NOVAR Musculoskeletal Research Institute (NMRI)

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Ballarat OSM and NOVAR Specialist Healthcare work closely with NMRI, a non-for-profit clinical research, training, and education institute based in Ballarat. Through collaboration with the community, we seek to improve the lives of patients with musculoskeletal conditions and diseases.  Our aim is to enhance the understanding and healthcare of musculoskeletal disease through published clinical and non-clinical research, by collecting and collating data utilised for information dissemination through publishing high quality articles in reputable journals and enhancing cooperation.

You can help by participating in our patient outcomes research program, and by making a tax-deductible donation to support the research institute.

No bones about it, we can’t do it without your support.

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Our Vision

Masters of responsible research and innovation, driving collegiality and improvement in musculoskeletal disease healthcare.

Our Mission

Innovative patient focused research institute that engages and enriches the community, through improved musculoskeletal healthcare outcomes via strong commitment to excellence in the field of traumatic and degenerative musculoskeletal disease.

Range-of-Motion Exercises for Arthritis

Stretches and range-of-motion exercises aim to improve the mobility and flexibility of your joints. To increase your range of motion, move a joint as far as it can go and then try to push a little farther. These exercises can be done any time, even when your joints are painful, as long as you do them gently.

Here are four range-of-motion exercises that you can do at home.

 

Arthritis Hand Exercise

Hand

Open your hand, holding the fingers straight. Bend the middle finger joints. Next, touch your fingertips to the top of your palm. Open your hand. Repeat 10 times with each hand. Next, reach your thumb across your hand to touch the base of your little finger. Stretch your thumb back out. Repeat 10 times.

Shoulder

Lie on your back with your hands at your sides. Raise one arm slowly over your head, keeping your arm close to your ear and your elbow straight. Return your arm to your side. Repeat with the other arm. Repeat 10 times.

Knee

Sit in a chair that is high enough for you to swing your legs. Keep your thighs on the seat and straighten out one leg. Hold for a few seconds. Then bend your knee and bring your foot as far back as possible. Repeat with the other leg. Repeat 10 times.

ArthritisExerciese_4

Hip

Lie on your back, legs straight and about 6 inches apart. Point your toes toward the ceiling. Slide one leg out to the side and then back to its original position. Try to keep your toes pointed up the whole time. Repeat 10 times with each leg.

Our team of Physiotherapists, Sport & Exercise Medicine physicians and Orthopaedic Surgeons will be able to specifically advise you of your capacity and frequency for undertaking these exercises based on your condition.

To learn more about how exercise can help alleviate the symptoms of osteoarthritis, check out Living Well with Osteoarthritis, a Special Health Report from Harvard Medical School.

 

5 Surprising Benefits Of Walking

 

The next time you have a check-up, don’t be surprised if your doctor hands you a prescription to walk. Yes, this simple activity that you’ve been doing since you were about a year old is now being touted as “the closest thing we have to a wonder drug,” in the words of Dr. Thomas Frieden, former director of the USA Centers for Disease Control and Prevention.

Of course, you probably know that any physical activity, including walking, is a boon to your overall health. But walking in particular comes with a host of benefits. Here’s a list of five that may surprise you.

  1. It counteracts the effects of weight-promoting genes.Harvard researchers looked at 32 obesity-promoting genes in over 12,000 people to determine how much these genes actually contribute to body weight. They then discovered that, among the study participants who walked briskly for about an hour a day, the effects of those genes were cut in half.
  2. It helps tame a sweet tooth.A pair of studies from the University of Exeter found that a 15-minute walk can curb cravings for chocolate and even reduce the amount of chocolate you eat in stressful situations. And the latest research confirms that walking can reduce cravings and intake of a variety of sugary snacks.
  3. It reduces the risk of developing breast cancer.Researchers already know that any kind of physical activity blunts the risk of breast cancer. But an American Cancer Society study that zeroed in on walking found that women who walked seven or more hours a week had a 14% lower risk of breast cancer than those who walked three hours or fewer per week. And walking provided this protection even for the women with breast cancer risk factors, such as being overweight or using supplemental hormones.
  4. It eases joint pain.Several studies have found that walking reduces arthritis-related pain, and that walking five to six miles a week can even prevent arthritis from forming in the first place. Walking protects the joints — especially the knees and hips, which are most susceptible to osteoarthritis — by lubricating them and strengthening the muscles that support them.
  5. It boosts immune function.Walking can help protect you during cold and flu season. A study of over 1,000 men and women found that those who walked at least 20 minutes a day, at least 5 days a week, had 43% fewer sick days than those who exercised once a week or less. And if they did get sick, it was for a shorter duration, and their symptoms were milder.

Our team of Physiotherapists, Sport & Exercise Medicine physicians and Orthopaedic Surgeons will be able to specifically advise you of your capacity and frequency of walking based on your condition.

To learn about additional benefits of walking, check out Walking for Health, a Special Health Report from Harvard Medical School.

Injections For Knee Osteoarthritis

 

Knee osteoarthritis (OA) is one of the most common and most costly issues facing our modern Australian population.

While knee replacement is often a very effective treatment for osteoarthritis pain, it is major surgery. Recent high-quality studies have shown that in some cases, knee arthroscopy (‘a clean-out’) may be no better (or even worse) than no treatment at all.

Between pain medications and surgery, there are injectable treatments that can improve knee pain and function. The most commonly used injections for knee OA fall into three categories: corticosteroids (“Cortisone”), hyaluronans (e.g. “Durolane” or “Synvisc”), and blood-derived injections (platelet rich plasma or “PRP”, and others).

Cortisone

Sometimes a knee may have some longstanding OA but has become suddenly more swollen and painful: in this situation a corticosteroid injection may settle the knee back to how it was beforehand. Corticosteroids are powerful anti-inflammatory drugs, but do not improve the overall cartilage health of a knee with OA, and care must be taken that there is no infection in the knee, as a cortisone injection may make this much worse.

Hyaluronans

Hyaluronans are synthetic versions of the natural fluid inside the knee joint. In a normal knee this fluid helps to lubricate the joint and to keep the cartilage healthy. In a knee with OA, the knee fluid is also damaged and does not protect the joint as it should. An injection of a synthetic hyaluronan replaces the unhealthy fluid. Over more than 25 years of use worldwide this has been found to be an effective means of improving knee pain and function. This works best in knees with mild rather than severe OA and is usually very well tolerated. Improvements are often seen to last for 12-18 months.

We use Durolane, which has virtually no risk of allergic reactions compared to Synvisc (about 2% risk). Another option is Cingal, which is a combination of hyaluronan and cortisone.

Platelet-Rich Plasma (PRP)

Blood-derived treatments aim to provide natural anti-inflammatory substances from the blood. Blood is taken from the patient (like for a blood test), and then treated to extract the chosen substances, before being injected back into the knee. PRP is the most studied version of these treatments and has been found to improve knee pain and function for 12-24 months.

At Ballarat Orthopaedics and Sports Medicine, we have the capacity to provide any of these treatments, and the experience and knowledge to help you choose which treatment is the best one for you.

Physiotherapy Hours Extending

Peta-Johnston

Ballarat Sports Medicine has recently welcomed Peta Johnston to our team. Peta is an experienced Physiotherapist who graduated from the Bachelor of Physiotherapy with Honours at La Trobe University in 2006. Since graduating she has worked clinically as a physiotherapist throughout western Victoria including public and private hospital settings as well as private practice. She has significant caseload experience in many areas of Physiotherapy practice including: orthopaedic inpatients/outpatients, geriatric evaluation and management, and community rehabilitation. Peta is a member of the Australian Physiotherapy Association and is currently undertaking her PhD into outcomes following anterior cruciate ligament (ACL) reconstruction surgery. Peta strives to apply evidence-based practice to help improve movement patterns and functional performance and real-life outcomes for her clients.

Peta has commenced providing an after-hours Physiotherapy service at Ballarat Sports Medicine.

Peta-Johnston

Point of Care Ultrasound (POCUS)

Point of care ultrasound (POCUS) has become increasingly important in many branches of medicine, from obstetrics to emergency medicine and anaesthetics. Technological advances in both ultrasound probes and connectivity have allowed for smaller machines that can provide images with as good a quality as the larger machines of 10 years ago. This means that ultrasound can be used in the rooms, or even at a footy club or sporting event.

In Sports Medicine we use ultrasound to guide many of our injections. Not all our injections need an ultrasound for guidance, but for some things it allows us to be sure we are treating exactly the right spot. Getting an injection under ultrasound guidance costs a bit more up front, but you get back more from Medicare.

Like with any tool, using an ultrasound requires training and practice. Our Sports Physicians spend time practicing and learning from experienced musculoskeletal sonographers (ultrasound technicians) to make sure their skills are up to date.

ACL Study

At Ballarat Sports Medicine, we have strong systems in place to support your return to sport after ACL reconstruction. Patients who have had an ACL reconstruction receive Physiotherapy, strengthening and a progressive return to sport plan. Periodic advanced progress testing with our Ballarat OSM & Ballarat Sports Medicine ACL return to sport testing protocol occurs at 3, 6, 9, 12 and if needed 15 months post operatively with our physiotherapist and orthopaedic surgeon. They check that patients are making good progress and to help keep on track for optimal results with performance and to reduce the risk of re injury.

If patients are receiving physiotherapy outside Ballarat Sports Medicine test results and recommendations going forward in rehabilitation are passed on to the treating team. These are some interesting finding from La Trobe University regarding return to pivoting sports after ACL reconstruction.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery

Historically, patients have been advised to withhold their Disease-modifying antirheumatic drugs (DMARDs) preoperatively, but the other joints suffer, and the patients struggle. Updates both in arthroplasty and foot and ankle surgery recommend continuing methotrexate.

DMARDs have made a massive improvement to medical management of rheumatoid arthritis, and other inflammatory joint disorders, reducing the previous reliance on steroids. The first generation of these are the “non-biologicals”. A number of RCT’s have been published, and the risk of infection was DECREASED with continuing non-biological DMARDs, with a relative risk of 0.39 (CI 0.17-0.91). Biological drugs act like proteins targeting specific areas of the immune system, examples include TNF inhibitors, Rituximab, and Belimumab. Currently most the data on the biologicals is not regarding perioperative periods. Although the infection rates may be lower, the scientific proof is not there yet. Generally, then, it is advised to do surgery in the week after missing a dose and recommencing once wound healing progressed.

For patients with severe SLE, it has been recommended to continue Mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus, but to withhold them for non-severe SLE. A discussion with the patient’s rheumatologist is clearly needed in SLE.

SUMMARY

DMARDs – continue

methotrexate
leflunomide
hydroxychloroquine
sulfasalazine

Biologics – do surgery in the week after a missed dose, recommence once wound healing is progressing well.

Patients with severe SLE – don’t withhold medication, get rheumatologist advice

Mild SLE – withhold:

Mycophenolate mofetil
azathioprine
cyclosporine
tacrolimus

Prednisolone
preferably operate with daily dose 20mg or less

References: Saunders, Noah E.; Holmes, James R. MD; Walton, David M. MD; Talusan, Paul G. MD. Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery, JBJS Reviews: June 2021 – Volume 9 – Issue 6 – e20.00201 doi:10.2106/JBJS.RVW.20.00201

Sports Medicine physicians can administer cortisone injections

Ballarat Sports Medicine physician can administer a range of injections to assist with pain, injury, and recovery. One of these is cortisone injections. The following provides an insight into cortisone. Patients should always be guided by a medical professional on the advantages and disadvantages of cortisone use.

Dr Greg Harris and Dr Bryn Savill are qualified to be able to assess your pain, injury and determine the best course of action for recovery, including if required the use of cortisone.

What is cortisone?

Cortisone is the name used to describe a group of drugs commonly known as corticosteroids. The types of cortisone used at BallaratOSM include Celestone (Betamethasone) and Depo-Medrol (Methylprednisolone). Cortisone is used to treat pain in various parts of the body where inflammation is felt to be the cause of this pain. The reason why cortisone is effective in treating such pain is because it is a powerful anti-inflammatory. It is not purely a painkiller. Cortisone is NOT an illegal steroid medication, such as those steroids used by some disqualified body builders and athletes.

Why inject cortisone?

In regard to musculoskeletal problems, cortisone injections are performed in order to reduce or even eliminate pain associated with a variety of disorders, such as:

  • Bursitis (most commonly subacromial and trochanteric bursitis)
  • Arthritis (any joint may be injected, including joints of the spine)
  • Nerve pain (most commonly for sciatica and carpal tunnel syndrome)
  • Some tendon conditions, such as plantar fasciitis, trigger finger, DeQuervain’s tenosynovitis). In pure tendon injuries cortisone is best avoided, as it can worsen a tendon tear.
  • Other miscellaneous conditions where inflammation is a contributor to the pain, for example frozen shoulder/adhesive capsulitis, Morton’s neuroma, ganglion cyst injections and Dupuytren’s contracture.

How is cortisone administered?

  • The skin is prepared using an antiseptic agent.
  • Many of the injections performed at Ballarat Sports Medicine will be done using ultrasound, with the needle being guided into the relevant body part. Some injections do not need guidance and can be done without the ultrasound.
  • The degree of discomfort during the procedure is generally mild, as the needle used is fine and local anaesthetic is mixed in with cortisone. If only one pass is planned (meaning that the needle will only penetrate the skin once) then local anaesthetic is usually NOT injected into the skin. It is our experience that injecting local anaesthetic into the skin in a single pass procedure is actually more painful, as local anaesthetic stings a little prior to taking effect. Also, the needle used to inject the local anaesthetic results in similar discomfort as the needle delivering the cortisone. Local anaesthetic is only injected into the skin if more than one pass is made through the skin. Of course, if you wish for local anaesthetic to be injected despite our recommendation, we are happy to do this.
  • A greater degree of discomfort may occur if:
    • the underlying inflammation is severe
    • the area to be injected is severely painful
    • the needle tip requires to be repositioned several times in order to distribute the cortisone effectively
    • a previous bad experience has resulted in a fear of needles, or there is a general anxiety/phobia of needles and other medical procedures.
  • In cases where a cyst, ganglion, bursa or joint is distended with fluid, the cortisone will be injected after an attempt to aspirate (remove) the fluid in order to improve comfort.

Benefits, Risks, Complications and Side-Effects of Cortisone

  • As for all medical procedures, there are risk associated with the administration of any medication, including cortisone. The chances of cortisone providing you with the benefit of pain relief in most patients outweighs the risk of experiencing a side effect(s) (discussed below). The decision to inject cortisone is not taken lightly and is carefully made by your referring doctor and based on your signs, symptoms and past medical history, as well as the suspected diagnosis. Frequently, a trial injection is made where the diagnosis is not clear, however the body region that is to be injected is suspected of causing your pain.

    The side effects and risks of a cortisone injection include:

    • Allergy to any of the substances utilised during the procedure, such as the cortisone, dressing, local anaesthetic or antiseptic. This is usually minor and self-limiting.
    • The cortisone may result in palpitations, hot flushes, insomnia, and mild mood disturbance. This usually resolves within 24 hours and no treatment is necessary.
    • Infection is a rare but serious complication (<0.1%), especially if injected into a joint. Most infections take at least a day or two to manifest, so pain at the injection site after 48 hours is considered to be due to an infection until proven otherwise. Even if not definitively proven, you may be commenced on empirical antibiotic treatment.
    • Local bruising.
    • Localised skin and subcutaneous fat atrophy (thinning resulting in dimpling).
    • Hypopigmentation (whitening of the skin) at the injection site. This most commonly happens in injections of the palm of the hand or sole of the foot.
    • Mild increase in blood sugar levels in diabetic patients for several days and may last up to a week.
    • Transient increase in pain at the injection site before the cortisone takes effect. Occasionally this may be severe, however usually lasts only 24–48 hours and is treated with a cold pack, paracetamol and anti-inflammatory medication. If this occurs and you are concerned, especially if the pain is not settling despite the above treatment, then please call contact your referring doctor so that they are able to examine, assess and manage you appropriately.
    • Cortisone injection administered directly into a tendon has been reported to weaken and damage the collagen fibres, thus carrying a risk of delayed rupture. For this reason, cortisone is only injected around the tissue surrounding a tendon and the tendon is rested for one week.
    • An extremely rare complication is avascular necrosis (bone death) which some doctors suspect may rarely occur when cortisone is injected into a joint, though this has not been proven.
    Remember that the side effects of cortisone that are commonly reported in the media, such as osteoporosis, weight gain, acne and diabetes only occur when taking cortisone tablets for at least several weeks (typically many months to years). These side effects do not occur with the careful use of cortisone injections.

Are there any alternatives to a cortisone injection?

Of course, there are. Since a cortisone injection is used for treating pain, it is an optional procedure. Other options should be discussed with you referring doctor and may include anti-inflammatory medications, exercise, physiotherapy and surgery to name a few.

How many cortisone injections are permitted?

There is no scientifically proven limit for cortisone injections, however as a general rule, three injections into the same body part are permitted over a twelve-month period. Injections more frequent than this are felt to place the injected tissue at risk of softening/ weakening, which may be an issue in a joint for example, as this may accelerate arthritis. Also, if you have failed to respond to a series of three injections, then it is probably time your condition was reassessed to find out if the diagnosis is correct. Has your condition worsened and are other forms of treatment, such as surgery, more appropriate?

If you do require more than three injections in a year, then the risk of the injection must be carefully balanced against the benefits of pain relief.

Management of concussion for AFL players

Management of concussion for AFL players

Sport related concussion is a topical injury particularly at AFL and NRL elite level, but an injury that can happen at any level of these sports. The Ballarat Football and Netball league utilise “THE MANAGEMENT OF SPORT-RELATED CONCUSSION IN AUSTRALIAN FOOTBALL – With Specific Provisions for Children and Adolescents (Aged 5-17 Years): for trainers, first-aid providers, coaches, club officials, players, and parents” as their concussion management tool, released by the AFL in April 2021.

Many sports at the elite level are moving to the use of specialist doctors in Sports Medicine rather than general practitioners as team doctors. Ballarat Sports Medicine physicians, Dr Greg Harris, Specialist in Sport & Exercise Medicine and Dr Bryn Savill, Registrar in Sport & Exercise Medicine, are both team doctors at elite level sport and conduct training at local AFL level for team trainers.

If you or your children have suffered a concussion injury or suspected concussion injury, both Greg and Bryn can assess your injury and provide specialist guidance for recovery and return to exercise, training and competitive sport.

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AFL Concussion

Head impacts can be associated with serious and potentially fatal brain injuries. In the early stages of injury, it is often not clear whether you are dealing with a concussion or if there is a more severe underlying structural head injury. For this reason, the most important steps in initial management include:

  • Recognising a suspected concussion;
  • Removing the player from the match or training; and
  • Referring the player to a medical doctor for assessment.

Any player who has suffered a concussion or is suspected of having a concussion (i.e. in cases where there is no medical doctor present to assess the player or the diagnosis of concussion cannot be ruled out at the time of injury) must be medically assessed as soon as possible after the injury and must NOT be allowed to return to play in the same match/training session. There should be an appropriately accredited first aid provider at every match and the basic rules of first aid should be used when dealing with any player who is unconscious or injured.

Important steps for return to play following concussion include:

  • A brief period of complete physical and cognitive rest (24-48 hours);
  • A period of symptom-limited activity to allow full recovery; and
  • A graded loading program (with monitoring).
  • Clearance by a medical doctor

Players should not enter the graded loading program until they have recovered from their concussion. Recovery means that all concussion-related symptoms and signs have fully resolved (for at least 24 hours) at rest and with activities of daily living, and they have successfully returned to work or school, without restrictions.

Any concussed player must not return to competitive contact sport (including full contact training sessions) before having moved through the graded recovery process and have obtained medical clearance.

The earliest that a player may return to play (once they have successfully completed a graded loading program and they have obtained medical clearance) is on the 12th day after the day on which the concussion was suffered.

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