Our Parkway Musculoskeletal Programme is led by a team of experienced consultant orthopaedic surgeons, and supported by nurses, physiotherapists and occupational therapists.

 

What are the Services available in Parkway Hospitals

Our Musculoskeletal Programme is delivered through our three hospitals:

• Gleneagles Hospital (272 beds 20 ICU and 50 specialists)
• Mount Elizabeth Hospital (357 beds 20 ICU and 270 specialists)
• Parkway East Hospital (123 beds 7 ICU and 50 specialists)

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Our range of services encompasses a comprehensive list of diagnostic and treatment options, and begins with a consultation with our surgeons. Depending on the nature of the problem, our specialists may recommend further investigations, such as:

 

Diagnostic Procedures

• Standard X-rays
• Computerized Tomography Scan (CT)
• Magnetic Resonance Imaging (MRI)
• MR (Magnetic Resonance) Arthrogram
• Dual energy X-ray absorptiometry (DXA)
• Electromyogram (EMG)
• Positron Emission Tomography (PET) Scan
• Diagnostic ultrasound
• Needle or open biopsy (for testing bone cancer)

Following the diagnosis of the injury or disorder, treatment may consist of medication, injections, referral to the rehabilitation team, surgery, or other treatment options

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Rehabilitation may be needed for various types of musculoskeletal disorders, either as a form of non-surgical treatment, or as part of the recovery process after surgical intervention. Comprehensive assessment and management is provided by our team of Physiotherapists and Occupational Therapists.

The aim of our programme is to rehabilitate the patient so that they can go back to mainstream life and sports with confidence as quickly as possible.

 

Non-Surgical treatment

Physiotherapist’s role

• Reduce pain and swelling, correct faulty biomechanics and soft tissue/muscle imbalances that contributes to the problem using a combination of manual therapy, electro-physical modalities and therapeutic exercises
• Where it is necessary to unload the injury, prescription and education on an appropriate walking aid
• Education on exercises and factors to prevent the recurrence of injury
• Teach stair-climbing with or without handrails

Occupational Therapist’s role

• Fabricate a customized external support (i.e. splint, orthoses etc) to protect the injured area
• Evaluate and prescribe aids and appliances
• Correct cognitive/perceptual problems

 

Post surgery treatment

Physiotherapist’s role

In addition to managing post-operative pain and swelling with the various modalities, and prescription/ education on appropriate walking aids, a progressive, structured exercise programme will be given to gradually improve mobility, strength, and ultimately, function

Occupational Therapist’s role

In addition to possibly fabricating customized external support, the therapist will also retrain the patient on activities of daily living (e.g. showering and dressing), as well as correcting any cognitive/perceptual problems

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Fractures

Effective fracture management is the cornerstone of general orthopaedics. Our surgeons have extensive training and experience in the management of fractures. Conservative management of fractures would typically involve attaining an optimum alignment of the fractured bones, and maintaining alignment plus protecting the injured part with a cast. Where it is necessary to off-load the injured portion, particularly when it involves the lower limbs, an appropriate walking aid is prescribed.

When the fracture is too extensive to manage conservatively, surgery is performed to internally fixate the fracture with instrumentation (i.e. wiring, plates, screws and nails); sometimes, when there are multiple sites of fracture, or if there is significant soft tissue injury and it is not possible to perform internal fixation, external fixators may used (this will be visible to the patient).

The rehabilitation team will work holistically with the surgeon to optimize and maintain range of motion and muscle strength.

 

Arthritis

Arthritis generally refers to an inflammation of a joint. In some forms of arthritis, such as osteoarthritis, the inflammation arises because the articular cartilage on the ends of bones become damaged or worn. Osteoarthritis tends to commonly affect weight-bearing joints more than non weight-bearing joints.

In other forms of arthritis, such as rheumatoid arthritis, the joint lining becomes inflamed as part of a disease process that affects the entire body. Some other types of arthritis are: seronegative spondyloarthropathies, crystalline deposition diseases, and septic arthritis.

Arthritis can be a major cause of lost work time and serious disability for many people, affecting their ability to function in daily activities. Though arthritis is mainly a disease in adults, children may also have it.

Treatment options for arthritis

When the arthritis can be conservatively managed, in addition to prescribing medication, the specialist may refer you to the rehabilitation therapy department.

Medication may consist of anti-inflammatory drugs, pain-control drugs, injections of cortisone into the joint to relieve pain and swelling, viscosupplementation or the injection of hyaluronic acid preparations to help in lubricating the joint.

The prescription of medication will take into account the type of arthritis, its severity, and the patient's general physical health. Patients with ulcers, asthma, kidney, or liver disease, for example, may not be able to safely take anti-inflammatory medications.

Rehabilitation

At the rehabilitation therapy department, the physiotherapist will use specific exercises and electro-physical modalities to improve joint stiffness, muscle weakness, and balance. If there is a need, a walking aid will be prescribed, and the appropriate use of the aid will also be taught.

In certain cases, the occupational therapist may need to custom fabricate a splint to protect the joint.

Surgery

Where non-surgical treatment is not recommended, or has failed to relieve pain and other symptoms, the surgeon will discuss the appropriate surgical procedure with the patient.

There are a number of surgical procedures, depending on the type of arthritis, its severity, and the patient's physical condition. These include:

• Realignment of the joints i.e. tibial osteotomy
• Removing the diseased or damaged joint lining i.e. debridement
• Fusing the ends of the bones in the joint together, to prevent joint motion and relieve joint pain i.e. Joint fusion
• Replacing the entire joint i.e. total joint replacement
• Replacing part of the joint i.e. hemi-arthroplasty
• Harvesting and culturing cartilage to replace degenerate cartilage i.e. cartilage transplantation

Advances in surgical techniques and implant designs have enabled more patients who have undergone joint replacement (hip or knee) to return to their previous activity levels, and achieving a significant improvement to the quality of living.

 

Bone Tumours

A bone tumour is a mass of abnormal cells that divides uncontrollably in the bones. The cause is unknown. Bone tumours may sufficiently weaken the bone to eventually cause a fracture. Bone tumours are mostly benign (slow growing and non cancerous) while some are malignant (fast growing and cancerous), and spread throughout the body (metastasise). Bone cancer that begins in the bone is known as primary bone cancer, while cancer that begins somewhere else in the body and spreads to bone is known as secondary bone cancer.

Symptoms of bone tumours

In many cases, there may be no symptoms, although the patient may notice a painless mass. It may sometimes be discovered incidentally when X-rays are taken for other reasons.

Where there is pain, it:

• Is generally described as dull ache in the area of the tumour.
• May or may not be aggravated by activity
• May awakens the patient at night
• May have accompanying fever or night sweats

What are the Treatment Options?

For benign tumours, the surgeon may recommend the removal (excision) of the abnormal tissues, followed by bone grafting to repair the bony defect.

For malignant tumours that require more aggressive treatment, procedures performed by the different specialists include:

Orthopaedic Surgeon

• Removing the cancerous tissues while preserving the surrounding muscles, bones and nerve supply – limb salvage surgery
• Amputation - Amputation removes all or part of an arm or leg in cases where the tumour is large and/or nerves and blood vessels are involved, all or part of the arm or leg may be cut off

Radiation Oncologist

• Radiosurgery i.e. applying accurately focused beams of radiation directly to the tumour target to arrest the growth; the treatment usually takes a few hours and can be achieved by either by the Gamma Knife machine or Linear accelerator machine
• Fractionated Radiotherapy is used for cancerous bone tumour that cannot be removed completely by surgery alone; given in daily small doses over a period of between 2-6 weeks, it aims to kill the remnant tumour cells
• Tomotherapy – our new machine, the 1st machine in South East Asia (located at Mount Elizabeth Hospital) for cancer treatment – started treatment of patients in March 2006; with Tomotherapy, the Radiation Oncologist can check the location of the patient’s tumour before each treatment, then deliver painless and precise radiation therapy based on carefully customized plan

Medical Oncologist

• Chemotherapy involves the used of drugs to kill the cancer cells. The drugs are either taken by mouth or given intravenously

Rehabilitation

The effect of non-surgical cancer treatment may leave the patient weak with poor activity tolerance. This can greatly affect daily functioning. The physiotherapist will structure an exercise programme to progressively improve the patient’s strength and aerobic tolerance. The occupational therapist will focus on practicing the various functional activities i.e. dressing and showering, to allow patients to slowly regain their independence.

When surgery has been performed, both the physiotherapist and occupational therapist will focus their attention on strengthening the unaffected muscles and teaching compensation strategies in performing daily functional activities. For amputees, training and education will focus on acquiring the skills to use the prosthetic limb normally.

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Spine Disorders

Disorders of the spine can be categorized as being degenerative (i.e. cervical and lumbar spondylosis, degenerative disc disease), or from an acute injury (spondylolysis, intervertebral disc herniation, sprains and strains). Disorders that do not fall specifically into any of these categories include tumours.

Cervical and lumbar spondylosis

Arthritis that affects the neck is known as cervical spondylosis; it is known as lumbar spondylosis if it affects the back. It may result from bony spurs and problems with ligaments and discs. The spinal canal may narrow and compress the spinal cord, and the nerves of the arms or legs. The severity varies from mild to severe neck or back discomfort or pain, numbness and weakness in the upper and/or lower limbs, to severe, crippling dysfunction that affects voluntary movement.

The diagnosis is based on interviewing and examining the patient. The specialist may send you for x-rays, MRI, blood tests (to rule out rheumatoid arthritis), and even a needle EMG procedure if there is numbness and weakness of the limbs.

Depending on the severity of the condition, the specialist may either prescribe some medication and refer you to the physiotherapist, or discuss surgical alternatives available to you.

Spondylolysis and Spondylolisthesis

Spondylolysis is when a stress fracture occurs in the pars interarticularis (portion joining the upper and lower joints) of the vertebra. It usually affects the fifth lumbar vertebra in the lower back, though the other spinal levels may sometimes be affected as well. A genetic factor (i.e. thin vertebral bones) may predispose to this injury.

Where stress fracture leads to the vertebra shifting out of it proper position, the condition is known as spondylolisthesis. Excessive slippage may press on nerves, and surgery may be necessary to correct the condition.

Intervertebral Disc Herniation

The intervertebral disc, which is the cushion between adjacent spinal vertebrae, is made up of the gel-like core (nucleus pulposus) encased in a fibro-cartilagenous shell (annulus fibrosus). Due to injury or the aging process, the nucleus may dehydrate (degenerative disc disease), leading to poor shock absorption capacity, and the annulus may get weaker and begin to tear. When the nucluse begins to extrude through the tear, the condition is known as disc herniation. Due to the proximity of the disc to the spinal cord and spinal nerves, a herniation may press against these structures, causing radiating pain, numbness, tingling, diminished strength and/or range of motion.

Spine treatment options

Anti-inflammatory medications may be prescribed to decrease pain and inflammation.

Epidural steroid (anti-inflammatory) injections are injected directly into the spinal canal to the affected nerve roots.

An external brace, such as a lumbar corset or cervical collar, can provide some support and help the patient gain some mobility, as well manage the pain. However, this is not recommended as a long-term solution as it will cause progressive stiffness and deconditioning of muscles.

Physiotherapy

The physiotherapist will aim to correct any muscle and mobility imbalances to achieve better symmetry and distribution of spinal stresses. He/she will also aim to reduce your pain, and educate you on strategies to cope and manage your condition. The physiotherapist may use a number of treatment options, such as joint mobilization or manipulation, electro-physical modalities (mechanical traction, ultrasound therapy, interferential therapy), and specific strengthening exercises.

Surgical treatment

The surgeon may perform either one or a combination of these procedures:

Laminectomy

The surgeon will remove the lamina (the back portion) of the vertebra to widen the spinal canal, and create more space for the spinal cord and spinal nerves.

Spinal fusion

A surgical procedure, where the spine is stabilized by fusing together two or more vertebrae, using bone grafts and metal rods and screws.

Discectomy

An option for disc herniation, the herniated portion of the disc is excised.

Disc replacement

In situations where most of the degenerative changes are in the inter-vertebral disc, total artificial disc replacements may be performed by substituting the human disc with a mechanical device that will simulate spinal function. The artificial disc may restore the height between the vertebral bodies, thus widening the passageway through which the nerve roots exit the spinal canal. It can also relieve pressure on facet joints, and help to maintain the natural curvature of the lumbar spine.

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