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.

VIEW COMPLETE AFL DOCUMENT

Return to exercise post-COVID-19 infection

Return to exercise post-COVID-19 infection: A pragmatic approach in mid-2022

Reference: D.C. Hughes, J.W. Orchard, E.M. Partridge, et al., Return to exercise post-COVID-19 infection: A pragmatic approach in mid-2022, Journal of Science and Medicine in Sport, https://doi.org/10.1016/j.jsams.2022.06.001

We posted in February (Returning to exercise after Covid-19) about returning to sport after COVID. With increasing experience in managing patients back to activity, we recommend the following approach

The following flow chart provides a safe pathway guide for individuals to return to exercise following Covid-19 infection.  The article identifies that the initial concerns of myocarditis in young healthy individuals has revealed very low rates and most individuals can return to exercise in 7-14 days post infection.

Our head of Physiotherapy at Ballarat Sports Medicine, Luke Blunden, recommends individuals consider the following flowchart along with medical advice for a return to exercise post Covid-19.

How a mother’s love and a miracle gave Xavier new life

When a car hit Xavier Mahabelo so hard it ripped the skin and muscle clean off his leg, his only shot at survival was on the other side of the world in a Melbourne hospital.

This wonderful article describes how our own BallaratOSM orthopaedic surgeon, Mr Shaun English, assessed Xavier’s injury on the ground in Madagascar in 2019, when he volunteered with Australian Doctors in Africa.  Shaun subsequently liaised with his colleague Professor Leo Donnan back in Australia, who offered to undertake the life changing surgery.  Read more about Xavier and the incredible gift dedicated orthopaedic surgeons provided HERE.

World Athletics Championships Oregon 22

Ballarat Sports Medicine’s Dr Greg Harris, Sport & Exercise Medicine Physician is soon to travel to Oregon, USA to be part of the World Athletics Championships. Greg will be the team doctor for the Australian contingent.

Initially the team will be based in Seattle for a pre-event training camp for 10 days before transferring to Eugene, Oregon for the main event, July 15th-24th 2022.  Greg will be reporting back to Ballarat Sports Medicine on his experiences upon when we aim to update our followers on social media about Greg’s experiences.  Outside the Olympics, the World Championships is the premier world event for track and field athletics.  It is not only a great honour and privilege being appointed to team doctor but a testament to the skills and experience that Greg brings.     

Greg will be unavailable for appointments from July 1st – July 29th but our Sport & Exercise Medicine registrar, Dr Bryn Savill will still be seeing patients. 

Perioperative Carbohydrate Loading

In our quest to improve Rapid Recovery Surgery, we’ve been carbohydrate loading our patients. Now there’s a Randomized Controlled Trial on the subject.

“Don’t upset the applecart” has been a key component to rapid recovery surgery. Simplifying peri-operative care has been a consequence. An old anaesthetic idea of “fasting for 6 hours” has been replaced with “no solid food for six hours, but free fluids until 2 hours prior to surgery”. By reducing the risk of vomiting, endotracheal tubes have been mainly replaced with laryngeal masks, which is more comfortable for the patients. By adding carbohydrate to the clear fluid (eg Powerade) the patients don’t feel as “starved” and have better energy mobilising after surgery. At BallaratOSM, we’ve done this since 2015, giving the patients a bottle of Powerade to have an hour before they’re due at the hospital.

In the Journal of America Academy of Orthopaedic Surgeons, there’s been a published randomised controlled trial, between 800ml “Nutricia Preop”, 400ml lemon flavoured water, and no water. No differences were found on the long list of things they tested…. Except readmission rate. The Odds Ratio of readmission was 0.08 between their carbohydrate loaded patients, and the entirely fasted group. p-0.024 Postoperative boluses of narcotics are more likely in the fasted group as well. Length of stay for their knee replacements, like ours, averaged a bit over a day.

We’ll stick to our plan of not upsetting the applecart.

Reference:

Kadado, Allen MD; Shaw, Jonathan H. MD; Ayoola, Ayooluwa S. MD; Akioyamen, Noel O. MD; North, W. Trevor MD; Charters, Michael A. MD. Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial.

Journal of the American Academy of Orthopaedic Surgeons: June 1, 2022 – Volume 30 – Issue 11 – p e833-e841 doi: 10.5435/JAAOS-D-21-00960