow down osteoarthritis progression. The last but not the least, don’t be too worried about your X-ray findings. Remember, there is poor correlation between joint pain and imagings.




2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee;

Radiographic Knee Osteoarthritisand Knee Pain: Cross-sectionalstudy from Five Diferent Racial/Ethnic Populations 2018;

Running does not increase symptoms or structural progression in people with knee osteoarthritis: data from the osteoarthritis initiative. Clin Rheumatol. 2018;

Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study), Guermazi et al. 2012.



Weight loss myths



The top four weight loss myths (by Renee J. Rogers)

  • Myth 1: The need to choose Diet over Exercise: Weight Loss = 80% diet + 20% Exercise. Eat Less and Move More is the general recommendation used to describe the likely more complicated relationship between lifestyle weight loss behaviors: diet and exercise. If we focus only on diet by cutting calories, we will lose fat mass and muscle mass at the same time. For this reason it is important to combine diet with exercise. The latter helps us to keep the weight off, especially if we do high level of physical activity (upwards of 225-250 min/week).


  • Myth 2: I Exercise, so I get to Eat more. Let’s be honest, some people definitely choose to use exercise as a way to burn more calories so they have more room for food later. If your goal is to lose weight, this method doesn’t work.


  • Myth 3: Burning Calories through Exercise means High-Intensity Workouts and Long Session at the Gym. The reality is that moderate-to-vigorous intensity exercise is recommended, and we want to work towards burning as many calories as possible through accumulating physical activity minutes. Achieving that volume can be done in a variety of ways (no one exercise mode is perfect).


Research shows that it is not just about the intense workout that happens in the gym. A study of 260 adults participating in a weight management program found that after 18 months, those that had greater amounts of light-intensity activity beyond structured moderate-vigorous exercise lost more weight.

All physical activity burns calories. More intensity equals greater caloric burn, but more overall volume, even at lower intensities and durations can add up too. Consider building physical activity into the entire lifestyle not just at the gym, to maximize overall volume. Activity programming should be designed to balance burning calories with individualized strategies that keep the person moving more and sitting less through their entire day. Even a one-minute activity break can be a move in the right direction.


  • Myth 4: Everything has to Change Immediately.


Stacking Behaviors: Everyone is different, so determining what the person feels more comfortable to start with (diet or exercise) may be a positive strategy. The end goal should be Diet + Exercise.

Start slow and go slow: Extreme changes are often not fun and not sustainable. We have to build a foundation for maintaining positive eating and activity habits for the long term.

Make a plan: We need to set short term goals that strategically introduce the next positive layer of weight loss behavior.


Low Back Pain: a major global challenge

A study published by the Lancet in 2018, reported that almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, with the biggest increase seen in low-income and middle-income countries. Disability due to back pain has risen by more than 50% between 1990 and 2015.

For nearly all people with low back pain, it is not possible to identify a specific cause (non-specific low back pain). Only a small proportion of people have a well understood pathological cause  e.g. a vertebral fracture, malignancy, or infection (specific low back pain).

Key messages:

  • Low back pain is an extremely common symptom.
  • Most episodes of low back pain are short-lasting with little or no consequence
  • People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain.
  • Disabling low back pain is over-represented among people with low socioeconomic status, where possibilities for job modification are limited.
  • Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes.

Prevention and Treatment of low back pain

  • There is lack of evidence for prevention of low back pain: back belt, ergonomic furniture, work-place education, no-lift policies, mattresses, lifting device. The only known effective interventions (based on low to moderate quality evidence) are exercise combined with education, or exercise alone.
  • Do not recommend passive electrical or physical modalities, such as ultrasound, transcutaneous electrical nerve stimulation (TENS), traction, short-wave diathermy, and back support for low back pain.
  • No one exercise seems superior to another.
  • Some guidelines do not recommend passive therapies, such as spinal manipulation or mobilisation, massage, and acupuncture, some consider them optional, and others suggest a short course for patients who do not respond to other treatment.
  • Spinal imaging is inappropriate for non-specific low back pain ( Brinjikji at el. 2015).







  • Interventional therapies (e.g. injections, surgery and medicines) have a limited role for non-specific low back pain.
  • Non-pharmacological treatments in the form of advice, reassurance, and activity should be the first line treatmen option for non-specific low back pain.
  • Paracetamol is not recommended.
  • Consider oral non-steroidal anti-inflammatory drugs (NSAIDs), taking into account potential risks, and if using them, prescribe the lowest effective dose for the shortest possible time.
  • Routine use of opioids is not recommended, since benefits are small and substantial risks exist, including overdose and addiction. If used, they should only be in carefully selected patients, for a short duration, and with appropriate monitoring.


Low back pain is very common and in most cases the pain is not caused by anything serious and will usually get better over time. The key factor is to keep yourself active and exercise. Remember that no one exercise seems superior to another. It is also crucial to avoid resting and do not use a back supports to protect your lumbar spine, otherwise you might end up in a vicious cycle: fear of movements –> muscle overactivity –> more pain.

There is a great ebook written by Dr Greg Lehman, a physiotherapist, which I highly recommend. The ebook is free and basically it helps you to understand pain.





Low Back Pain: a major global challenge, The Lancet, 2018;

  1. Brinjikji at el. 2015.



Keep yourself active and fit!!!

Why is so important to keep yourself active and fit?

Globally people are becoming less active, this is partly due to a busy life style. We have become reliant on our cars, using these for even the shortest of distances. Due to changing times and covid-19 many people are now working from home, meaning even less activities and exercises. Due to advanced technology, fast food and shopping can be done without living the house again reducing activities.

Let’s see a few numbers…

The World Health Organization (WHO) in 2010 identified physical inactivity as the fourth leading risk factor for global mortality (6% of deaths globally).

This follows high blood pressure (13%), tobacco use (9%) and high blood glucose (6%). Overweight and obesity are responsible for 5% of global mortality.

Insufficient physical activity is a key risk factor for noncommunicable diseases (NCDs) such as cardiovascular diseases, cancer and diabetes.

Physical activity has significant health benefits and contributes to prevent NCDs.

Globally, 1 in 4 adults is not active enough.

More than 80% of the world’s adolescent population is insufficiently physically active.

How much of physical activity is recommended (for adults aged 18-64 years)?

  • Should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity.
  • For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week, or equivalent.
  • Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

Moderate aerobic activity: walking, riding a bike, dancing, hiking, doubles tennis, water aerobics, rollerblading.

Vigorous activity: jogging or running, swimming fast, riding a bike fast or on hills, sports (football, rugby, netball, hockey), aerobics, gymnastics, martial arts.

In general, 75 minutes of vigorous intensity activity can give similar health benefits to 150 minutes of moderate intensity activity.

It is important to know that vigorous intensity activity increases our cardiorespiratory fitness which allows us to live longer .

Cardiorespiratory fitness is an indication of a person’s overall physical health, and improving it should be the aim of everyone because it helps us to live better and more than anything longer.

A study pubblished in 2018 by Jama, compares cardiorespiratory fitness long-term with mortality. The take aways from this study are:

  • Cardiorespiratory fitness is inversely associated with long-term mortality.
  • High aerobic fitness is associated with the greatest survival and is associated with benefit in older patients and those with hypertension.
  • Cardiorespiratory fitness is a modifiable indicator of long-term mortality, and health care professionals should encourage patients to achieve and maintain high levels of fitness.


It is crucial that we find at least half an hour everyday for some activities and exercises. We have no excuse. Stop saying “I don’t have time”, “I am a full-time parent , “I am too old”, “I am too stressed”, etc. Stop lying to yourself! If you really want you can find easly 30 minutes a day. It is the only tool he have, combined with a healthy diet, to reduce the risk of cardiovascular diseases, cancer and other pathologies. In this way, we are going to live better and longer.



  • The World Health Organization (WHO), Physical Activity, 2010;
  • Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing, JAMA 2018.