DISCOVER THE FUTURE OF MEDICINE

INNOVATIONS IN HEALTHCARE

Be in the know: Your comprehensive guide to the latest medical breakthroughs, health economics and the right treatment options for you.

DISCOVER THE FUTURE OF MEDICINE

5STEPS

A new beginning Why the way we perceive and treat pain is changing

Going for gold Olympian Sarah Webb on sports injury recovery

SEAN LOCKE PRIVATE

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Striding ahead

From musculoskeletal injury to neuropathic conditions, there are more solutions than ever to assuage pain and enhance quality of life. Creating new, refined methods of treatment with better results is vital for all.

Innovation is the lifeblood of good healthcare. From pain management to treatment of trauma, research and de-velopment is essential to im-

proving optimise patient experience and results. Care must be taken to drive initiatives ever forward in eve-ry aspect and branch of modern med-icine.

An exciting timeOf all fields, it is perhaps ortho-paedics that holds some of the

most dramatic and exciting develop-ments – and yet it is also an area often neglected, certainly in proportion to the wide-ranging, deep-reaching ef-fect musculoskeletal damage and conditions frequently have on peo-ple’s lives. In April 1998, in Lund, Swe-den, a conference was held to propose a Bone and Joint Decade. The driv-er behind the initiative was a per-ceived mismatch between the huge and growing burden of musculoskel-etal disease and the low priority ac-corded to musculoskeletal medicine, surgery and rehabilitation across the world.

A broad area of developmentUK scientists have played a lead-ing role in achieving progress,

translating knowledge into pow-erful treatments. In drugs, for in-stance, with the so-called ‘biologics’; these are drugs manufactured by re-combinant DNA technology that ei-ther mimic or block the actions of the body’s signalling molecules: ef-fectively curing diseases such as in-flammatory arthritis, where previ-ous treatments could only partially keep it in check.

In musculoskeletal surgery, steady progress has been made in the design of implants, for fixing fractures or re-placing destroyed joints, with new designs and new materials. Howev-er, as in other branches of medicine, a burning question is whether a para-digm shift is possible towards regen-erating damaged tissues rather than replacing them, through the use of the patient’s own stem cells.

Stem cells are found in virtually all tissues and are presumably there to drive remodelling in response to demands on the tissue and to initi-ate repair when needed. Cell thera-

py has been used in localised dam-age to joint cartilage for many years but the evidence for its effectiveness is far from cast-iron. Nobody has yet figured out how to use this approach for the more generalised conditions such as osteoarthritis and osteoporo-sis, where the big burden of disease lies. We have much more to learn about how to harness stem cells be-fore they will make a serious chal-lenge to the established remove-fix-or-replace strategies of current ortho-paedics, but the long-term prospects are exciting.

A clear objectiveThe goals of the Bone and Joint Decade remain entirely valid:

raising awareness of musculoskele-tal disorders has the potential to con-tribute hugely to the nation’s quality of life through people’s own efforts and the work of the NHS.

The musculoskeletal system is there to allow us to move around and do things when we get there. It’s about improving and sustaining eve-ryone’s quality of life, from the ama-teur gardener to elite sportspeople.

“I took it upon myself to find the best surgeon I could - not only to carry out the operation but someone who also understood the importance.”

Taking careOlympic sailor Sarah Webb on the importance of good bone health and treatment.

WE RECOMMEND

PAGE 4

Don’t suffer in silence p. 101. How the perceptions and treatment of chronic pain are being challenged.

Making waves p. 122. The giant leaps forward being made in biological technology.

INNOVATIONS IN HEALTHCARE, 3RD EDITION, APRIL 2010

Country Manager: Willem De GeerEditorial Manager: Danielle StaggBusiness Developer: Christopher Emberson

Responsible for this issueProject Manager: Clarisse O’DellPhone: 0207 665 4414E-mail: clarisse.o’[email protected]

Distributed with: The Sunday Telegraph, May 2010Print: Telegraph Media Group

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We make our readers succeed!

David MarshProfessor of clinical orthopaedics, UCL

1Innovative thinking can be as influential as new techniques

and medications. The British Or-thopaedic Association and the Brit-ish Society of Rheumatologists have now embarked on an innova-tive, similar collaboration aimed at revolutionising the provision of musculoskeletal services general-ly.

2This is at an early stage but po-tentially could yield great

progress and would buy a lot more quality of life for the limited bucks we are going to have in the coming years.

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Question: What difference can innovative research and development really make to patients’ lives?Answer: From an Olympic athlete to an amateur runner, new methods of healing are enhancing – and often dramatically changing - lives.

For Sarah Webb, the sailor and Olympic gold medallist, surgery provided the dif-ference she needed to win. “I had just an-nounced my second Olympic campaign to defend my Olympic gold medal when I snapped my anterior cruciate ligament (ACL),” she says.

“I took it upon myself to find the best surgeon I could - not only to carry out the operation but someone who also un-derstood the importance and would play a part in a full and quick recovery after-wards. My surgeon Tim excelled my ex-pectations and winning my second gold medal was a testament to his skill and hard work,” says Sarah.

Sarah’s surgeon the knee special-ist and consultant orthopaedic surgeon Tim Spalding performs not just ACL re-construction surgery that is extreme-ly commonplace yet, as in Sarah’s case, life-changing and career-saving - but al-so new techniques for other types of inju-ry that give a vastly improved hope of re-habilitation, improved recovery time and better pain management.

There are many new ways now in which orthopaedic injury – with causes ranging from trauma to age-related de-generation – can be helped heal, from new repair methods to minimally invasive surgery and implants.

Every year around 30,000 people dam-age their knee cartilage, from simply twisting it while gardening to playing contact sports. The usual surgical treat-ment is to improve mobility and pain by removing the damaged part of the carti-lage in the knee via keyhole arthroscopy, a meniscectomy. Meniscectomy is a com-monplace operation and usually results in a good degree of success but some peo-ple still experience significant pain, says Mr Spalding.

Up until now, it has only been possible to either remove the damaged cartilage further or to have a meniscus transplant from a deceased donor – a rare procedure, prinicipally due to the lack of donor tissue available.

But now a new treatment allows the cartilage to be regenerated with the sup-port of a scaffold device inserted during keyhole surgery – allowing, for the first

time, the meniscus to be sufficiently re-paired.

Mr Spalding works with two different scaffold devices: a porcine collagen im-plant and a synthetic polymer implant. Both work by guiding new tissue growth using the body’s own healing process in patients with an irreparable meniscus tear or loss of meniscus tissue - provid-ing reabsorbable scaffold for the growth of new tissue in the meniscus.

For both implants, the recovery peri-od is long – no contact sports for year, no running for six months, and the use of crutches for 8 weeks after the operation - but in many patients the result is worth the wait.

“It’s about minimising pain in those who still have pain and discomfort de-spite surgery, and about minimising the need for further meniscectomy – which makes sense for both the patient ‘s bene-fit and for the health economics of service provision,” says Mr Spalding. “It’s incred-ibly exciting.”

And it’s not just severe or traumat-ic injuries that benefit from innovative research. A new range of hyaluronic ac-

id-based injectables also offers hope for sprains and osteoarthritis and are due to be launched in the UK next month. Hy-aluronic acid can significantly reduce the rate in recurrence of injuries such as sprains, offers significant improve-ment in the pain suffered and a vastly im-proved recovery time. Hyaluronic acid is not a new development but improved de-livery methods mean that it’s now hoped that the new injectables will play a role in improving management of common injuries such as ankle sprain and tennis elbow, currently treated simply by RICE (rest, ice, compression, elevation) and an-algesics.

A new dual-weight molecular weight hyaluronic acid injectable for osteoar-thritis of the knee also promises better pain relief and increased mobility - a vast improvement on the existing single mo-lecular-weight injectables.

The importance of good bones

EMILY DAVIES

[email protected]

CHANGE

“Tim excelled my expec-tations and winning my second gold medal was a testament to his skill and hard work.”Sarah Webb Olympic gold medalist and sports injury patient

INSPIRATION

PLAIN SAILINGGetting the best treatment possible was vital for Olympian Sarah Webb.PHOTO: PRIVATE

The following conditions should be seen early by an appropriate doctor/surgeon so that an adequate treat-ment programme is instituted to prevent further damage and ensure early recovery

A partial or complete tear of the Achilles tendon (or heal-

cord). This injury occurs most common-

ly in rugby and at squash. The in-jured sportsperson is usually mak-ing a strenuous run or a sudden change of direction. They feel like someone has kicked them at the back of the leg just above the heel. The tendon just above the heel feels tender and they cannot stand on tip-toe. Prompt treatment is essen-tial and this can either be cast treat-ment or an operation, but neglect is likely to result in a poor outcome.

A neck injury in contact sports – typically horse- riding, rugby

or wrestling. Neck injuries should always be

treated seriously and require an ex-pert assessment through an Acci-dent & Emergency Department – do not delay assessment because seri-ous further injury to nerves can be a consequence.

TOP TIPS FOR SPORTS

INJURY RECOVERY

AIM FOR THE BEST

1STEP

!

!

Professor Angus WallaceLeading sports surgeon


The secret of support

One of the most important elements of the health service is orthotics - the assessment of the whole body for bi-omechanical problems by orthotists which results, if appropriate, in pre-scribing or fitting an orthosis. An or-thosis is an externally applied device, often called a ‘brace’ or ‘splint’.

An orthosis can improve function, reduce pain, and prevent deformity, says Simon Dickinson, the orthotic clinical lead at Nottingham Univer-sity Hospitals NHS Trusts.

“Although relatively few in number compared to other healthcare profes-sionals, orthotists treat thousands of NHS patients every week for condi-tions such as foot pain, knee instabil-ity, stroke, diabetes, multiple sclero-sis, cerebral palsy and arthritic con-ditions”, he says.

“As innovation, improved under-standing of biomechanics and im-proved technology has advanced it has been proven that orthoses al-so can be used to successfully treat many conditions which cause pain and instability”.

If prescribed and used correctly they can reduce the need for surgery, improve recovery time from injury and surgery, prevent injury and re-duce the rate of progression of pain-ful conditions.

“Innovation and improved under-standing in orthotics has given an

understanding of how we move and function”, says Simon. “It has proved much, from why, for instance, that we develop conditions such as oste-oarthritis to how we can reduce foot-related problems due to diabetes”.

Recent innovations include iden-tifying the specific genes that deter-

mine the shape of our feet and how we function - this understanding of genetic morphology has led to a spe-cific insole system to be developed to address the mechanical needs of each inherited foot type, says Simon. “This type of analysis has the poten-tial to reduce strains on the body that are known to cause joint damage, ar-thritis and pain”.

An additional innovation current-ly undergoing clinical trial is a new brace to treat clavicle fractures - al-though only a few patients have been treated the results have been very promising with patients having a re-duced need for surgery, reduced pain, and reduced recovery time. This is potentially a major advance for pa-tients and could be an enormous cost saving for the NHS.

A number of government-commis-sioned reports (Pathfinder project, Fully Equipped and Orthotic Service in the NHS: Improving Service Provi-sion, Hutton et al 2009) have shown the wide-ranging impact of effective orthotic services treatment for pa-tients’ lives and the health economy.

The potential to further improve patient’s lives, reduce pain and possi-bly prevent disease is very real – and as an as an essential service with any healthcare setting. It does however require increased research, funding and recognition.

”Innovation in orthotics has given an under-standing of how we move and function.”

Simon DickinsonNottingham University Hospitals NHS Trust

EMILY DAVIES

[email protected]

Question: What about inno-vation beyond medicine and sur-gery?

Answer: Orthotics is a crucial, far-reaching service for many in-juries and conditions in which in-ventiveness is key.

A HELPING HANDOrthotics offer support for hundreds of patients with joint conditions.PHOTO: NHS

INSPIRATION

FACTS

From foot orthoses to spinal braces

and knee orthoses, the purpose and de-

sign of an orthosis may change over time

to match the needs of the patient.

Orthotics have proved that abnormal

foot function biomechanically increases

the strain on the ankles, knees, hips and

back as well as the muscles of the lower

limb. Foot orthoses (insoles) are used to

relieve mechanical strain, pressure, re-

duce foot, ankle, knee, hip and back pain

and improve the function of the foot/an-

kle.

Recent studies show significant im-

provements in pain reduction in knee ar-

thritis with the use of foot orthoses. Foot

orthoses can significantly reduce the

need for surgery.

Orthotic treatment can improve recov-

ery time from injury or stroke and can re-

duce the need for surgery

Orthotic treatment can save the NHS

money: for every £1 spent on orthotics

the NHS saves £4

SOURCE: SIMON DICKINSON

HOW WE MADE IT

Appreciate the scale

1Chronic pain has a huge impact on people’s lives and on the

health economy. At one point, for in-stance, the Department of Work and Pensions put more money into re-search of back pain than the Depart-ment of Health - such was the dam-age suspected to the economy caused by days lost through worklessness.

Governments are beginning to see the need to address the problem of chronic pain but more needs to be done and it needs to be a multi-facto-rial solution. It’s never going to have a simple, single answer.

Challenge perceptions

2There has been a recent shift: a move away from seeing chron-

ic pain as strictly a medical problem to addressing it via a biopsychosocial model – looking at wider causes and how they may be addressed from a wider perspective. This is the way ahead: there needs to be proper rec-ognition of the psychological side ef-fects of chronic pain.

Utilise support networks

3Treatments work properly only with good support mecha-

nisms, from seeing the right health-care specialist to the reassurance that chronic pain is not going to con-demn their lives - that they can en-joy life and even some sort of exer-cise. There is undoubtedly benefit to be found from working and engag-ing with society.

Change practices

4A new way of assessing and managing pain is needed, such

as the triage-style system currently in use in Southampton rather than the system of elimination that is so often the default system we have at the moment, where too often a pa-tient is bounced around between constant referrals – from a GP to or-thopaedics to rheumatologists and back to the GP, for instance.

PROF CERI PHILLIPS, PROFESSOR OF HEALTH ECO-NOMICS AND HEAD OF THE INSTITUTE FOR HEALTH RE-SEARCH, UNIVERSITY OF SWANSEA

PROF CERI PHILLIPS’ BEST

TIPS ON PAIN MANAGEMENT

4ALWAYS LOOK TO IMPROVE

2STEP


TIPS

FEEL GOOD WHILE DOING GOOD1. Try to build up gradually- know your limits.2. By working with weights you can gently build up muscle strength.3. Build a routine. Consist-ency lessens the risk of over-exerting yourselfPHOTOS: RANPLETT, KUTAY TANIR,

VISUAL FIELD, ISTOCK

1 2 3

Prevention is better than cure, and many sports and exercise injuries can be pre-

vented by preparing properly for your chosen activity. Be sure to build up gradually and plan your training programme so that your activity is stepped up gradually. Check you’re using the correct technique – this is especially important when taking up a new activity or sport.Lastly, always remember to warm up. This prepares the body for exercise or your chosen sport by starting to divert blood flow to the muscles you will be using.

PREVENT, PROTECT, TREAT

Look after yourself- and your game

INSPIRATION

Dr Foot Pro Features:

Built-in 4˚ Arch Support It helps to neutralise the negative effects of hard, flat, unnatural surfaces by controlling excess motion (pronation) and realigning the foot and ankle to its natural position.

Deep Stabilising Heel CupKeeps the foot’s natural padding directly under the heel to absorb shock and support your weight as nature intended.

UsabilityIt has a ¾ length design that takes up less room and is easily interchanged from shoe to shoe. They fit all types of regular men’s and women’s (low-heeled) footwear.

Poron® Shock Dot in centre of heelIt provides an additional layer of comfort and shock absorption to the heel, a high impact area and relief from localised pain and inflammation.

Made of flexible, long-lasting, shock-absorbing E.V.A.Firm support, yet enough flex to allow short ‘break in’ time. The same material is used for the midsole of good quality athletic footwear.

Dr Foot Pro InsolesEffective relief from heel pain, knee pain, leg pain, back pain and many common foot problems

Dr Foot Pro insoles re-align the feet and ankles to their natural position and to correct body posture. They provide natural, lasting relief and comfort from heel, knee, aching legs and back pain.

£23 for a pair or buy 2 pairs of insoles for a 20% discount for £37 FREE UK DELIVERY Call 0800 19 53 440 or visit www.drfoot.co.uk


Question: What is so interest-ing about orthobiologic develop-ments and why are they so im-portant?

Answer: New solutions offer better, quicker recovery with few-er complications – and an earlier return to normal activity.

Andrew Unwin, an orthopaedic sur-geon at the Windsor Knee Clinic whose practice is in arthroscopic knee surgery ( knee procedures aided by “keyhole surgery”) has been using allografts in revision anterior cruci-ate ligament (ACL) surgery for some time and in primary ACL surgery for the last two to three years - and has been generally pleased with the re-sults.

About 5,000 such procedures per year are performed within the UK and 20,000 per year within the US. In parts of the US such as California over half of primary ACL reconstruc-tions in those over 25 years of age are performed using allograft and larger percentages for revision surgery, says Andrew.

While most authorities would agree that the traditional methods of using the patient’s own tissue, an autograft, offers the best quali-

ty tissue, and certainly the cheapest source of graft material, this comes at a price, says Andrew - patients often have short, medium and long-term symptoms due donor site problems, and the recovery from an ACL recon-struction can be longer due to symp-toms from the donor site.

There has been a very signifi-cant improvement in the harvest-ing and processing of allografts in re-cent years, says Andrew. In the past large doses of radiation treatment were needed to “sterilise” the grafts and make them safe with respect of bacterial, viral and spore infections - such treatment rendered the grafts relatively safe but weakened the grafts considerably.

“There have been a number of in-novations and advances in technol-ogy in graft processing with less-er quantities of irradiation and also what would appear to be a very en-couraging new chemical processing technology to render grafts safe from

Andrew UnwinConsultant Orthopaedic surgeon, Windsor Knee Clinic

LEARN TO GROW YOUR OWN SUCCESS

EMILY DAVIES

[email protected]

NEWS

MAKING PROGRESSDevelopments in treat-ment means the use of keyhole surgery is rising, while recovery time is fallingPHOTO: ISTOCK PHOTO

UTILISE BIOLOGICS

3STEP

What has been the impact and benefits of allografts and similar developments in biologics?

!-In those over 25-30 who par-ticipate in recreational sports,

where speed or recovery is not so important, allografts offer a good alternative with quicker recovery times and less post-operative pain, although at a financial cost. The allografts would appear to offer enough strength for recreational sport.

Patients are able to have sur-gery with less surgical trauma, less pain and a quicker short to medium-term recovery. For the 25 to 40-age patient group I use allografts for want a quick re-covery to get back to work and allografts help in this respect.

What do you hope for the future of biologics and orthobiologics?

!– There has been considerable work with growth factors and

tissue scaffolds to encourage heal-ing and replacement of tissues. Grafts may be able to become in-corporated within patients with more security, and allow quicker recovery times and more prompt return to sport. Many surgeons al-ready use the body’s own growth factors within both autografts and allografts by using a technology called “Platelet Rich Plasma” where blood is taken from the pa-tient, spun down to give a concen-tration of platelets rich in growth factors, and this is applied to grafts.

I would expect there to be signif-icant advances in this type of tech-nology over the next few years. It would be ideal to place growth fac-tors within grafts, and keep them there, to allow for better graft in-corporation.

QUESTION & ANSWER

Andrew UnwinOrthopaedic surgeon and knee expert

infection but with lesser effects on the strength of a graft,” he says. The BioCleanse technology is one exam-ple of this, the tissue sterilisation process validated to eliminate virus-es, bacteria, fungi and spores from tissue without impacting the struc-tural or biomechanical integrity of the allograft, outlined in the June 17, 2004 issue of The New England Jour-nal of Medicine examining a study

done by the Centers of Disease Con-trol and Prevention in the US.

In seeking to eliminate concern over disease transmission through allografts, technologies such as this will propel forward the future of or-thopaedic surgery – and its results for patients and health service alike.

FACTS

Biologics is the umbrella term for medicinal products such as blood and blood components, tis-sues, vaccines and re-combinant therapeutic proteins created by biological processes (rather than by chemis-try). Biologics are taken from a range of natural sources – human, animal or microorganism – and are produced by biotechnology methods and other technologies.

Replacing ligaments with-in the knee traditionally involves a patient having to donate their own tissues to replace the ruptured liga-ment – an autograft. Anterior cruci-

ate ligament (ACL) re-construction is the most commonly per-formed procedure in the UK and worldwide

in this respect. two most common sources

of autograft for ACL recon-struction are the patellar tendon

(kneecap tendon) or the inner ham-strings.

An alternative to autograft is the use of allografts, xenografts or synthetic material to replace the ruptured ligaments or other tissues within a knee. An allograft is tissue harvested from another human and a xenograft is tissue from an animal (e.g. a pig).


Don’t suffer in silence

People suffering from severe pain are nine times more likely to be unable to work due to sickness compared to those who are not suffering from pain, according to a study of 9,419 adults released earlier this month at the British Pain Society’s annual sci-entific meeting.

Many now that conclude that gov-ernment policymakers and commis-sioners should see pain as a clinical priority and target it effectively to ensure patients with pain are treated at an early stage before the condition becomes chronic. The study conclud-ed that there is a significant associa-tion between pain and reduced men-tal health of an individual and socio-economic disadvantage, so having a considerable impact on the patient & society in terms of work production and costs to health services.

Chris Morgan, one of the study’s authors, says: “There is plenty of ev-idence to suggest that developing chronic severe pain can result in so-cio-economic disadvantage. Getting patients back to their best health and well-being means providing ad-equate training and resources.”

Next month, experts including budget holders, strategic decision

makers, clinicians & patient associa-tions from across Europe will gath-er in Brussels at an event organised by (EFIC®) The European Federation of IASP(International Association for the Study of Pain) & supported by Grünenthal GmbH, to discuss the social cost of chronic pain and strate-gies for the future.

The quality of life for patients with persistent pain can be tremendously affected if it is not adequately treat-ed. Patients are exhausted not only

physically, but also mentally and so-cially.

Chronic pain is multi-factori-al and, according to research by the Chronic Pain Policy Coalition, near-ly eight million people (1 in 7 of the population) in the UK suffer ongoing problems. Chronic pain is one of the most common reasons for a patient to visit a GP, accounting for 4.6 mil-lion GP appointments each year at a cost of £69 million. However, only 2 per cent of these have seen a special-

ist, and a quarter believes that their doctor does not know how to treat pain.

“The impact of moderate and se-vere pain is considerable in terms of work productivity and costs to healthcare services”, says Dr Joan Hester, past president of the British Pain Society and consultant in pain medicine at King’s College Hospital, London. “The study highlights that there is limited awareness and un-derstanding about the impact of per-sistent pain. It is vital that more edu-cation is provided to help healthcare professionals to be able to assess the severity of pain, improve early man-agement of pain and prevent it from becoming persistent.”

“It’s not surprising that many healthcare professionals are calling for severe pain to be recognised as a disease in its own right”, says Heath-er Wallace, chair of Pain Concern: “As a charity for people in pain, we know that proper training for healthcare professionals is needed to improve the treatment of pain and prevent suffering. It would reduce the burden on the NHS as well as improving pa-tients’ socio-economic status.”

With many experts calling for better pain management, CHANGE PAIN is an educational programme developed by Grünenthal for clini-cians and allied professionals which aims to go part of the way in assisting healthcare professionals improve the management of chronic pain.

“Getting patients back to their best health and well- being means provid-ing adequate train-ing and resources.”Chris Morgan Chronic pain expert

EMILY DAVIES

[email protected]

Question: How can the issue of pain be readdressed?

Answer: With many experts calling for better pain manage-ment, the devastating impact of chronic pain is increasingly be-ing recognised – but more needs to be done.

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1

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A MISUNDERSTOOD PROBLEM1. Organisations, such as Pain Concern, can give people suffering from chronic pain a voice.2. Every aspect of a sufferer’s life can be affected causing great stress and worry.3. Severe pain can leave those afflicted feling isolated and helpless.PHOTOS: MATTHEW GONZALEZ,

JACOB WACKERHAUSEN, ISTOCK

SHOWCASE

NEWS

APPRECIATE THE SCALE OF

THE ISSUE

4STEP

DR BEVERLY COLLETT’S TIPS

Persistent, or chronic, pain affects

7.8 million people in the UK - it’s thought

around 13% of population suffer.

It can arise from a variety of causes,

from musculoskeletal to the pain of a hys-

terectomy scar.

It’s defined as pain that’s lasted long-

er than 6 months and after healing would

have been expected to have taken place.

The effects are far-reaching; 25% of

patients are depressed, 25% lose their

job and 50 to 60% have problems sleep-

ing.

Much of improving the effects of pain

involves learning to live with it, not elimi-

nate it. For example, we advise chronic

pain patients to plan and pace their lives

according to their pain load rather than

get into the commonplace chronic pain

cycle of overactivity one day, underactiv-

ity the next.

Anyone with persistent pain must ask

for a referral from their GP to a specialist

pain clinic, where a multi-disciplinary ap-

proach can consider the whole picture of

their pain and how it is affecting them.

What’s significant about persist-ent pain?

!”Chronic, or persistent, pain is much more complicated than

simply the cause of the pain itself. Pain is usually a warning sign but with chronic pain, that’s no longer simply the case – it shows that the nervous system has become in-volved. It’s vital to look at the psy-chology of pain and how it affects a person as a whole.

In chronic patients an MRI scan, for instance, might show no struc-tural reason for the pain despite the patient suffering agonising pain. This is because the nerves are work-ing in an overexcited fashion and in-creasing the activity of nerves in the spinal cord, making the pain experi-ence worse. We call this “wind-up”. Studies now show that pain impuls-es to the brain activate the limbic system – the part of the brain where we feel fear, emotions and what con-trols sleep, thus proving how deeply affecting pain is at every level.

Professor Irene Tracey at the Functional Magnetic Resonance Im-aging Centre , University of Oxford, has produced much research show-ing the changes in the spinal cord in a chronic pain patient.

What’s the best way to approach it?

!”It’s important to address pain in a way that recognises the

different problems it can effect and not just its cause. Drugs help 1 in 3 people and therapy such as osteopa-thy can certainly be helpful but a multi-disciplinary approach is ideal – we use a combination of treatment including nurses, physiotherapists, and clinical psychologists.

How could the situation be im-proved?

!”The paucity of undergraduate medical education with regard

to pain management has much to answer for and there is an argument that chronic pain should be consid-ered a disease in itself. We now often prescribe drugs that are surprising to a patient – for instance, anti-de-pressants to treat a patient’s nerve pain. We are trying to move multi-disciplinary clinics beyond the hos-pital and out into the community, to improve access to pain management for all.

QUESTION & ANSWER

Dr Beverly CollettThe Internation-al Association for the Study of Pain, chair of the Chronic Pain Policy Coali-tion and consultant in pain medicine, University Hospital Leicester


Build the future’s foundation

FINDING THE ANSWERNew materials offer new leads for surgeons and patients alike PHOTO: PRIVATE

Orthopaedics and trauma affect a huge range of people – the British Or-thopaedic Association estimates that 1 in 2 of us will experience an ortho-paedic problem at some point in our lives. Orthopaedic surgery is a dy-namic and exciting field, pushing continually forward with a stream new discovery to improve patients’ quality of life and reduce costs to the health economy.

From new materials to new tech-niques, the benefits and outcome for patients are improving rapidly with advancement in knowledge and ex-pertise.

For instance, the outcome of joint replacement surgery has advanced dramatically with the introduction of new materials that are versatile and more compatible than ever be-fore with bone itself. Implants are secured to human bone in one of two ways – they are either cemented (ce-ment is used to secure the implant to the bone) or cementless (natural hu-man bone grows into, or heals direct-ly to, the artificial implant). Several

factors determine which method is used; most notably the quality of the natural bone to which the implant must adhere.

Trabecular Metal implants have the porosity and structure that al-lows for extensive bone in-growth, which creates a bond between the implant and the bone, and elimi-nates the need for bone cement. The more porous the implant material,

the more space is available for bone to grow in and secure the implant. Whereas other materials used for or-thopaedic implants are only 35 per cent to 50 per cent porous, Trabecu-lar Metal material is 75 - 80 per cent porous.

“Using a material such as Trabec-ular Metal allows us to reconstruct bone defects in patients who have previously been turned down for sur-

gery, or in those who are risk of hav-ing an early failure of the surgery, thus now enabling surgery,” explains Lawrence O’Hara, consultant ortho-paedic and trauma surgeon, Royal Bournemouth Hospital and Poole General Hospital. “It also allows us to avoid more extensive approaches which potentially put nerves at risk, and avoid dislocations in hip sur-gery because we can place it at the true centre of the hip, while possess-ing similar flexibility to bone - stud-ies have indicated that implant ma-terials that don’t flex well can cause bones to recede and lose strength over time”.

“It’s really been a major advance that’s allowed me to take on more complicated projects and to achieve greater success – returning people to good function which historically might not have been possible,” points out Andrew Manktelow, consultant orthopaedic surgeon at Queen’s Med-ical Centre, Nottingham University Hospitals NHS Trust.

“As our use and understanding of Trabecular Metal increases in prima-ry and revision hip surgery, I would expect it to be put to use in oth-er fields, possibly fracture surgery’. These kind of innovative develop-ments are incredibly exciting.”

“Using a material such as Trabecular Metal allows us to recon-struct bone defects in patients who have previously been turned down for surgery”

Lawrence O’HaraConsultant orthopaedic surgeon

EMILY DAVIES

[email protected]

Question: Musculoskeletal disease, injury and conditions are a leading cause of pain and worklessness. What’s being done to improve the results for orthopaedic patients?

Answer: From new materials to refined techniques, research and development promises fresh hope.

NEWS

BE INVENTIVE

5STEP

FACTS

1 in 2 of us will need orthopaedic treat-

ment at some point in our lives.

40% of all surgeons in the UK work in

trauma and orthopaedics.

Road traffic accidents are the leading

cause of death and disability for people

under age 45.

According to the National Joint Reg-

istry, in England and Wales there are ap-

proximately 160,000 total hip and knee

replacement procedures performed

each year. Approximately the same

number of hip and knee joints are re-

placed.

One of the common needs in the over-

60s age group is for an artificial hip: a

British orthopaedic surgeon, the late Pro-

fessor Sir John Charnley, led the way by

carrying out the first full hip replacement

in 1962 at The Wrightington Hospital in

Lancashire.

SOURCE: BRITISH ORTHOPAEDIC ASSOCIATION / BONE

AND JOINT DECADE / NATIONAL JOINT REGISTRY

Hip replacements are one of the most commonplace opera-tions. Why are they so important?

!”Hip surgery affects a mas-sive variety of people – my pa-

tients have ranged from age 13 to 97 – who, crucially, are generally well. A hip replacement is a life-chang-ing operation, reliably improving a patient’s quality of life. This can vary from the return to everyday activities and the ability to enjoy family activities, to a return to work and sometimes a return to active recreational hobbies, even to sport.

The success of hip replace-ments is well-established. Why is innovation so important?

!”Innovation is vital to im-prove patients’ outcome –

longer lasting implants, a quicker return to activity, good pain man-agement and fewer complications.

Revision surgery to improve or repair earlier replacement sur-gery is particularly significant. Why, and how it is being acceler-ated?

!”Revision surgery is often more complicated than first

time surgery for various reasons.The patients may be elderly with

more complicated medical con-cerns, the failure of the initial im-plant can result both in bone loss and a reduction in the quality of the bone remaining around the hip, which can make reconstruc-tion more challenging. Anything that can assist the surgeon in com-pensating for these problems will be beneficial for patients. For ex-ample working with more bio-compatible and versatile materials such as Trabecular Metal gives me a greater chance of success in re-construction. This versatility, and the ability of these implants to fix so well to bone, might allow me to consider surgery in cases that had previously been felt to be too se-vere to consider revision surgery.

QUESTION & ANSWER

Andrew Manktelow Consultant ortho-paedic surgeon at Queen’s Medi-cal Centre, Not-tingham Univer-sity Hospitals NHS Trust.


How to turn pain into purpose

Judy Birch, 54, from Dorset, is a linguist and former secondary and adult education teacher. She is also the founder and chief executive of the Pelvic Pain Support Network after suffering more than 30 years of chronic pain. Today, Judy and the Network are contributing their expertise on the patient perspective on the National Institute for Clinical Excellence (NICE) on chronic pain.

My pain started at age 17, with very painful pe-riods. By 25 I was una-ble to stand due to the

monthly back pain. It was dismissed by a GP but an ultrasound showed a large mass on the left side that need-ed to be operated upon, and surgery revealed a grapefruit-sized ovarian cyst. I was diagnosed with endome-triosis.

My left ovary was completely de-stroyed and was removed. We’d been told that the endometriosis could cause problems conceiving, so al-though starting a family was not in our immediate plan we starting try-ing to conceive. My right ovary was working fine so I conceived quite quickly but miscarried; I thank-fully conceived my daughter, who’s now 28, soon after but once I stopped breastfeeding my pain returned and got worse. Several years later my hus-band and I tried to conceive again, but were unable to.

I also had several surgeries on the other ovary, a pelvic abscess and deep endometriosis in the appendix. By then I was unable to sit due to un-bearable pain - after a lengthy trawl of consultants through Europe, a sur-geon in France suspected nerve in-volvement and I was operated on to release a trapped pelvic nerve.

Many years later the pain has de-creased; I have been able to resume some activities and have taken up dancing, though I still have the pain between the rectum and vagina and am unable to sit without severe pain.

But the treatment I did get wouldn’t have been achieved if I hadn’t battled to get there. My work on what became the Network began after we bought a computer when our daughter was doing her A-levels and I began brows-ing the internet to look at the re-search on endometriosis and pelvic pain. I began to use message boards posting about my experience. I also contacted and went to see several ex-perts throughout Europe. The infor-mation I gained was tremendously helpful but it was not being dissemi-nated. I realised that there was a gap that wasn’t being filled. The Network was born and in 2006 formalised into how it is today.

Chronic pain is complicated and many patients with chronic pain are forced to self-manage their condition without any support. There is fre-quently a lack of knowledge amongst GPs and practice nurses, resulting in a lack of access to treatment.

Coping with chronic pain is so de-bilitating and challenging and affects all aspects of a person’s life. During the last 15 years significant advances

have been made in the understand-ing of pain mechanisms and the rea-sons for the development of chronic pain but more needs to be done. The issue of pain management needs to be addressed earlier on in medical ed-ucation and careers. A recent survey found that physiotherapists and vets have more hours in their curriculum dedicated to pain management than doctors, nurses or midwives.

At the Network we frequently re-ceive requests from girls and women of all ages who have suffered years of pain and who have not even been of-fered a basic internal examination by their GP. There’s also potential for pa-tients to access a wider range of treat-ments. Prescribing off-label may help some patients but not all doctors will do this (as I understand it they are allowed to as long as the patient is aware of this and any risks).” .

Communication and empower-ment go far. Judy says: “There’s still little patient involvement. Patients often need time to talk, and not al-ways to doctors; talking to others with similar issues can be very mo-tivating. For patients to be told to simply put up with persistent pain is unhelpful and, I think, inhuman. Patients need a sense of hope. In a civilised society, how much pain do we expect people to tolerate?

“Patients need a sense of hope. In a civilised society, how much pain do we expect people to tolerate?”

Judy BirchFounder and chief executive, (pelvicpain.co.uk) Pelvic Pain Support Network and chronic pain sufferer

MAKE A STAND

PERSONAL INSIGHT

The NHS can’t afford to miss out on medical technology. Medical tech-nologies ranging from advanced wound dressings to life-saving car-diac devices can dramatically im-prove patients’ lives. A child with type-one diabetes using an insulin pump is liberated from multiple in-jections and can get on with a nor-mal school and family life.

Cost effective devices also help the NHS make essential savings, by shifting care closer to home and maximising precious front-line resources. For example ad-vanced wound dressings need to be changed less frequently, and help mitigate infection.

Benefits are not confined to health – efficiencies are possi-ble right across Government. Spi-nal cord stimulation can reduce chronic pain and support partici-pation in work, while ophthalmic implants can improve older peo-ples’ sight, reduce dependence on home help and social care. But pa-tients in the UK continue to miss out on proven NICE-approved tech-nologies that are readily available elsewhere in Europe. We need a be-havioural shift in order realise the value of medical technologies and ensure patients access the technol-ogies they need, now. THE MTG WORKS TO IMPROVE ACCESS TO

MEDICAL DEVICES: WWW.MTG.ORG.UK

PROFESSIONAL COMMENT

Barbara HarphamChairman of the Medical Technol-ogy Group and Director of Heart Research UK

WHY DOES PAIN GO UNTREATED?Some people are reluctant to take prescribed pain medications

such as co-codamol (containing codeine and paracetamol) due

to unpleasant side-eff ects, including drowsiness, feeling sick and

dizziness. These side-eff ects are usually present for a short time

after commencing treatment. However, many pain medications

cause constipation, which can lead to pains and cramping in the

abdomen, great diffi culty opening the bowels and sometimes

a reduced appetite. This may persist throughout treatment of

pain, even despite addition of laxatives, which work by softening

the stool and enhancing the rhythmic contractions of the gut.

Constipation can be so debilitating that it may cause people to

change their daily routine and have a lesser quality of life.

WHAT IS THE ANSWER?There are many ways to improve constipation, including exercising

(30 minutes, fi ve times a week), drinking plenty of fl uids and

eating a healthy balanced diet rich in fruit and vegetables. Some

people respond well to a change in diet and laxatives, however,

some patients remain unsatisfi ed and may benefi t from discussing

their symptoms with a doctor, nurse or pharmacist. A range of

treatments are available to help improve the management of pain

and help manage side-eff ects, like constipation, which may be due

to the painkillers.

More detailed information about what pain is, the diff erent types,

and causes, can be found at www.targetingpain.co.uk/patient.This

website also has a section on diff erent treatment options and taking

action against your pain.

Felicia Cox Senior Nurse, Pain Management Service, Royal Brompton and Harefi eld NHS Foundation Trust,

has written this article on behalf of Napp Pharmaceuticals Limited.

Don’t suff er in silence

Chronic pain can be isolating and depressing; it can stop people from performing even the simplest tasks of daily living, such as dressing,

bathing and preparing meals. In 2009, the Chief Medical Offi cer reported that pain aff ects 7.8 million people in the UK each year. The most

common sites of chronic pain are muscles, bones and joints. Back pain and osteoarthritis account for over 50% of chronic pain. Sometimes

chronic pain goes untreated, why?

April 2010 UK/UNA-10079

As one of the UKs’ leading research charities and with a strong reputation for delivering innovation in medicine , Kidney Research UK is seeking primary care Practices interested in participating in the roll out of an novel approach to improve the treatment of people with chronic kidney disease (CKD). The approach uses a number of simple, defined quality improvement interventions and focuses both on medical practitioners and patients.

CKD is common affecting about 10% of the population and is set to rise due to our increasing longevity and ageing popluation. The number of people requiring kidney dialysis is set to double by 2014 to over 45,000, but a high prevalence of cardiovascular disease (CVD) and diabetes could increase this further. Consequently, there is a need for optimised treatment in primary care for those individuals with early stage kidney disease. Most of these patients have mild disease but are at risk of morbidity and mortality from CVD as well as progression of CKD to more advanced forms.

Early identification of CKD in primary care is highly beneficial since there is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce the risk of CVD. However, because of a lack of specific symptoms, people with CKD are often not diagnosed, or diagnosed late when CKD is at an advanced stage. The early identification of CKD and the provision of cost effective therapies is therefore a major public health issue which has recently been highlighted as a priority in the UK.

If CKD remains undetected and untreated, progression to more advanced stages can have a severe impact on the quality of life of patients especially when renal replacement therapy (RRT) is required. Referral to secondary care services is required with frequent attendances to mange the condition and its late complications. There can also be social and psychological effects such as unemployment and depression. In addition the need to provide renal replacement therapy carries a disproportionately high cost to the NHS and interventions/therapies to prevent this are highly cost effective: the cost of dialysis care for one patient is estimated at over £35,000/year.

Despite these facts it is recognised that there are significant variations in performance and understanding of the management of CKD (both in health professionals and patients). This project aims to address this performance gap and to lessen the variation in practice in primary care, through the use of a care bundle approach.

Care bundles provide a means of improving care by delivering it in a more structured way. A care bundle is made up of a small number of processes that have been demonstrated to work individually, so that performing them collectively and reliably improves patient outcomes.

Care bundles were first applied in highly controlled secondary care environments, such as intensive care units and operating theatres. They have achieved some notable successes, with practitioners seeing the abolition of harm, despite achieving less than 100% reliability in clinical practice. In other words, when the clinicians do things well enough, biology takes care of the last few percent.

Thus outcomes can be improved in primary care through the more reliable application of recommended best practices which are set out in guidelines from both NICE and SIGN and place new emphasis on the detection and reduction of proteinuria and strengthen existing recommendations on the control of blood pressure. We have distilled the essence of this guidance and embedded a set of Patient Empowerment tools within, thus forming a CKD care bundle which is simple to use and will work within current capacity.

We are inviting Practices to adopt the care bundle on condition that if they are not already achieving 95% or more composite reliability, then they will undertake an internal iterative improvement cycles. Practices will be supported by coaching and mentorship from trained clinical improvement advisors and experts in this field and will also receive support from within the network of participating Practices.

For nearly 50 years and supported primarily through donations from the public and independent funding bodies, Kidney Research UK has been at the forefront in the successful development of key advances in the care of individuals with kidney disease. This project, supported by the Health Foundation, provides a significant opportunity to develop best practice on a wider scale in the primary care setting leading to the development of skills and knowledge of clinicians and increase the meaningful and empowering involvement of patients.

Kidney Research UK and the project team’s joint goal is to see the care bundle approach being used widely in Primary care. If you are interested in finding out more please contact [email protected].

Registered Charity No: 252892 Registered Scottish Charity No. SC039245

Great fun, great cause great day out!

Join us for our London Bridges Walk 2010

Chelsea Bridge Vauxhall Bridge Lambeth Bridge Westminster Bridge Jubilee Bridge Waterloo Bridge London Bridge Blackfriars Bridge Millennium Bridge Southwark Bridge Tower Bridge

Sunday 13th June 2010

Starts 11am

Fee includes Medal

and Event T-shirt

Refreshments and

Entertainment available

throughout the day!

Book online!Online registrations available for individual and

group/family bookings. Easy and simple to do!

NEW VENUE

BATTERSEA

PARK

For more information or to register visit:

www.kidneyresearchuk.orgTo contact the Kidney Research UK events team,

email: [email protected]

or call: 08456 12 12 26

London Bridges Walk 2010Sunday 13th June 2010 11am start from Battersea Park, Boules area

Registration fee: £10 per person, 16 years and under: £4 To register please complete this registration form, All registration fees are non-refundable.

Online registrations available for individual and group/family bookings. Please visit www.kidneyresearchuk.org/londonbridgeswalk

Whilst there is no fixed sponsorship for this event, we need to reach our fundraising target of £150,000.

By setting yourself a fundraising goal of £60 per person you could help us save lives.

PERSONAL INFORMATION (Please use BLOCK CAPITALS)

Title First name Surname

Address

Town/City Postcode

Home tel Work tel

Mobile

Email (Mandatory)

Date of birth Please let us know what T-shirt size you require S M L XL XXL No T-shirt required

HOW DID YOU HEAR ABOUT THIS EVENT? (Please tick box)

Word of mouth/family /friend Previous participant Newspaper/magazine Call from Kidney Research UK Realbuzz.com

Kidney Research UK Shop/Staff (Name ) Kidney Research UK website Radio

Poster/Flyer (Location ) Other ( )

PAYMENT INFORMATIONWe accept payment of the registration fee by all major credit & debit cards. If paying by cheque, please make it payable to Kidney Research UK.

Name on card

Please debit my Visa Access Mastercard Switch Maestro Electron Visa Debit with the sum of £

Card no.

Expiry date Valid from

Issue no. (Switch cards) Security no. (the 3 digit number found on the reverse of the card)

Signed Date

Please return completed entry forms along with your registration fee to:

Events Team, Kidney Research UK, King’s Chambers, Priestgate, Peterborough PE1 1FG

Telephone: 08456 12 12 26 email: [email protected] Registered Charity No: 252892 Registered Scottish Charity No. SC039245

PLEASE NOTE: Entries will not be processed unless the disclaimer is signed. If participants are under the age of 18, disclaimers must be signed by a parent or guardian.

(Office use only)

Ref:

I agree to take part in this event entirely at my own risk. I agree that Kidney Research UK, its sponsors, the event organisers, contractors and agents shall not be liable in any way for any injury, loss, damage or death that might occur as a result of my participation in the event. I am not aware of any medical condition or other reason why I should not participate in the event. KIDNEY RESEARCH UK STRONGLY RECOMMENDS ALL PARTICIPANTS TAKE OUT PERSONAL ACCIDENT AND MEDICAL INSURANCE FOR THIS EVENT. In order to participate in the event, I will endeavour to raise as much sponsorship as I can to fund research to save lives. Kidney Research UK reserve the right to cancel the event or alter the date or time of the event for any reason. If the event is cancelled a full refund will be given (excluding registration fee). By signing this form I confirm that I have read and understood the terms and conditions set out above and consent to Kidney Research UK holding my personal details on a confidential basis for the express purpose of

participating in the event. By taking part, all participants confirm they are happy for any stories or photographs taken during this event to be used by Kidney Research UK to publicise events and Kidney Research UK generally.

We would like to send you details by post or email, of other events that you might be interested in. Tick this box before returning the form to us, if you would prefer us not to keep your details for this purpose. Your details will not be passed on to a third party.

I understand that the place granted to me has cost the charity money, and I will endeavour to raise the pledged amount as outlined above. Please find enclosed my registration fee made payable to Kidney Research UK. I understand that this fee is non-refundable in the event of my withdrawal prior to the event.

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KIDNEY RESEARCH UK DISCLAIMER Please read and sign as indicated

WHY ARE YOU TAKING UP THIS CHALLENGE?

IN AN EMERGENCY WHO SHOULD WE CONTACT?

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Kidney Research UK: Innovation in Primary Care to tackle the growing burden of chronic kidney disease

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DISCOVER THE FUTURE OF MEDICINE

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