Orthopaedic and sports medicine

A/Prof Solomon Yu
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In this Product Explainer Geriatrician A/Prof Solomon Yu explains the importance of integrating muscle health screening, diagnosis and management in routine clinical practice, and the role of early intervention including HMB enriched oral nutritional supplementation for preventing and reversing sarcopenia.

Andrew Lavender
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Where there are players and a game to be won, you can expect some “rough and tumble” on the sporting field. But when do the bumps become a problem for players? And what can we do to protect them from traumatic brain injury?

Prof Robin Daly
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In this Product Explainer Prof Robin Daly, Chair of Exercise & Ageing, Deakin University explains how a HMB enriched oral nutritional supplementation can help to protect muscle mass, strength, and function, and its potential role in the management of sarcopenia (5 mins).

Joyce McSwan
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This article discusses the assessment and management of acute low back pain in general practice according to the best available evidence to date.

Expert/s: Joyce McSwan
Joyce McSwan
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Joyce McSwan explains that LBP is one of the leading causes of diminished quality of life and disability worldwide.  In primary healthcare, it is one of the most common presenting ailments.

Expert/s: Joyce McSwan
Dr Linda Calabresi
Clinical Articles iconClinical Articles

According to a neat little randomised control trial published in JAMA, wearing individualised biomechanical footwear can significantly reduce knee pain in patients with osteoarthritis. The six-month study also showed that the footwear improved the function of the knee as judged by gait studies into velocity and step length.

University of Queensland
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Most children will recover fully from concussion, but one in ten has persistent symptoms. University of Queensland researchers have just completed a study between these symptoms and long-term disability risk, and the results are striking. Poor sleep post-concussion in particular was linked to reduced brain function and decreased grey matter, with fatigue and attention difficulties also being potential indicators. Using information on reductions in brain function, researchers were able to predict with 86 percent accuracy how children would recover two months from sustaining a concussion. “Generally, children with persistent concussion symptoms will have alterations to their visual, motor and cognitive brain regions but we don’t have a clear understanding of how this develops and how it relates to future recovery,” said study author and UQ Child Health Research Centre Research Fellow, Dr Kartik Iyer.

Brian Brooks
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Active kids sustain injuries. It is estimated that every year more than 100,000 Canadian children and adolescents get a concussion while participating in normal childhood activities, like sports and play. Most kids return to school and activities within about one month of the injury, but sometimes they need specialized concussion treatment and rehabilitation. Our recent study, published in the Journal of Head Trauma Rehabilitation, found that psychotherapy can improve adolescents’ insomnia after concussion and that it also improves overall post-concussion recovery.

Dr Linda Calabresi
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It’s that time of year. Cold weather. Footy season. Finals approaching. Muscles pulled. Ankles twisted…. Of course, the elite sportspeople will have their support team to strap, massage, rehabilitate and retrain the injured joint or muscle – coaxing it back to good health. But for your average ill-fated weekend exerciser with a sprained ankle, they will present in general practice (generally on a Monday) wanting advice on how to expedite their recovery inexpensively and in a manner that doesn’t risk further injury.

Prof Alan Pearce
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Concussion is a temporary disturbance in brain function following an impact to the head. It can also occur after a blow to the body, if the force is transmitted to the head. Most people associate concussion with sports but they can occur anywhere, even at work or school. There are many signs and symptoms of concussion, which may present differently between individuals. These include headaches, nausea, vomiting, slurred speech, dizziness, temporary loss of memory, and inability to focus. Loss of consciousness only occurs in around 10% of concussions. Most people with concussions recover relatively quickly. Around 90% will recover within several days to a couple of weeks. But sometimes symptoms continue beyond a couple of weeks. When symptoms persist beyond three months, the person may be diagnosed as having persistent post-concussion symptoms.

Rest is not always best

We don’t know exactly how common concussions are, because they’re under-reported. Some people don’t think they are a serious injury, so don’t seek treatment, while others mask their injury because they don’t want to be seen as weak. The World Health Organisation classifies concussion, which is a type of traumatic brain injury, as a critical public health issue. Complete physical and mental rest used to be recommended after a concussion. Since 2017, however, the concussion treatment guidelines have evolved to reflect the science. While rest in the immediate 24-48 hours after a concussion is still advised, patients are now encouraged to undertake low-intensity exercise (such as walking, light jogging, or stationary cycling) and light mental stimulation (such as work or study) over the following days. Recovery is individual, but the intensity of physical and mental activity should gradually increase over time and should not exacerbate or worsen the symptoms.

Persistent symptoms

Formerly known as post-concussion syndrome, persistent post-concussion symptoms occur in around 1-10% those who have suffered a concussion. The exact prevalence is unknown due to methodological differences between studies and how persistent post-concussion symptoms are defined within these studies. As with concussion, persistent post-concussion symptoms vary among individuals but may include headaches, balance problems, light or noise sensitivity, anxiety and depression. We still don’t know why some people’s symptoms persist for many months, sometimes even years. But we suspect psychology may play a role. While the evidence is limited, early psychological intervention for those with ongoing symptoms, which involves educating the person on why they are feeling this way, has been shown to be effective at reducing the anxiety and depression that accompany persistent post-concussion symptoms. Despite psychological support, some express continued physical symptoms, such as headaches, balance problems, and light/noise sensitivity; reflecting possible changes or abnormalities in the brain. Fatigue, both mental and physical, is common in people with persistent post-concussion symptoms, but is often overlooked, despite it significantly impacting on quality of life.

What can measures of fatigue tell us?

Our new research suggests people with persistent post-concussion symptoms may have ongoing problems with fatigue and cognitive function because of changes to the way information is transmitted to and from their brain. We used transcranial magnetic stimulation, a non-invasive brain stimulation technique, to measure participants’ brain function and neural processing. When compared to both age-matched controls, as well as a group of people who have recovered from a previous concussion, we found people with persistent post-concussion symptoms were slower to complete the set activities – and their outcomes were more varied. We have previously compared brain responses via this method in retired Australian Rules and Rugby league players and found abnormal responses compared to other people of the same age with no history of head trauma. The next stage of our research is to better understand who is vulnerable to persistent post-concussion symptoms and how the condition can be treated. We understand how to diagnose and treat concussion in the short term, but we’re yet to uncover how to best assist people with persistent post-concussion symptoms to return to leading productive lives.   Alan Pearce, Associate Professor, School of Allied Health, La Trobe University This article is republished from The Conversation under a Creative Commons license. Read the original article.
Dr Linda Calabresi
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Why are Australians having rehabilitation as an inpatient after their total knee replacements rather than as an outpatient at a rate higher than any other country in the world? And why are our rates of inpatient rehabilitation as opposed to community or home-based rehab increasing? That’s what researchers were investigating in a study just published in the MJA. Could it be inpatient rehab was associated with better health outcomes for the patient than the other options? Or were patients too complex, lived too far away or needed greater supervision to allow them to have their rehab off-site? As it turns out, the reason inpatient rehabilitation rates are increasing has much more to do with private hospitals being able to access funding than any patient factors. According to the study authors, more than 50,000 total knee replacement operations were performed in Australia in 2016, about 70% of which took place in a private hospital. In that year, 2016, 45% of patients underwent inpatient rehabilitation following surgery. This represents a substantial increase from the 31% who had the same inpatient service back in 2009. This bucks an international trend. “Inpatient rehabilitation rates in the United States decreased from a peak of 35% in 2003 to 11% in 2009, with a mean rate during 2009-2014 of 15%,” the researchers said. Randomised controlled trials have failed to show the functional improvements achieved through inpatient rehabilitation are superior to those achieved with home- or community-based rehabilitation. However, the cost was significantly more. A recent analysis including almost 260 privately insured patients at 12 Australian hospitals put the cost differential at an average of $9500. And even though the mean age for patients undergoing inpatient rehab was slightly higher than for those who did not (71.0 vs 67.3 years), and they were more likely to have comorbidities and live alone, the study authors said the differences didn’t explain the wide variation in admission rates from hospital to hospital. “Patients in hospitals with high rates of inpatient rehabilitation were similar to those in hospitals with low rates, eliminating patient complexity as the reason,” they said. It seems the greatest determinant of whether a person had inpatient rehabilitation was the hospital in which the total knee replacement took place. “This factor was substantially more important than the clinical profile of the patient,” the study authors said. They suggested some private hospitals were encouraging inpatient rehabilitation because they were able to access funding on a per day basis for the rehab, in addition to the payment received for the knee surgery. The study authors concede it is an attractive business model, but while these hospitals may be offering excellent rehab in terms of services and facilities, it all comes at a cost ‘that, for many patients, is not justified by better outcomes.’ They suggest the proportion of patients receiving inpatient rehabilitation after a total knee replacement could be reduced, improving health care efficiency without harming health outcomes. “Reducing low value care will require system-level changes to guidelines and incentives for hospitals, as hospital-related factors are the major driver of variation in inpatient rehabilitation practices,” they concluded.   Reference: Schilling C, Keating C, Barker A, Wilson SF, Petrie D,  Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data. Med J Aust. 2018 August 27. 209(5): 222-7. Available from: https://www.mja.com.au/journal/2018/209/5/predictors-inpatient-rehabilitation-after-total-knee-replacement-analysis doi:10.5694/mja17.01231  

Dr Jonathan Grasko
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In 1889, Dr Charles-Édouard Brown-Séquard, a world-renowned physiologist and neurologist, whom first described a syndrome which bears his name, published in The Lancet, a paper based on a series of lectures. He described a number of experiments done on animals and humans (including himself) which involved injecting an ELIXER derived from blood from the testicular artery, semen and fluid extracted from freshly crushed animal testicles. He concluded “…great dynamogenic power is possessed by some substance or substances which our blood owes to the testicles.” and “I can assert that the … given liquid is endowed with very great power.”1 The inherent belief that human performance can be improved by the addition of an ELIXER can be traced to ancient Greece.  Athletes and warriors ingested berries and herbal infusions to improve strength and skill.2 The intrinsic risk attached to these substances has always been appreciated. Scandinavian mythology mentions Berserkers (ancient Norse warriors) would drink a mixture called "butotens", to greatly increase their physical power at the risk of insanity. They would literally go berserk (where the modern meaning of the word arises) by biting into their shields and gnawing at their skin before launching into battle, indiscriminately injuring, maiming and killing anything in their path.3 This unrelenting desire to out-compete rivals at any cost seems to be branded into the human psyche. The willingness to partake of substances that may inevitably be detrimental even to the point of death has been repeatedly demonstrated. Thomas Hicks, an American born athlete won the 1904 Olympic marathon having received multiple injections of strychnine by his trainer. Hicks survived his ordeal but never raced again.4 An attempt at understanding the extent of this risk-taking behaviour was undertaken by physician Dr Bob Goldman. In his research involving elite athletes he presented a scenario where success in sport would be guaranteed by the ingestion of an undetectable substance, however with the inevitable outcome of death after five years. He concluded that approximately half the athletes would take the drug. This scenario has been dubbed the “Goldman's dilemma”.5 A more recent repeat of this study yielded a lower correlation.6,7 During the Second World War soldiers on both sides were given amphetamines to counteract fatigue, elevate mood, and heighten endurance.8,9 Following the war these drugs – nicknamed “La bomba” and “Atoom” by Italian and Dutch cyclists -  started to enter the sporting arena with the intention of minimising the uncomfortable sensations of fatigue during exercise.10 In the 1950s, there was the perception in the USA that the great success of the Russian weightlifting team was solely due to the use of performance enhancing drugs. Dr John Ziegler in collaboration with CIBA Pharmaceuticals and under FDA approval developed the first oral anabolic steroid, methandrostenolone. U.S. Athletics, which believed they needed chemical assistance to remain competitive, gave their entire Olympic weightlifting team methandrostenolone.11 Zeigler was later quoted when finding out that athletes were taking 20 times the recommended dose - "I lost interest in fooling with IQ's of that calibre. Now it's about as widespread among these idiots as marijuana."12 This belief came to a head in the 1960 Olympic Games where Danish cyclist, Knud Enemark Jensen collapsed and died while competing in the 100 km race. An autopsy later revealed the presence of amphetamines and nicotinyl tartrate in his system.13 In the 1967 Tour de France, British cyclist Tommy Simpson, who had previously been named Sports Personality of the Year by the BBC, died during the 13th stage after consuming excessive amounts of amphetamines and brandy. Simpson’s motto was allegedly "If it takes ten to kill you, take nine and win!"14 Simpson's death created pressure for sporting agencies to take action against doping. This ultimately led to the formation of The World Anti-Doping Agency (WADA) in 1999 as an international independent agency composed and funded equally by sport movements and governments of the world. Every year they publish an updated list of banned drugs. In general terms these fall into three groups:15 M1. Manipulation of Blood and Blood Components M2. Chemical and Physical Manipulation M3. Gene Doping Gene doping is the use of gene therapy in order to improve athletic performance in competitive sporting events. It would involve the use of gene transfer to increase or decrease gene expression and protein biosynthesis of a specific human protein. This could be done by injecting the gene carrier into the athlete using a viral vector or by transfecting the cells outside the body and then reintroducing them. WADA has placed significant resources in order to detect this process.  Currently there is no evidence that this is common practice.16,17 In addition to the traditional incentives such as fame, honour and power, the past 60 years has brought with it the most potent of drivers - money, which in western culture embodies all three.  The financial incentives to both the sporting institutions and athletes have been profound. With some authorities claiming almost a 250% increase in revenue with the introduction of industrial scale performance-enhancing drugs.18 The supplements industry has already exceeded $60 billion per year. 19 The combination of primal ambition and ever improving designer performance- enhancing modalities makes the future of professional sport, I believe, the realm of the highest bidder. References:
  1. Dr Charles-Édouard Brown-Séquard, The Effects Produced On Man By Subcutaneous Injections Of A Liquid Obtained From The Testicles Of Animals. The Lancet, 20 April 1889.
  2. Kumar, Rajesh. "Competing against doping". Br J Sports 1 September 2010
  3. The Saga of King Hrolf Kraki
  4. Pariente, R., & Lagorce, G. La Fabuleuse Histoire Des Jeux Olympiques. Livres Bronx Books, Lasalle, QC, Canada. ODIL France 1973
  5. Goldman, Robert; Ronald Klatz (1992). Death in the locker room: drugs & sports (2nd ed.). Elite Sports Medicine Publications. p. 24. ISBN 9780963145109.
  6. Connor, James; Woolf, Jules; Mazanov, Jason (January 2013). "Would they dope? Revisiting the Goldman dilemma" (PDF). British Journal of Sports Medicine. 47 (11): 697–700.
  7. Connor, James; Jason Mazanov (2009). "Would you dope? A general population test of the Goldman dilemma.". British Journal of Sports Medicine. 43 (11): 871–872.
  8. Doping of athletes, a European survey, Council of Europe, France, 1964
  9. Grant, D.N.W, Air Force, UK, 1944
  10. Timothy D. Noakes, Tainted Glory — Doping and Athletic Performance, NEJM 2004; 351:847-849August 26, 2004
  11. John D. Fair, "Isometrics or Steroids? Exploring New Frontiers Of Strength in the Early 1960s, Journal of Sport History, Vol. 20. No. 1 (Spring 1993)
  12. Wade N, Anabolic steroids: doctors denounce them, but athletes aren’t listening. Science (1972).176, 1399–1403.
  13. Maraniss, David (2008). Rome 1960: The Olympics That Changed the World. New York: Simon & Schuster. p. 111.
  14. Graham M. R., Exercise, Science and Designer Doping: Traditional and Emerging Trends, Journal of Steroids & Hormonal Science, October 28, 2011
  15. https://www.wada-ama.org/en/who-we-are
  16. WADA, The Gene and Cell Doping Expert Group
  17. Pray, L. (2008) Sports, gene doping, and WADA. Nature Education 1(1):77
  18. Mitchell Grossman, et al, Steroids and Major League Baseball, Berkeley College
  19. Nutrition Business Journal
  This article was first published in Medical Forum October, 2016
General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.