It's been rather quiet on the blog lately but fret not!! We have an insightful new post for you to read at the Bristish Journal of Sport Medicine Blog. The post entitled "Cutting sporting Australians to their knees: time for more investment in sports injury prevention" was penned by our very own Professor David Hunter.

Professor Hunter is a rheumatology clinician researcher whose main research focus has been clinical and translational research in osteoarthritis (OA). He is the Florance and Cope Chair of Rheumatology and Professor of Medicine at University of Sydney and the Royal North Shore Hospital and Consultant Rheumatologist at North Sydney Orthopaedic and Sports Medicine Centre.

Click here to read Professor Hunter post

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Dr Joanna Makovey is a scientist with over 20 years experience in medical research. She has been a member of the musculoskeletal research group at the Department of Rheumatology of the RNSH since 1996. She completed her PhD in 2009 and has over 30 publications. She is affiliated with the Institute of Bone and Joint Research (Northern Clinical School, the University of Sydney). Outside of work, Joanna enjoys yoga and travelling.

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Mindfulness is about being here, now. It’s about being 'present' or in the moment. While the idea is really very simple, embodying mindfulness is not always easy. We’ve all had experiences of being completely absorbed in what we are doing - perhaps walking on the beach, playing with a child, looking up at a magnificent sunset, or enjoying the first mouthful of a delicious meal. These moments are moments of mindful awareness and we have them all the time. It’s just that they are brief and fleeting.

Soon enough our minds wander off into streams of consciousness – analysis, remembering, planning and a myriad of other distractions. We might pull into the driveway and suddenly come to our senses, unable to remember the drive home because we were replaying the day’s events in our minds.

What does mindfulness meditation involve?
The practice of mindfulness meditation is really just about stretching out these moments of present-focused awareness by training our minds to keep coming back to what is happening right now. It is described as shifting out of the 'doing' mode and into the ‘being’ mode, or switching out of autopilot.
At first this involves picking something to pay attention to – like the flow of your breathing, the shifting sensations in your body, or the many sounds around you – and noticing each time you end up distracted so that you can gently coax your attention back. This returning to the now, over and over, becomes a habit, just as practising scales on a piano or kicking the footy develops muscle memory. We stop 'missing precious moments' and start being fully engaged with what is happening as it unfolds.

What does mindfulness meditation have to do with pain?
Practising mindfulness meditation can be helpful for people with persistent pain, which has shown moderate effect in reducing pain intensity. Compared to standard care for pain, meditation also seems to improve other aspects of life, such as depression, quality of life, acceptance, sleep quality and physical function. When it comes to short term pain, people report less distress and can tolerate more pain when they have had meditation training, compared to people who do not meditate6.
Overall, the current evidence suggests that mindfulness-based treatments are about as good as well-established psychological treatments for pain, like Cognitive Behaviour Therapy (CBT). However, since the research on meditation is newer, it is not yet as strong and convincing as the research on CBT. We still need to do more high quality studies to figure out which types of pain meditation helps most with, what doses of meditation work best, and what the essential ingredients are that make meditation helpful.

How does mindfulness meditation help with pain?
While research on meditation and pain are still in its early days, there a few important ingredients that we know of:

1.Relaxation
Relaxation is a helpful side effect of meditation and is very important for coping with pain. This is because while pain is stressful in itself, the stress also exacerbates and maintains pain. Relaxation helps to calm down your nervous system, which often becomes 'sensitised' when pain persists for a long time and boosts your body’s natural pain modifiers, such as "feel good" hormones.

2.Acceptance
Mindfulness is about accepting what is here right now as best we can, including pain, so that we can soften and be more receptive to what happens next. This is very different from being resigned to a life of pain. Mindfulness is all about curiosity and what some people call 'beginner’s mind'. Research shows that people who learn how to accept their pain respond better to various treatments and have better overall pain outcomes.

3.Mental flexibility
Negative thoughts drive negative feelings, which can sensitise our nervous systems and increase our pain. Thinking very negatively about pain, or what we call 'pain catastrophising', is one of the strongest predictors that short-term acute pain will become longer-term persistent pain. Mindfulness meditation can reduce the burden of these negative thoughts because it changes our relationship to thinking itself. We start to see thoughts as just 'mental events' rather than facts, which lessens their impact. In other words, we don’t as easily buy into the negative story around our pain. This is especially important in overcoming the upsetting emotional impacts of pain, such as depression and anxiety.

4.Pain with less distress
Exciting research using brain scanning technology like functional magnetic resonance imaging (fMRI) is beginning to shed light on patterns of activity in the brain when a person is in pain and when they are meditating. It looks like people are still aware of the sensory aspects of pain during mindfulness meditation but they experience it as less unpleasant since it does not activate as many of the brain networks related to memory and emotion. In other words, meditation trains your brain to experience pain with less distress.

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Rachel Choi is a PhD student at the Murray Maxwell Biomechanics Lab and the Raymond Purves Research Lab at the IBJR. Her research interest in tendon biology coincides with a personal interest in music and sporting performance, and associated injuries. She graduated in 2012 from the University of Sydney (B. Engineering (Biomedical), B. Commerce (Economics)), while squeezing in academic credit for wind orchestra and symphony orchestra during her year of study abroad at the University of California Irvine.

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The surf was perfect this morning, as was my post-surf breakfast at the local cafe. Equipped with one functioning leg and one walker boot, I had surmounted the last of the cafe stairs when a familiar conversation begins: “What have you been doing to yourself”, in reference to my boot. I’ve had a total rupture of my right Achilles tendon. “How did it happen?” Playing touch footy. “Ah, some really rough fields eh?” Well, actually no, I was just taking off in a straight line with the ball in hand. “Achilles tendon, gee that must’ve really hurt”. Nope. It took me a good half minute to deduce that I might have a total Achilles tendon rupture. The pain only really set in after the operation.

Just as I appreciate the kindness shown to me as a crutch user, I really do enjoy these “crutch/cast conversations”. However, I find it awkward anticipating the complete mismatch in how much we know about tendons.

Irony alert: Yes, I am a PhD student in tendon biology with an Achilles tendon rupture.

I find myself in a unique position where I’m a tendon rupture patient (right leg), a chronic tendinopathy patient (left leg), and also a tendon basic science researcher in training (brain, bilateral). So Bob, my dear waiter, how much did you want to know about my tendon exactly?

If two years of PhD research has taught me anything, it’s that tendon injuries and pain occur with many variations. What we know is only a small part of what’s happening inside and around our tendons. And so it’s natural that my waiter’s guesses about my conditions didn’t match up with my very own, unique patient experience. MyInjury™? iRupture™?

But let’s start with what we know.

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Dr Rodrigo Megale is a Brazilian physician specialising in geriatrics , graduated from Medical School (UFMG) in 2002, with advanced training in Internal Medicine (2002-2004) followed by Geriatrics (2004-2006) through accredited residency programs (MEC). He has Masters Degree in Public Health (Epidemiology) from Fiocruz and is, currently, undertaking his PhD in The University of Sydney - Medical School.

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It is usual among older adults to think that musculoskeletal pain is a benign symptom related to the “wear and tear” of ageing. If you are in your 70s or 80s, you probably have already heard from health professionals that chronic pain is something that you should get used to, and that it is a very common age-related condition. I, myself, have said that to many of my patients. It turns out that having chronic or persistent musculoskeletal pain is not as benign as it was thought to be.
Several studies have shown an association between chronic pain and frailty, a pre-disability condition, clinically characterised by weight loss, exhaustion, weakness, slowness and low physical activity. Those who have been experiencing bothersome joint or low back pain might be worried at this moment; however, there is no reason for that. If your pain is not interfering in your daily living activities, and your doctor has already assessed it in order to rule out any serious condition, there are some tips that can help you cope with your symptoms.

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The first important thing that you need to know about chronic pain is that, in many cases, the source of pain is not only joint inflammation, cartilage damage or disc degeneration/ protrusion. Actually, it seems that our brains play a very important role in this condition. Chronic pain usually involves a problem in the so called “descending inhibitory pathway”, which is part of your body’s pain management system, and it is controlled by your brain. That is probably why some patients report less pain when they are surrounded by loved ones or when they are on a pleasant trip. Our brain is capable of modulating the pain we feel. If you focus on your pain and drive all your attention towards your suffering, your behaviour could probably “enhance” your pain. On the other hand, if you drive your attention away from your suffering and try to focus on positive aspects of your life, there is a reasonable chance of achieving pain improvement.

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Today's blog post is brought to you by Dr Helen Liang of the Sutton Arthritis Research Laboratory led by Professor Chris Jackson.

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I am a Postdoctoral Research Fellow from the Sutton Arthritis Research Laboratory, who is currently supported by the Ulysses Club Arthritis Research Fellowship, to carry out a research project that aims towards developing new medicines to provide better treatment for rheumatoid arthritis patients.

Rheumatoid arthritis is the second most common type of arthritis and one of the most damaging forms. People with this condition not only suffer severe pain, but their death rate within the first 10 years of diagnosis is also 3 times that of healthy individuals. The common clinical symptoms of arthritis include pain, swelling and stiffness of joints, inflammation, and damage to joint structures that results in joint weakness and deformity, which ultimately interferes with the most basic daily tasks such as walking and standing.

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Weight loss is very commonly spoken about when it comes to OA. Today we have a post exploring some studies about how weight loss is related to knee OA.

Today's post is written by Dr Sarah Meneses, a researcher and physiotherapist based at the Institute of Bone and Joint Research. Dr Meneses completed her PhD on laser therapy and stretching exercises at the University of Sao Paulo and takes a strong interest in conservative management of osteoarthritis.

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It is well known that being overweight or obese can lead to health issues over the time. The joints that carry this extra load suffer and it is common to see a high prevalence of osteoarthritis (OA) within overweight and obese people.

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A recent study showed that losing either 5 kg or 5% of body weight has preventive effects on both the structural and clinical signs of knee OA in middle-aged, overweight and obese women without OA.

The authors stated that is necessary to design strategies that are implementable in primary care and effective in reducing body weight of overweight and obese subjects at high-risk of developing knee OA. However, it is important to note that this was an observational study (where researcher are unable to control as much), and we cannot assume a causal relationship (where one variable results in a particular outcome), as there may have been other factors that influenced the results.

Another recent study showed the effect of bariatric surgery (to reduce the size of the stomach) prior to total knee replacement as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis.

The authors advised that ideally, a team approach should be used to treat severely obese patients with knee arthritis in which various health care professionals are in place to help a patient lose weight, improve his or her health, and optimize nutrition before joint replacement to maximize its benefits. The outcomes of this study may assist physicians when counseling patients and developing an individualized treatment plan that includes optimization of overall health, nutrition and weight prior to knee replacement.

These two studies had different subtypes of overweight or obese participants. In the first were included people without OA and in the other were included people in the end-stage of the disease. However, both studies showed a positive effect of weight reduction in the prevention or management of OA. So, keep track of your weight! Speak with your GP and find a real weight loss target for yourself. A weight reduction of 5% already promotes benefits to your health!

Runhaar J, de Vos BC, van Middelkoop M, Vroegindeweij D, Oei EH, Bierma-Zeinstra SM. Moderate weight loss prevents incident knee osteoarthritis in overweight and obese female. Arthritis Care Res (Hoboken). 2016 Feb 11. doi: 10.1002/acr.22854. [Epub ahead of print]

McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation. J Bone Joint Surg Am. 2016 Jan 20;98(2):e6. doi: 10.2106/JBJS.N.00416.

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Welcome to the very first post of 2016! We have writing for us today, Mrs Jillian Eyles, a researcher and physiotherapist at the Institute of Bone and Joint Research. Jill has had many years of experience in clinical physiotherapy at the Royal North Shore Hospital and has recently taken a strong interest in research about knee and hip osteoarthritis.

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We all know we should exercise for our general health, what you may not know is why exercise is so important in the management of knee osteoarthritis and which type of exercise is best.

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How will exercise help my knee osteoarthritis?
People are often concerned that exercise will cause further damage to their osteoarthritic knee. Rest assured this is a myth! In fact, clinical research has proven that exercise is an effective treatment for knee osteoarthritis and the benefits include:

- Reduction in knee pain
- Improved ability to move around normally
- Improved quality of life
- Reduction in the knee feeling like it is ‘giving way'
- Improved mood
- May assist in weight loss (if required)
- May even help slow down the disease process

So, what is the right type of exercise for my knee osteoarthritis?

Strength training:
Muscles around the knee and hip stabilize the knee and help maintain normal postural alignment during walking and other activities. Muscle weakness is common in knee osteoarthritis. Some muscles become so disused they fail to fire altogether. Strengthening exercises help to build up weak muscles around the hip and knee to protect the knee from forces that load and stress the cartilage.

Strengthening exercises need not require a gym or fancy equipment; some exercises can be performed using your bodyweight alone. You may even prefer to complete your strengthening program in the pool (hydrotherapy or aquatic physiotherapy). The effects of an intensive strengthening program may be felt for up to 6 months, but an ongoing strength maintenance program is recommended for lasting effects.

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Neuromuscular control:
Neuromuscular control is a form strengthening exercise based around everyday movement. People with knee osteoarthritis often adapt their movement patterns to compensate for their knee symptoms. These abnormal movement patterns can cause further weakening of key muscles leading to pain and disability. Exercises that improve the control of the knee during movement also strengthen the muscles around the knee joint and thus help to reduce symptoms of knee osteoarthritis. These exercises are particularly important for those people with osteoarthritis behind the knee-cap.

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Flexibility training:
Often osteoarthritic knees feel stiff. However the loss of movement in the knee is not caused by the joint alone but also often involves the muscles. Stretching exercises aim to improve the flexibility of the body by stretching out tight muscles, joints and other tissues. This may lead to improvements in pain. Stretching can be incorporated into any exercise program, or you may want to take a class that focusses on flexibility such as yoga.

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Fitness training:
We all know that aerobic exercise is good for our heart health; research shows that it is also good for our knees and mental well-being! Aerobic exercise may also help us to shift unwanted kilos that make the pain from knee osteoarthritis a whole lot worse. Low impact activities such as walking, swimming, cycling, aerobic exercise classes and aquafitness are good choices. Aim to include at least 30 minutes of physical activity (at the level of a brisk walk) every day.

There seem to be so many types of exercise I can do- which is the best choice?
Current research suggests that a combination of strength, fitness and flexibility training is the most effective way to reduced pain and improve your ability to move around (and do the things you enjoy!). You may want to mix up the type of training that you do so that it doesn’t become a chore. The best choices of exercise type are the ones that you enjoy, and if you exercise with a friend or two it may double up as a social activity- anyone for coffee after?

How do I start exercising for my knee osteoarthritis?
It is important to seek advice from a health professional before you start an exercise program. Ask your physiotherapist or GP to help get you started with an exercise program that is right for you!

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