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

Guest blog by Andy Bell, Deputy Chief Executive, Centre for Mental Health

Having a musculoskeletal condition increases your risk of having a mental health problem, and people with a mental health condition are more likely to have a range of MSK problems. Yet the way services for both are organised and the ways professionals in each are trained offers little recognition of the overlaps between them.

Mental health and MSK conditions share some common traits and challenges. Both are complex and diverse. Many are poorly understood. And neither has traditionally been afforded priority status within the NHS.

Nonetheless, both are finally gaining recognition by policymakers as causes of long-lasting distress, pain, poverty and disability. The NHS Long Term Plan, for example, includes a welcome focus on improving mental health support, including an extension of psychological therapy provision for people with long-term physical conditions. And a new five-year MSK strategy sets out a range of actions that statutory bodies such as Public Health England and charities including Versus Arthritis and ARMA will take to prevent MSK conditions and improve support for those living with them.

The MSK strategy specifically notes the links with mental health, citing a fourfold higher risk of depression among people living with chronic pain and a 50% higher risk of back pain among people with depression [1]. It goes on to note that integrated working may therefore help to support people with co-occurring needs more effectively, though gives little detail about what that might mean in practice.

Centre for Mental Health is now working with partners in both mental and physical health to highlight the often neglected physical health needs of people living with long-term mental health conditions such as schizophrenia, bipolar disorder or personality disorders through a collaborative called Equally Well [2]. Having a severe mental illness is known to cut short life expectancy by 15-20 years. But for many it also comes with chronic pain and disability. And too often people’s physical symptoms are ignored or overshadowed by their mental illness.

We want to change that by ensuring that people working in and using mental health services have a bigger focus on physical health, and that those working in physical health can work equally well with someone who has a mental health diagnosis as they can with someone who does not. For MSK professionals, this may mean being more aware of the nature and impact of mental health conditions, and being able to work in trauma-informed ways [3]. Building links with mental health professionals and service users can help to ensure people get timely help where possible to prevent MSK problems and whenever necessary to offer the right help and support to people who need it.

Some services, for example Sussex MSK Partnership [4], understand the importance of ‘no health without mental health’ (one of its three core values) and the value of people who use services being recognised as equal partners in designing and delivering this sort of support [5].

It is vital that people living with long-term mental health conditions get the same recognition for their physical health needs, with MSK professionals available to meet their needs in ways that they find helpful and convenient (including for those who may be in hospital for their mental health).

Achieving equal health for people with mental health conditions requires the whole health and care system to work differently. But ultimately, it is about the interactions professionals have with people day to day. And through Equally Well we hope to work with ARMA and colleagues across the MSK sector to enable people to bring about change at every level of the system and to ensure no one is left without the support they need for their physical and mental health.

References:

[1] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/810348/Musculoskeletal_Health_5_year_strategy.pdf
[2] https://www.equallywell.co.uk
[3] https://www.centreformentalhealth.org.uk/engaging-complexity
[4] https://sussexmskpartnershipcentral.co.uk/
[5] https://www.hsj.co.uk/patient-and-public-involvement/patient-leadership-for-real-the-sussex-model-for-patient-partnership/7022549.article

Guest blog by Dr Jeanelle de Gruchy, President of the Association of Directors of Public Health

To its great credit, New Zealand has become the first country in the world to produce a “wellbeing budget” – a commitment to prioritise population wellbeing as the main mission of the government. A similar philosophy was adopted in Wales in 2015, with the Well-being of Future Generations Act requiring public bodies to think about the long-term impact of their policies on both people and places.

This is a bold and exciting approach for anyone living with a musculoskeletal condition or campaigning for change on their behalf – and for the wider public health community. It puts the highest value on quality of life when it comes to national policy and investment decisions. The Association of Directors of Public Health has long championed taking a whole system and long-term view of how we create and support the health and wellbeing of everyone in society.

What does that mean in practice?

The ADPH recently published updated versions of our life course policy position statements capturing the collective views of Directors of Public Health in local government. There are four documents covering: Best Start in Life, Living and Working Well, Healthy Ageing and Health Inequalities.

Our statement on Living and Working Well focuses on the ‘working age’ population – the approximately 63% of people between the ages of 16-64 – and how to promote healthy, happy and productive lives. We know that the biggest causes of poor health (‘morbidity’) in England are low back and neck pain.

Delivering change means putting a greater emphasis on improving the social determinants of health – such as housing, air quality, education, income and food – factors which overwhelming shape our health and driving down inequalities in how long we live in good health (‘healthy life expectancy’).

It means promoting good mental health by intervening early to prevent the adverse childhood experiences that can have a lifelong impact. We know that along with mental health, poor musculoskeletal health (like back and neck pain) accounts for the majority of sickness absence in the UK, making this an issue of concern beyond the health sector. As ARMA highlights in its policy paper Musculoskeletal and Mental Health, we need to understand the inter-relationship between MSK conditions and mental health rather than treating them in isolation.

It means enabling people into good work and creating healthy workplaces which prevent many musculoskeletal conditions arising, as well as supporting those with musculoskeletal conditions to thrive in work.

These are all areas that need to be addressed in the upcoming green paper on prevention.

Finally, more funding for public health is now critical. A spending review is expected at some point this year and there is a growing consensus that public health investment – in its widest sense – must be a priority. In February, ARMA – and many of its members – signed up to a public letter in the Times, coordinated by ADPH and supported by 54 organisations, setting out the case.

The government has the welcome ambition to improve healthy life expectancy so that, by 2035, we are enjoying at least five extra years of healthy, independent life, whilst closing the gap between the richest and poorest. If the public health funding gap continues to grow, this ambition will not be met, with the costs being borne by the NHS, the economy and individuals.

We look forward to working with ARMA in the months ahead to raise the voice of public health and echo the call recently made by the APPG on Wellbeing Economics for a spending review which walks the walk on wellbeing.

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.