This is a category taken from the full feed of Musculoskeletal and Arthritis news provided by ARMA's members.
  • The Arthritis and Musculoskeletal Alliance (ARMA) is the umbrella body for the arthritis and musculoskeletal community in the UK, and our mission is to transform the quality of life of people with musculoskeletal conditions. We have 33 member organisations ranging from specialised support groups for rare diseases to major research charities and national professional bodies.

Guest Blog

The Oxford University Hospitals Foundation Trust Pilot

By Dr Christopher Speers, Sport and Exercise Medicine Consultant Oxford University Hospitals Foundation Trust

Physical inactivity is the fourth leading cause of death worldwide1 and it contributes significantly to the worldwide burden of non-communicable disease2, 3. Hospitals, historically, have been dominated by a culture of rest4. Promoting rest contradicts the evidence which clearly demonstrates that disease outcomes are better for moving more and that post hospital syndrome, or hospital deconditioning, leads to increased risk and adverse outcomes5, 6. Furthermore, there is a significant evidence-base demonstrating the potential for physical activity to improve management and treatment outcomes for a wide range of long-term health conditions, including arthritis7.

Healthcare provides a unique point of access to a section of the population who are likely to gain the most from only small improvements in increasing their physical activity. Therefore hospital admission is a key opportunity to influence patients to change behaviour for the better. This preventative approach to healthcare is a key objective of the NHS 10 year plan8.

‘Moving Healthcare Professionals’ forms part of Public Health England’s (PHE) ‘Everybody Active Every Day’ strategy9, and aims to engage professional networks to support understanding and awareness of, and greater engagement in, physical activity among the wider public.

In 2017, PHE and Sport England invited expressions of interest from applicable NHS Trusts (i.e. the Trust employs a Sports and Exercise Medicine (SEM) consultant to deliver a SEM pilot in secondary care. We were successful and were commissioned to deliver an SEM pilot that focused on the integration of physical activity into care pathways within secondary care.

The primary aim of the SEM pilot was to explore the potential for multi-disciplinary SEM teams in secondary care to contribute to patient outcomes through targeted and tailored support to integrate physical activity into the care plans of in-patients prior to discharge. We developed physical activity interventions across five different clinical pathways involving multi-morbidity and frailty (figure 1). Each intervention was designed using the COM-B model and Behaviour Change Wheel10. A clinical champion was employed within each pathway to develop and deliver the interventions, provide leadership and training to other staff within that clinical setting.

clinical pathways diagram

A range of different interventions were used to improve the levels of physical activity in patients, but underpinning our approach was an ambition to target healthcare professionals and change their behaviour to improving the frequency and quality of conversations between staff and patients about physical activity. Tools to do this included integrating the Exercise Vital Sign11, 12 into electronic patient records, staff training in motivational interviewing, exercise classes, as well as bed-, chair-based, and standing-exercise programs matched to functional ability of patients. A community navigator was available to help patients and staff members find community-based exercise teams and classes during the discharge process to ensure integrated care.

External independent evaluation was undertaken by the National Centre for Sport and Exercise Medicine in Sheffield; early reports have shown that this approach is highly valued and acceptable to patients and staff within the NHS. We have learnt a huge amount about integrating physical activity into secondary care systems throughout the pilot, and are going to publish our findings, learning and experience in the form of an ‘Active Hospital Toolkit’ later in 2019. This will be accessible through the Moving Medicine website.

References:

  1. Kohl HW, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, Kahlmeier S; Lancet Physical Activity Series Working Group. The pandemic of physical inactivity: global action for public health. Lancet. 2012 Jul 21;380(9838):294-305.
  2. Lee IM, Shiroma EJ, Lobelop F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012 Jul 21;380(9838):219-29.
  3. Blair SN. (2009) Physical inactivity: the biggest public health problem of the 21st century. British Journal of Sports Medicine; 43:1-2
  4. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc . 2009;57:1660–1665.
  5. HM Krumholz Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013; 368:100-102.
  6. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee M, et al. (2011) Minimum effort of physical activity for reduced mortality and extended life expectancy. The Lancet; 378:(9798): 1244-1253.
  7. Gleeson, M., Bishop, N. C., Stensel, D. J., Lindley, M. R., Mastana, S. S. & Nimmo, M. A. 2011. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nature Reviews Immunology, 11,
  8. NHS England NHS Long Term Plan. https://www.longtermplan.nhs.uk/ (accessed on 27.03.2019.
  9. Public Health England 2014. Everybody Active Everyday: National Physical Activity Framework. In: ENGLAND, P. H. (ed.). London: Public Health England.
  10. Michie, S., Atkins, L. & West, R. 2014. The behaviour change wheel: A guide to designing interventions, Great Britain, Silverback Publishing
  11. Sallis R, Franklin B, Joy L, et al. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis 2015;57:375–86.
  12. Coleman KJ, Ngor E, Reynolds K, et al. Initial Validation of an Exercise ‘Vital Sign’ in Electronic Medical Records. Med Sci Sport Exerc 2012;44:2071–6

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By Jill Hamilton, Professional Engagement Manager, National Ankylosing Spondylitis Society

Exercise is the single most important thing that anyone with axial SpA (AS) can do to self-manage their condition. It’s not always possible though; if someone is experiencing a flare or has severe physical disability as a result of their condition then exercising on land can be pretty much impossible. Exercising in water however is a lot easier; the warmth and the buoyancy make stretches more effective, it’s less painful, it’s easier to stay upright because the effect of gravity is less, it requires less physical effort and afterwards you usually have a really good night’s sleep!

In my time working at NASS I have had the privilege to see first-hand the benefits that people with axial spondyloarthritis (axial SpA) including ankylosing spondylitis (AS) have from being able to exercise in a hydrotherapy pool. Through our network of branches and local NHS services, people with axial SpA (AS) have been well looked after over the years.

I recall visiting one of our branches a while back and a member walked in whilst I was giving an update on what was happening at NASS. He came in clearly in the middle of a massive flare and looked completely crushed when he saw that we were sitting around talking. ‘Is there no hydrotherapy tonight?’ he asked, barely able to walk as his joints had stiffened up and the pain had taken over his body. At this point I stopped talking and said, ‘OK that’s enough from me, time for hydrotherapy everyone’. I knew from looking at him he couldn’t wait a minute longer – medication was having no effect and hydrotherapy was the only thing that was going to help him, even for just a few hours.

It saddens me that in recent years, the closure of hydrotherapy pools has become more common in NHS settings. Too often they are seen as a waste of money and an easy way for the trust or CCG to save some cash. It is a misunderstood form of treatment – to those who don’t use hydrotherapy it is a luxury; for those who do use it, it is essential to keep mobile and minimise pain.

NASS recently funded some research conducted by Melanie Martin, Advanced Physiotherapy Practitioner at Guy’s Hospital in London and Claire Jeffries, Physiotherapy Manager and Clinical Specialist in Hydrotherapy and Rheumatology at Queen Alexandra Hospital in Portsmouth, which looked at attitudes towards hydrotherapy. On average, people gave 7.7 out of 10 for how much hydrotherapy complemented their care overall.

Some of the recent comments that have been published by NHS trusts have been incredibly short-sighted. It seems that their view is, if it isn’t a cure, it’s not a valid treatment. Surgery and pharmacological interventions just aren’t possible for everyone though and so finding alternative forms of treatment is vital.

For a person who lives with chronic pain, the benefits of any treatment are very important; having those few days where you can feel ‘normal’ and get on with your every-day tasks are priceless. Don’t we all deserve those moments?

NASS is joining forces with other organisations to campaign to save our hydrotherapy pools. If you know of a pool under threat or simply would like to learn more about how to advertise your pool and utilise it to the fullest, get in touch. The hydrotherapy pools that are the most successful and the most protected is where they are used by people with a range of conditions and needs. We need to get the message out there just how important this treatment is, and we need the support of ARMA members to do it.

Musculoskeletal support professionals in the community

by Dr Rob Hampton, GP and Occupational Physician

Across the world, chronic musculoskeletal conditions such as osteoarthritis, inflammatory disorders and common regional conditions such as back, neck, shoulder, hip and knee pain now represent the single greatest cause of years lived with disability 1. When measuring their negative impact on employment, self-reported wellbeing and day-to-day function, chronic musculoskeletal pain conditions are every bit as invasive as other chronic conditions such as heart failure, diabetes and COPD. People with chronic conditions increasingly have access to dedicated, usually nurse-led services that provide support with exacerbations and link the patient to GP and secondary care when required. Even the traditional ‘Cinderella’ conditions of dementia and mental health now benefit from improved recognition and coordinated care. I would argue that chronic musculoskeletal conditions are now the true Cinderella in the UK, a fact recognised by NHS England through their partnership with the Arthritis and Musculoskeletal Alliance (ARMA) called the MSK Knowledge Network. Its focus is on bringing knowledge and people together to improve outcomes for people with MSK conditions in England.

There are several projects that show the value of community-based support for people with musculoskeletal problems. The Joint Pain Advisor pilot in South London 2 is an example of the power of professional support to help people adapt to chronic pain problems and reduce demands on healthcare resources, particularly GPs. The power to encourage self-care and de-medicalise chronic musculoskeletal pain have been cornerstones of pioneering services such as the Back Pain Programme in South Tees 3 and the Pain to Prospects Programme in Leicester 4. These services win awards, are reproducible beyond the pilot phases and could provide a level of support to the people with chronic musculoskeletal conditions similar to that for conditions such as heart failure, diabetes and COPD. My impression is that the biopsychosocial approach required is just ‘not medical enough’ to receive CCG funding but ‘too medical’ to attract financing from the social or welfare sector.

Will the evolution of Primary Care Networks announced in January 2019 through the NHS long-term plan provide the right environment for ongoing community based musculoskeletal support? Let’s hope so. If ARMA take up this cause with NHS England, progress can be made.

References:

  1. Global Burden of Disease Study 2013 Collaborators. (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386:743–800. 
  2. A Walker, R Williams, F Sibley, D Stamp, A Carter, M Hurley. (2017) Improving access to better care for people with knee and/or hip pain: service evaluation of allied health professional‐led primary care. Musculoskeletal Care. https://doi.org/10.1002/msc.1189
  3. NHS England (2017) National Low Back and Radicular Pain Pathway 2017, Together with Implementation Guide http://www.ukssb.com/pages/Improving-Spinal-Care-Project/National-Backpain-Pathway.html. (accessed January 2019).
  4. Hampton R. (2013) From Pain to Prospects? – helping people on welfare benefits with chronic pain. Pain News. 2013;11(4):227 –230.

by Leyla Hannbeck, Director of Pharmacy at NPA

People living with musculoskeletal conditions are often taking several prescribed and over-the-counter medicines, so come into frequent contact with their local pharmacist. For example, someone with arthritis may be taking Co-Codamol for pain relief, patches for heat therapy and amitriptyline for depression. (ARMA’s policy paper on mental health is a cogent reminder about the complex interplay of mental and physical conditions).

But even frequent visitors to pharmacies may not be aware of the full range of NHS services available there.

If you are taking two or more prescribed medicines for a long term condition, the NHS Medicines Use Review, also known as a medicine check-up or medicine MOT, is a free NHS service that can help you get maximum benefit from your medicines. You can ask your pharmacist questions about your medicines at any time, particularly if you have an urgent problem, but an MUR provides a perfect opportunity for an in-depth conversation with a pharmacist in a consultation room. You may want to discuss the drugs you have been prescribed, any problems or side-effects you are experiencing or whether there is a more effective way of taking them.

Such services are designed to ensure a thorough conversation about the patient’s medicines use. Yet patients occasionally “leave the consultation room with the real issue still in their back pocket” (to steal a phrase originally used by a patient in Leeds). So please feel free to ask your pharmacist anything at all about your medicines, your health and wellbeing. It is better to reveal too much information than not enough, so bring up problems even if your doctor or pharmacist hasn’t asked about them.

Medicines shortages

Changing the subject, you might have seen coverage in the news about medicines shortages and the supposed link to Brexit.

Please be assured that whatever the Brexit scenario that finally emerges, pharmacists will put the needs of patients first, as they always do.

The government has worked with the pharmaceutical industry to put in place a number of contingency measures to ensure continuity of medicines supply in the event of disruption caused by a no deal Brexit. This includes asking manufacturers to hold an additional six weeks supply of medicines in the UK as buffer stock in case the UK leaves the EU with no-deal and without a transitional agreement.

There is also legislation that would allow pharmacists to substitute medicines that are in short supply with suitable alternatives, under strict protocols. This is a sensible contingency – it means that pharmacists will be able to take action to help patients get their medicines in a timely fashion, without the need for referral back to a GP.

Meanwhile, our advice to all patients is this:

  • If you take medicines for the treatment of your medical condition, make sure you order your repeat medicines in plenty of time – well before your current supply runs out – to ensure you get what you need, when you need it.
  • If there is a shortage of your usual medication, please do not be tempted to get medicines from a family member, friend or an unregulated source; many on-line sources of medicine are unregulated and you will not receive the same protection as you would if you obtained the medicine from a regulated source. Always ask your pharmacist, who can vouch for the safety of the product and give you professional advice.

Guest blog by Suzanne Rastrick, Chief Allied Health Professions Officer, NHS England

As I look back on 2018 it has been a great year for AHPs and for the NHS. 2018 has seen acknowledgement of ‘the Brilliance of AHPs’ by Simon Stevens, the Chief Executive of NHS England and development of a number of work areas which have highlighted how AHPs can support the challenges faced by the Health and Social care system in England. AHPs are a diverse group of practitioners recognised for their autonomy with proven ability to apply innovative solutions to the challenges facing communities across health and social care, but also in wider settings such as education, the military, justice, independent and voluntary sectors. AHPs have repeatedly evidenced their ability to take on new roles and step outside traditional boundaries; I view them as 14 jewels each with a unique skill set that can be applied to address the challenges facing communities today.

An excellent example of how AHPs can support current system challenges has been the development of the First Contact Practitioner (FCP) model for people with musculoskeletal conditions. The FCP model has been developed to enable people to access prompt, timely, specific advice and management for their musculoskeletal condition, be that through seeing an Osteopath, Physiotherapist or Podiatrist. Without FCP, people are required to see a GP first to access appropriate management. Access to the right care will support individuals to manage their condition and continue with activities important to them, be that work or leisure.

My first priority for any service development that includes AHPs, is the provision of safe and effective care for citizens, the publication of The Musculoskeletal Core Capabilities Framework for first contact practitioners’ has supported this aim. ARMA delivered this work programme in partnership with NHS England, the National Clinical Director for MSK services and the Elective Care Transformation Programme. The outcome is a document detailing the knowledge, skills and behaviours deemed essential for First Contact Practice. The provision of guidance in this area will ensure consistency and effectiveness of first contact services. The implementation of first contact services for people with MSK conditions, where AHPs with expertise in MSK are very much part of the general practice and primary care team, will improve access to person-centred musculoskeletal care and support.

It was a pleasure to be involved with the development of this framework. Delivery of this model is being rolled out nationally, as a person-centred approach, enabling shared decision making and acknowledging that appropriate management can be achieved for people with MSK conditions without the need for involvement of the GP or a practice nurse, freeing their clinical time to manage people who require their specific skills and expertise.

by Dr Hamish Reid, Consultant in Sport and Exercise Medicine, Moving Medicine design and development lead

Moving Medicine is an exciting new initiative by the Faculty of Sport and Exercise Medicine in partnership with Public Health England and Sport England. It is dedicated to spreading best practice, research and advice to clinicians and patients to create a healthier, happier and more active nation. On the 16th October 2018 the initiative was formally launched by the Honourable Matt Hancock, Secretary of State for Health and Social Care, headlining the flagship set of resources to support high quality conversations on physical activity across a broad range of chronic diseases including musculoskeletal pain.

Why is it important?

The UK is currently suffering epidemic levels of physical inactivity in keeping with global trends. This inactivity causes a heavy burden of morbidity and mortality. This burden, In contrast to communicable disease, can be prevented and effectively treated through moving more. In no areas is this more important that musculoskeletal conditions.

At the heart of intervention in healthcare lie conversations between healthcare professionals and members of the public. These conversations provide a unique opportunity to interact with the least active members of society, but many healthcare professionals currently lack the skills, knowledge and systems to deliver impactful conversations on physical activity.

How has it been developed?

The ‘prescribing movement’ resources have been developed by a large team of Sport and Exercise Medicine doctors in consultation with 300 medical specialists, general practitioners, researchers and patients. The foundations of the content lie in robust reviews of the literature on physical activity in specific diseases and differ from other resources summarising the evidence base on physical activity as the structure has been designed by clinicians for clinicians to use in practise. A knowledge into action framework, Delphi study and behavioural change framework have underpinned this iterative development process. The result enables the user to dig as deep as they want to into the evidence base, embedded in a time-based framework to support good quality conversations based on established behavioural change techniques and motivational interviewing theory.

What does this mean for musculoskeletal care?

The Moving Medicine musculoskeletal pain resource has been designed with experts in musculoskeletal care in partnership with many ARMA members. Due to the exceptional input from the ARMA network this resource has been developed to fulfil an unmet need in the excellent resources available. It is a practical resource to support and inform clinical staff in routine practice and has been designed to support conversations.

We encourage everyone to use and share the resources. If you are keen to find out more or contribute to the Moving Medicine to get in touch with us at contactus@movingmedicine.ac.uk, join our Facebook ambassador group or follow us on twitter @movingmedicine – we would love to hear from you.

Visit the website at www.movingmedicine.ac.uk.

The BOA is nearing the end of our Centennial year and reflecting on 100 years of developments in orthopaedic surgery. While innovation in surgical techniques has dramatically improved patient care, the changing nature of healthcare delivery systems, rationing and access to care mean that many patients are still struggling with the day-to-day impact of MSK conditions.

During our Congress last week we heard powerful stories from patients on the impact of waiting for surgery. From a patient waiting for carpal tunnel release who was struggling to deal with basic daily tasks such as handling money, preparing food or getting dressed to another describing his wait for knee surgery, in huge amounts of pain with increasingly reduced mobility impacting on overall fitness and the ability to enjoy life.

It is undoubtedly a challenging time for MSK patients in the NHS. There is chronic under supply of resources for NHS services, and huge increases in the numbers of people waiting longer for surgery in many parts of the UK. In April this year we issued a press statement to highlight the situation in England, and shockingly, at the time of the release, there were still some trusts that had not resumed elective operations after the winter moratorium. The number of people who had waited over 18 weeks was at its highest level for many years and the graph below shows that this has been progressively deteriorating for several years (source: Waiting times data).

The number of people waiting over a year has also increased markedly in England, while the situation in Northern Ireland is even more stark, and we are speaking to the Chief Medical Officer there about this next month (see graphs below – source: Waiting times data).

The figures overall are stark:

  • The number of people in England waiting over a year for T&O surgery reached a high of 978 in June 2018, which compared to 375 a year earlier (a 260% increase).
  • The number of people waiting more than 18 weeks reached a peak of 81,663 in April 2018; the highest level since reporting began November 2010.
  • A BOA survey of hospitals in England received 84 replies from BOA Link people and 31 % of these had experienced winter closures of 3 months or more.

These delays have also had a major impact on orthopaedic trainees, who are losing opportunities to learn. This impacts the future workforce and is a situation we are continuing to monitor closely.

At our Congress we discussed access to Elective Care in further detail. The HSJ recently reported our concerns about Sussex CCGs policies that patients for hip surgery meet the requirement of: “uncontrolled, intense, persistent pain resulting in a substantial impact on quality of life … which have failed a reasonable period of conservative treatment of at least 6 months.” (HSJ article) We highlighted the BMJ coverage of growing numbers of Individual Funding Requests for hip and knee replacement as a result of more restrictive CCG policies. (BMJ article).

During the year we’ve done as much as we could to get our messages out to the media and speak out on behalf of our patients about the restrictions on access to care. Besides the articles above, have received coverage in the Telegraph, Times, and Daily Mail among others. We are making plans to develop relationships with key decision makers, both through ARMA, but also directly. We also continue to promote and highlight the joint position statement from ARMA.

Most recently we have been working with four specialist societies (BESS, BSSH, BASS and BASK*) to respond to the latest attempt to limit seven orthopaedic operations through the Evidence Based Interventions consultation. We as a profession agree that there are some operations where this is appropriate, but for others we have raised issues about the proposals, the consultation and the data it is based on. Our full response was posted online last week, here in our News section.

The BOA is very aware that our concerns are shared right across the ARMA community and are pleased to be part of this alliance, working together to shine a light on these important issues as part of our continued commitment to be “Caring for Patients, Supporting Surgeons”.

(*British Elbow and Shoulder Society – BESS, British Society for Surgery of the Hand – BSSH, British Association of Spine Surgeons – BASS and British Association for Surgery of the Knee – BASK.)

Guest blog by Professor Anthony Woolf, Chair, ARMA

[Republished from the NHS England blog]

Musculoskeletal (MSK) conditions have a huge negative impact on the health of the population.  People with MSK problems making a first approach to health services can find it difficult to access the right support and some experience delays in getting the correct diagnosis and management, which can result in prolonged impact such as ongoing pain and work loss.

Launched a few weeks ago, the Musculoskeletal core capabilities framework for first point of contact practitionershas been developed in partnership by the Arthritis and Musculoskeletal Alliance (ARMA), NHS England, Skills for Health, Public Health England and Health Education England to ensure that people with MSK problems get what they have expressed they want – rapid access to diagnosis and early management advice, being fully involved in their care through shared decision-making and self-management. They want confidence in the advice they are receiving and in the capabilities of the health practitioner, their problems and concerns understood and responded to and they want a holistic approach to their problem.

This framework aims to ensure that the range of healthcare professionals who work with patients with MSK problems can play a full role in helping to manage any MSK problem appropriately at the first point of contact.  Working in a team and sharing challenges, first contact MSK practitioners can ensure the person with an MSK problem gets rapid access to the right support without the person getting lost in what can feel like a maze of different care pathways. The first point of contact is important to ensure that potential emergencies are recognised and that the next step in the pathway occurs seamlessly and as efficiently as possible.  This will also help relieve pressures on primary and secondary care. 

By making it clear what capabilities are required, we hope the framework will encourage training and development to increase the number of practitioners from different professions who will fulfil this vital role. Importantly, this is not about creating a new MSK workforce as many already fulfil this role, but is about recognising existing capabilities within practitioners’ scope of practice and ensuring services are delivered consistently by multi-professional teams.  One challenge might be that we have all become too ‘specialised’ in healthcare, but the person with the MSK problem wants and needs a holistic approach to get the best outcome.

This framework of core capabilities offers clear definitions against which to improve and assure – for employers, clinicians, regulators, primary care training hubs, commissioners and practitioners themselves.  It also emphasises the need for modernised skill sets that support person-centred approaches and include shared decision-making, prevention, and support self-management and focuses on what enables people to stay active and independent.  Most importantly it will give the public assurance of the capabilities of the person they are seeking help from.

There is a growing consensus across health and care for new approaches and targeted interventions to promote healthier ageing. This framework has been developed by the whole musculoskeletal sector – including patients and health professionals – collaborating on an issue we all agree is important. It is focused on the needs and expectations of people with MSK problems; with recognition by the health professions that there needs to be harmonisation of core capabilities across the sector to ensure that the right care is provided from that first point that someone presents with an MSK problem seeking a solution.

ARMA is pleased to have played a part in creating this framework that should make a real difference to patient outcomes.