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Diagnostic & Treatment Modalities


Diagnostic & Treatment Modalities

What is Autologous Conditioned Plasma (ACP)

Autologous Conditioned Plasma (ACP) is a method of concentrating platelets and growth factors from your own blood to re-inject into the site of injury to promote healing. A small amount of venous blood is drawn from your arm using a specially designed needle and syringe. The syringe is then placed into a centrifuge and spun. This separates the plasma, which contains platelets and other growth factors from the blood.

The plasma is then extracted carefully and re-injected to the target area.

What should I do after the treatment?

  1. Rest the affected area for the first 24-48 hours from moderate to vigorous exercise. Daily activities are ok. Ideally, you should avoid intensive activities for the first 2 weeks after injection.
  2. If there is pain during this period, ice the area and/or take pain medications.
  3. Any bandage placed over the injected site can be removed after 1-2 hours, if there is no bleeding.

When is ACP considered for treatment

The ACP injection procedure is not regarded as a first line treatment for injuries. Therefore, it is usually considered when conventional and evidence-based treatments have been tried and have not resulted in the desired outcomes. There is no guarantee that the ACP injection will improve your symptoms.

Possible Risks or Side Effects

ACP injection is a safe procedure. There may be pain, bleeding, or bruising at the blood draw or injection site. There is also a small risk of infection at the injection site, which typically presents with increased pain and redness 2-4 days after the injection. You may have a fever, find that movement is painful and the injection site may feel warm. Please see your family doctor immediately, or go to our Accident and Emergency Department, if you suspect that you have developed an infection after an injection.

What is bone mineral densitometry (BMD)

BMD is a test done to measure a person's bone mineral density (BMD). The measurements are used for the diagnosis of osteoporosis, estimation of the fracture risk and assessment of response to treatment.

There are three ways of doing BMD, but the most commonly used method is DEXA.

Dual Energy X-Ray Absorbitary (DEXA)

DEXA is a simple, low-radiation (about a quarter of a chest x-ray dosage) test that measures the mineral content of the bones.

A detector detects the energy emitted after an X-ray is passed through the patient. The more the bone mass, the greater is the obstruction to energy passing through. Thus the more energy emitted, the weaker is the bone.

The computer processes the data, tabulates the results and calculates the bone mineral density (BMD value). Two scores generate from this scan. One is the T-score, which indicates the amount of bone loss by comparing the patient's BMD at his/her current age to the peak bone mass achieved by young individuals.

The other, the Z-score, retakes the patient's bone loss to his/her age- matched peers' expected bone loss to assess whether the patient's BMD is normal.

Why DEXA is used (in comparison with other methods of BMD)

​DEXA ​Ultrasound ​Quantitative CT Scan
  • Cheap. Short time scanning
  • Not operator dependent so results can be compare across time.
  • Relatively safe, low dose of radiation
  • Safe, no x-ray.
  • Operator dependent. If the operator holds the probe differently, it can generate different values. Thus results are not comparable.​
  • Very accurate as it can calculate at every level.
  • Time consuming.
  • Not cost effective.

Osteoporosis and BMD

Osteoporosis is a condition where bones become thin and weak as bone tissue is lost faster than it can be replaced.

It is diagnosed when the bone mineral density (BMD) measured by bone densitometer falls below a critical threshold of 2.5 SD(standard deviation) from the average BMD of young healthy people.

Osteoporosis results in brittle bones. Bones in the wrist, spine and hip have the highest risk of breaking. As the condition is painless, people with osteoporosis are often unaware of it until their bone collapses or breaks. BMD is thus carried out as a predictive and preventive measure.

Who should do the scan?

Osteoporosis has no symptoms. To detect osteoporosis before your bones fracture, you should have a BMD scan done, especially if you are in the high risk group for osteoporosis.

Bone loss is a natural process for both men and women. However women have a higher risk of getting osteoporosis. The following checklist should help you assess your risk factors.

If you:

  • have menopause or your ovaries have been removed (oestrogen level decline);
  • are over 50 years old;
  • have lost height over the years;
  • are small framed or have smart bones;
  • are lactating (breast-feeding);
  • seldom take milk or milk products (too tittle calcium in the diet);
  • are not physically active and seldom exercise;
  • smoke;
  • drink coffee, tea or alcohol regularly;
  • have family members with osteoporosis;
  • have fair skin;
  • your risk of getting/having osteoporosis increases with the number of checks.

Preparation and expectation

There are no special preparations required for BMD. You may eat and drink as usual and take your regular medicine where necessary.

On the day of your appointment, you will be asked to change into our hospital robe and your height and weight measurements wit! be taken. The radiographer will then assist you to lie down on the examination table.

Usually, the scan will be performed at your spine and hip. You will be required to remain still while the x-ray is being taken. For the spine examination, your legs will be propped up on a box to straighten the lumbar arch.

Your feet will be aligned to a Perspex immobaliser for the hip examination so as to maintain the position of the hip.

The whole procedure takes about 20 minutes to half an hour. You should not feel any discomfort during the examination. When it is done, a report will be generated and the findings either explained or sent to your referring doctor.

What is Corticosteroid Injection?

Corticosteroids are anti-inflammatories and should not be confused with anabolic steroids. Corticosteroid injections are often used to treat selected conditions affecting the joints, tendons, and ligaments. An injection can deliver medication directly to the affected area to provide short term relief of pain, inflammation and swelling.

How is the injection performed?

After identifying the specific site and using sterile technique to clean the skin, a small needle is carefully inserted. Your doctor may use an ultrasound scanner to guide the injection. A mixture of corticosteroid and local anaesthetic is usually delivered in the same syringe. This procedure takes less than 10 minutes and is done in the clinic.

What are the risks?

When indicated, a local corticosteroid injection is a safe and effective procedure. Potential side-effects include:

  1. Crystal Synovitis (Steroid Flare)
  2. The injected corticosteroid may crystallise, causing pain. The reaction may occur within the first 2 days after the injection. Please call your doctor’s office or follow up if you are concerned you may have a steroid flare reaction. You can ice the area for 15 minutes 3–4 times daily. You may also take oral pain medications for temporary relief.

  3. Allergic reaction
  4. Skin discolouration (hypopigmentation)
  5. Lightening of the skin over the injection site may occur and this can last for a few months after injection.

  6. Fat Atrophy
  7. If the injection site is close to the skin surface, you may notice a slight ‘depression’ or ‘dimpling’ of the skin which can persist for several months. This is due to atrophy of fat at the injection site. For injections at the heel, such as for planter fasciitis, atrophy of the heel fat pad can cause discomfort when walking or standing.

  8. Temporary Increase in Blood Glucose Level
  9. If you are a diabetic, you should monitor your blood glucose for the 3 days after the injection, and if you are taking insulin, you may need to adjust your insulin medication dose temporarily.

  10. Weakening or rupture of tendons or ligaments
  11. To minimize this risk, we inject the cortisone around and close to the tendon. For this reason, we avoid cortisone injections directly into tendons and ligaments. Ultrasound guidance helps to increase the accuracy of the injection. We also advise that you avoid vigorous physical activities for the first two weeks immediately following a corticosteroid injection.

  12. Infection
  13. If there is an increase in pain or redness in the days following an injection, there may be an infection. You should see your family doctor immediately, call the sports medicine clinic, or go to our Accident & Emergency Department, if you suspect that you have an infection following an injection.

    In conclusion, a corticosteroid injection is recommended only if the benefits outweigh the risks. Your doctor will discuss the side-effects with you and will only proceed with the procedure with your informed consent.

What should I do after the injection?

  1. Rest the affected joint for the first 24-48 hours from moderate to vigorous exercise. Daily activities are ok.
  2. If there is pain during this period, ice the area and/or take pain medications.
  3. Any bandage placed over the injected site can be removed after 24 hours.
  4. Light exercise is allowed after the first 48 hours. However, you should avoid intense activities and exercise for the first 2 weeks.

The numbness from the anaesthetic may wear off after a few hours and pain may return until the anti-inflammatory effects of the corticosteroid starts working, which sometimes can take up to 3-4 days.

Electrodiagnostic testing is used to evaluate muscle and nerve function in the setting of numbness, pain, or weakness. Electrodiagnostic testing typically includes electromyography (EMG) and nerve conduction velocity (NCV) testing. During EMG testing, a tiny needle (pin electrode) is inserted into muscles and the electrical activity of the muscle is recorded by a computer to evaluate for any abnormal muscle or nerve activity. During NCV testing, electrodes are taped to the skin and a computer delivers a small electrical impulse to test a nerve's speed and strength which may be abnormal in the setting of nerve injury, impingement, or disease.

Diagnoses that may be referred for electrodiagnostic testing include: carpal tunnel syndrome, peripheral neuropathy, diabetic neuropathy, cervical radiculopathy, lumbosacral radiculopathy, sciatica, plexopathy, or nerve injury from trauma or fractures. Electrodiagnostic testing is performed in the Changi General Hospital Clinical Measurement Unit (CMU).

Diagnostic musculoskeletal ultrasound is used evaluate your muscle, tendons, ligaments, joints, nerves, and other soft tissue, to detect swelling, tears, and other abnormalities due to injury. Ultrasound can also be used to guide injections and Extra-corporeal Shock Wave Therapy to increase accuracy.

Compared to other diagnostic modalities like x-rays and CT scans, musculoskeletal ultrasound is helpful due to it’s non-invasiveness, no radiation exposure, accessibility, and ability to perform dynamic real-time assessments of musculoskeletal disorders.

Extracorporeal Shock Wave Therapy (ESWT) is a non-invasive method of treating specific soft tissue injuries. ESWT evolved from Extracorporeal Shock Wave Lithotripsy (ESWL), where shock waves are used to break down kidney stones. In ESWT, lower energy levels are used in Sports Medicine and Orthopaedic conditions to stimulate an individual’s own tissue healing mechanisms. Sports medicine physicians use focal shock waves to the affected region that are accurately guided by real-time ultrasound images.

Indications for ESWT

The indications for EWST include

  • Plantar Fasciitis
  • Tennis or Golfer's elbow
  • Patellar Tendinopathy (jumper's knee)
  • Rotator Cuff Tendinopathy (In the shoulder)
  • Achilles Enthesiopathy and Tendinopathy

What is a Shock Wave?

A 'shock wave' is a pulsed wave that delivers a sudden high pressure to a targeted area, followed by a negative pressure. "Extracorporeal" means that the shock wave is delivered from outside the body.

How do Shock Waves Heal an Injury?

It is thought that the shock waves trigger the body's repair mechanism through the local release of various growth factors. Shock waves also over-stimulate pain transmitting nerve endings. This leads to a short-term reduction in pain and sensitivity.

What does the Treatment Involve?

The course of treatment involves 2 outpatient sessions that are usually spaced one week apart. Before each session, avoid heavy meals (light meals are fine). Wear clothes that will allow the injured site to be exposed easily. Inform your doctor of any medical conditions or if you are pregnant. Sometimes it can help to decrease discomfort during the procedure if you ice the area for 10 minutes before the ESWT or take a pain medication before arriving for the appointment.

During the ESWT session, you will be positioned comfortably on an examination table. An ultrasound scanner is used to accurately guide the shock waves to the injury site. You will feel a strong 'tapping' sensation with each shock wave, and the treatment usually lasts 10 minutes.

What should I do after the treatment?

You can resume your normal daily activities after each treatment. It is ok to ice the area if you have local discomfort. Aggravating activities (e.g. running in the case of heel spurs) should be avoided until 2 weeks after the second ESWT session. Concurrent therapy (e.g, physiotherapy, or orthotics) may be prescribed to address the underlying biomechanical causes of the injury.

Are there any Adverse Effects?

The shock waves may be uncomfortable or painful but most patients tolerate it well. Minor bruising may develop, but that is temporary and rare.

How Can I Access ESWT Treatment?

You will need to see a doctor at SSMC first to confirm the diagnosis and decide if ESWT is medically indicated.

Each session of ESWT will last about 30 minutes total inclusive of preparation time.

What is Viscosupplementation?

Inside a healthy joint, there is a small amount of lubricating fluid, called synovial fluid. The primary composition of synovial fluid is hyaluronic acid. Hyaluronic acid provides lubrication in the joint movements. It also absorbs shock which goes through the joint, e.g. when the person hops or jumps.

In osteoarthritis, the cartilage in the joint wears out and the synovial fluid also becomes diseased and lose its lubricating and shock-absorbing abilities. The joint loses the protective mechanism and pain, stiffness and loss of function occur in the joint.

Hyaluronans are substances similar to hyaluronic acid in synovial fluid, in terms of lubricating and shock-absorbing abilities. Hyaluronans are injected into the joint affected by osteoarthritis, and they replace the diseased synovial fluid, protecting the already damaged cartilage lining from further damage caused by friction.

When is Viscosupplementation considered for treatment?

Viscosupplementation is not regarded as a first line treatment for joint osteoarthritis. Therefore, it is usually considered when conventional and evidence-based treatments, such as exercise, weight loss, physical therapy have been tried and have not resulted in the desired outcomes. There is no guarantee that viscosupplementation will improve your symptoms.

How is it done?

The doctor will clean the joint with anti-septic solutions. He or she may inject a local anaesthetic to the joint, and withdraw some of the diseased synovial fluid from the joint before injecting the hyaluronan preparation into the joint.

What should I do after viscosupplementation?

  1. Rest the affected joint for the first 24-48 hours from moderate to vigorous exercise. Daily activities are ok. Ideally, you should avoid intensive activities, e.g. running, for the first 2 weeks to prevent joint fluid build-up.
  2. If there is pain during this period, ice the area and/or take pain medications.
  3. Any bandage placed over the injected site can be removed after 1-2 hours, if there is no bleeding.

How long does the pain relief last?

The onset of pain relief varies between individuals. Most patients experienced full pain relief 6 weeks post-injection, but there are patients who experienced pain relief as soon as 1 week post-injection.

Viscosupplementation is not a cure for osteoarthritis, and hence there may not be permanent symptom relief. Although a single viscosupplementation can provide up to 6 months of pain relief. Hence there might be a need for a repeat injection

Possible Risks or Side Effects

Viscosupplementation is a safe procedure. There may be pain, or bleeding to the injection site. Some patients might also develop a rash. These are usually mild and do not last more than 3 – 5 days.

There is also a small risk of joint fluid build-up, infection, or acute swelling (flare reaction). If you have symptoms such as a fever, find that movement is painful, or the joint feels warm, see your family doctor immediately, or go to our Accident and Emergency Department, if you suspect that you have developed a joint infection or flare reaction.