Arthritis and Musculoskeletal Alliance
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

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.

Guest blog by Ms. Nuzhat Ali, National MSK Lead, Public Health England

Health inequalities are avoidable, unjust differences in people’s health that are persistent and difficult to shift, until and unless we actively focus on them as a society and a whole system.

People living in the most deprived areas in England can expect to spend nearly 20 fewer years in good health compared with those in the least deprived areas. The trajectory and the scale of the inequity worry me for at least three reasons – it is:

  • A societal injustice, one that has serious consequences for us all in many ways
  • A factor in slowing down life expectancy and healthy life expectancy
  • Increasing demand for health care which equates to increasing costs

Health is dependent on so much more than healthcare.  Research from the Canadian Institute of Advanced Research, Health Canada, Population and Public Health Branch found that healthcare contributed no more than 25% to our health, and others like McGiniss et al found from their research that it is a 15% contribution. Our genes, lifestyle behaviours, environment, housing, socioeconomic and working conditions, and much more are all key determinants of our health. Surely this points to the need for us all to focus greater attention to these factors in meaningful ways.

The Determinants of Health (Dahlgren and Whitehead, 1991)

The figure above shows the main determinants of health as layers of influence. At the centre of the model, individuals are endowed with non-modifiable factors that influence health potential, including age, sex and constitutional factors.  

Surrounding the individuals are layers of influence that can be modified. The innermost layer represents the personal behaviour and way of life adopted, such as smoking habits and physical activity, with the potential to promote or damage health. Individuals interact with friends, relatives and the community, and are therefore affected by the social and community influences represented in the next layer. Mutual support within a community can sustain the health of its members in otherwise unfavourable conditions.

The wider influences on a person’s ability to maintain health include their living and working conditions, food supplies, and access to essential goods and services. Overall, there are the economic, cultural and environmental conditions prevalent in society as a whole, represented in the outermost layer.

What do we know about the relationship between musculoskeletal (MSK) health and inequality?

Gender differences:

An estimated 17.8 million people live with a MSK condition in the UK, which is around 28.9% of the total population. Of these, 7.7 million are men and 10 .1 million are women.

Socioeconomic differences:

People who live in the most deprived areas are much more likely to report arthritis or back pain than people in equivalent age groups who live in less deprived areas. 40% of men and 44% of women in the poorest households report chronic pain, compared to 24% of men and 30% of women in the richest households.

Among people aged 45–64, the prevalence of arthritis is more than double in the most deprived areas (21.5%) compared to the least deprived areas (10.6%). Further, people of working age (45–64 years) are almost twice as likely to report back pain (17.7%) as those from least deprived areas (9.1%).

Physical inactivity, obesity and comorbidity are all strongly associated with deprivation. People in the most deprived areas develop multi-morbidity 10–15 years earlier compared to those in the least deprived.

My top three humble suggestions on how we might tackle this wicked system problem:

  • Balance the medical model of health with the social model of upstream efforts on wider determinants of health. This means working in partnership and collaboratively across sectors and with our community’s
  • Focussed secondary prevention in primary care is the best way to get quick wins in narrowing health inequalities (King’s Fund)
  • Provide targeted support to help people find and remain in good work

Public Health England (PHE)’s mission is to protect and improve the nation’s health and wellbeing, and reduce health inequalities. PHE have published a range of tools and resources to support professionals to tackle inequalities. PHE’s guidance – Reducing health inequalities: system, scale and sustainability – set out a revision of the DHSC’s Health Inequalities National Support.

For further information, you can visit PHE’s return on investment tool for MSK conditions, Health Matters and the recently published review on muscle and bone strength and balance.

Guest blog by Tom Embury, Public Affairs Officer, British Dietetic Association.

The Allied Health Professions most commonly associated with arthritis and MSK conditions are probably our colleagues in Physiotherapy and Occupational Therapy, but the British Dietetic Association (BDA) believe dietitians have a key role to play in supporting patients and working with colleagues as part of multidisciplinary teams to prevent and treat these conditions.  

The BDA is one of the world’s oldest nutrition and dietetic bodies and represents the 9,000 or so dietitians working in the UK, as well as students, dietetic assistants and affiliate members. It is well established that diet has an important role to play in protecting against or helping to manage conditions such as osteoporosis and arthritis.

Being overweight or obese is also a key risk factor for MSK conditions, and diet is the single biggest factor in causing or reversing obesity. It is also increasingly obvious that the relationship works the other way, with conditions such as arthritis making eating and preparing food more difficult, and increasing the risk of malnutrition, especially amongst older people.

Joining ARMA is part of the BDA’s efforts to highlight and develop what dietitians do in a wider range of roles, conditions and sectors. In particular, we are currently prioritising the central role we think dietitians can play in prevention and public health. It was the theme of our recent Dietitians Week campaign, which is now in its fifth year, and preventing and managing MSK conditions was one of the many varied roles we featured.

We’re looking forward to learning more from colleagues in this field and contributing the BDA’s perspective to the work of the Alliance. We’re keen to share our resources through the MSK Knowledge Hub, such as our Free Food Fact sheets, which include specific dietary advice for osteoporosis and osteoarthritis, as well as more general health eating advice and nutrient specific information on calcium or vitamin D. We hope by adding our voice to the alliance we can help to transform the quality of life of people with musculoskeletal conditions.

by Dr Steven Boorman CBE, Director of Employee Health, Empactis,
Chair of the Council for Work and Health

As I head towards the milestone later this year of passing my thirtieth year in occupational health, I find myself optimistic mixed with the “glass half empty” of recognising that the same barriers remain in place: barriers to those who want to work with long term conditions. Over my career I have worked regularly with ARMA members and experts, and I have personal experience of working with a MSK condition.

The recent “Improving Lives” consultation and subsequent Government Strategy paper highlighted that since 2013, 400000 more people have become disabled (rising to over 7 million across the UK) and 3.7 million people have a musculoskeletal disorder, yet only 1.7 million of these are employed.

For people of working age without a disability the employment rate is around 80% but for those with disabling conditions the figure is 46%.

Let’s be clear, I do understand that for some people employment is not feasible. However, we do know that, providing it is good work, work does benefit your health. The social, financial and other benefits of work activities can improve many conditions, including many MSK conditions, reducing disability and frequency of recurrence or exacerbation. My profession, occupational health, isn’t about trying to force those that can’t to work, to do so risks harm and isn’t good for employers or employees! On the contrary it is about helping those that want to work to match their health conditions to the work available … which is easy to say, but can be challenging, particularly if a condition such as a MSK disorder has symptoms that vary over time and may be unpredictable in its impacts.

But my reflection here is that whilst we know such conditions are painfully common, we haven’t yet managed to adapt our health, social care and employment practices to adequately help those that want to be in work to be there.

Let’s start with sickness certification. It’s not always easy to see a GP, and whilst conceptually the idea of changing a sick note to now include an option to advise an employer about potential work adjustments is a good one, the reality is that many GPs lack the training or the time to adequately explore options during a short clinical consultation. My time spent working to improve disability assessment also taught me how difficult it is to adequately consider changing function with time and so, in the mistaken belief that it’s the safest option, often it’s easier to say “unfit for work”.

Annually 300,000 people become sick and lose their jobs and come in to the benefits system, many with MSK, often also associated with other conditions. Benefits assessments focus on the information collected on the day and don’t consider the barriers or practical difficulties that prevent work. If things improve to enable a consideration of returning to work, the risk may be loss of benefits and a long wait and further assessments to get them back, and the challenge of finding employers (even given the requirements of Equality legislation) willing to adapt and match work to physical needs can also be hard.

Occupational health advice may help, but “Improving Lives” shows clearly that it is not there for many – many, particularly smaller, employers have limited knowledge or access to OH and to be brutally honest the quality and experience of OH providers to cope with complex fluctuating conditions can be poor. Again, Occupational Health assessments are often undertaken at a point in time and whilst they will include consideration of symptoms and disability changing, flexible working adjustments can be hard to create.

At its simplest, what’s needed are mechanisms to enable a person who wants to work with a long term and changing medical problem to be able to interact with their employer / manager without delay and with the capability to change work to match needs at the time. Again, I recognise that this isn’t always feasible or practicable, but now working for a technology firm, I realise that real-time solutions are achievable, but under-utilised. Given the right and timely information most employers want to support their employees to enable work, but poor communication and understanding often makes this difficult.

Eric Topol, the American Cardiologist and technology pioneer, criticised the medical profession for being too slow to change and adapt. I find myself today reflecting that, whilst the “Improving Lives” work rightly highlights the needs to make changes in the way we operate our health and social care systems to improve the chances for people who can to work, to make this feasible we have to make it easy – easy for employers to know what’s needed and how to meet those needs; easy for the employee to understand and communicate those needs; and easy for the care systems to support needs as they change.

I hope it doesn’t take another thirty years for this to happen, and as I learn more about what changing technology can do, I am optimistic that it won’t!

Guest blog by David Albury, Board Director Innovation Unit

Why have so many innovations in the NHS failed to make the impact they might because they remain in isolated pockets and never spread? Here at the Innovation Unit we decided to look at this question from a more positive angle and ask where innovation has spread and what made that possible?

There is broad agreement that the pressures and challenges currently facing the NHS can only be addressed through developing and scaling innovations that significantly improve outcomes whilst significantly reducing costs. This is as true in musculoskeletal services as in other sectors.

But proven innovations and best practice tend to spread slowly in the NHS. Innovations such as first contact physiotherapist or ESCAPE-pain remained as isolated pockets of good practice long after they had been shown to be effective. ESCAPE-Pain is now rolling out in many areas, thanks to a grant from Sport England, but the first evidence that it worked was as long ago as 2007.

The barriers to spreading innovation have gained a lot of attention. The Innovation Unit, in collaboration with the Health Foundation, wanted to look at the enablers – what will help the spread of good practice. We looked at ten examples of successful spread of innovation in the NHS. Our report identifies common factors that enabled their spread. Whilst none of the case studies were in MSK, the key enablers we identified will apply equally well to MSK innovation.

Our eight key enablers

In pursuit of spread:
1. Building demand through existing networks and narratives
2. Using evidence to build demand
3. Balancing fidelity, quality and adaptability
4. Scaling vehicles rather than lone champions

Creating the conditions for spread:
5. Capitalising on national and local system priorities
6. Using policy and financial levers to kick start momentum
7. Commissioning for sustainable spread
8. External funding to support spread

Read Against the Odds for more on the eight key enablers and some provocations for system leaders, funders and innovators. We hope you will find it useful as you face the challenges of how to spread innovation and good practice in MSK across the NHS.

Guest blog by Satjit Singh, Chief Executive, Society for Promoting Chiropractic Education

It is great that most of us will live to an age that our parents could never imagine. Better living standards, improved public health and an NHS accessible to all, have all helped.

This is excellent, but living longer means that we are likely to be working longer. It also means that for us to enjoy that longevity, we need to live active, fulfilling lives. Too many of the population are afflicted by ‘aches and pains’, mainly back and neck, i.e. musculoskeletal. This not only has physical implications, but like so many chronic problems, has effects on mental health too.

Musculoskeletal problems are responsible for 30% of visits to a GP 1 and have an enormous impact on the quality of life of millions of people in the UK; 10.8 million working days are lost as a consequence of musculoskeletal conditions1. Our healthcare sector, already under so much strain, has to cope with the burden of an increasing number of people presenting with MSK issues; our economy certainly cannot afford to lose so many man-days.

Not only are we faced with an increasing MSK burden, we also lack the healthcare resources to deal with it. NICE recommends manipulation as part of the package of care to deal with this; however, regulated manipulative therapists, comprising mainly chiropractors, osteopaths and some physiotherapists, are nowhere near what the country needs. We only have 3,000 chiropractors, 5,000 osteopaths and some 1,100 physiotherapists who are members of the MACP 2, trained to undertake manipulation. We need more, many more. Not only do we have an ageing population, our health workforce is ageing too. We have seen the consequences of that amongst GPs; other professions are also not immune! The ability to access a ready pool of healthcare professionals from Europe, will reduce significantly, post-Brexit.

Looking around at the chiropractic profession, I saw that there were only three universities in the UK offering chiropractic degrees. Many schools in the country were not even aware of the profession, to make it available as a choice to their A-level students. Given the current rates of growth in the UK profession, it would take over a century to achieve current rates of chiropractor access in Canada or Denmark.

That is why The Society for Promoting Chiropractic Education was established last year. Launched by George Freeman MP, former Life Sciences Minister and Chairman of the Prime Minister’s Policy Board, it aims to encourage school leavers to consider a career in chiropractic; whilst simultaneously working with universities to offer chiropractic degree programmes.

London South Bank University has launched a new four-year masters course in chiropractic and students will start their course in Autumn 2018. What is especially important, is that students will learn in multi-professional settings alongside others studying physiotherapy, nursing and occupational health. This will ensure that future graduates understand how they fit into the wider health landscape. Other programmes are planned in poorly served geographical locations.

Our aim is to work towards a situation where healthcare professionals practising manipulation become part of direct access arrangements within GP practices. For that to happen, we need more of them.

References

  1. https://www.england.nhs.uk/ourwork/ltc-op-eolc/ltc-eolc/our-work-on-long-term-conditions/si-areas/musculoskeletal/
  2. https://macpweb.org/home/index.php?p=366