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Quarterly magazine of BackCare, the UK’s National Back Pain Association

WINTER n 2019


Video gaming: everything to play for?

also in this issue: Physical activity Women and over-55s drive new activity statistics Sports conditioning How the top teams avoid injury before big matches Community Calculating the full value of clinical research



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NATIONAL BACK PAIN ASSOCIATION You shop. Amazon gives • Amazon donates 0.5% of the net purchase price (excluding VAT, returns and shipping fees) of eligible purchases to the charitable organisation of your choice. • AmazonSmile is the same Amazon you know. Same products, same prices, same service. • Suport your charitable organisation by starting you shopping at smile.amazon.co.uk TALKBACK l WINTER 2019


A matter of balance and re-education ELITE cyclist Daniele Bennati (39) announced his retirement recently, citing back pain as the reason for his decision. An 18-year career in the professional peloton is pretty good going considering the physical demands of the Grand Tours and the assorted injuries they bring (in Bennati’s case, these include a fractured vertebra and broken collarbone). High intensity competition and high-speed crashes aside, cycling is regarded as a relatively low impact activity compared with other sports, and yet backpain remains a common complaint among cyclists at all levels. For the majority, the reason may be simple. Going for long rides flexed over with hunched shoulders and a hyperextended neck will most likely lead to discomfort – during and/or after your ride. Fortunately, this can be simply remedied by regularly checking your technique and position while riding – maintaining a forward tilt of the pelvis and putting your back, neck and shoulders into neutral – it should improve your efficiency too! The British Chiropractic Association discusses how to aid movement and protect against injury by improving core stability, focusing in this issue on rugby internationals. There are lessons here on basic functionality for those of us simply trying to stay active in the face of ever more sedentary lifestyles. Three quarters of chiropractors have treated patients with injuries linked to sedentary lifestyle habits. Increasingly, these include young people whose back and neck pain stems from overuse


of mobile technologies and computer games. This trend is evident in our special report from the US (p10) which looks at the phenomenon of eSports in schools and colleges, where elite performers are experiencing injuries to the neck, back and upper extremities. Researchers found that even after 30 minutes of competitive play, the muscular tension and slumped posture of the “athletes” can lead to back pain and other musculoskeletal conditions. The body loves to move and staying in one posture for too long is invariably going to bring pain and irritation. Technology in all its applications continues to present new challenges for health practitioners – to assess and pinpoint the causes of injury and then to re-educate, re-balance, manipulate, stretch and strengthen and ultimately, restore a full range of pain-free movement.

Richard Sutton Editor

CPD anatomy updates for practice educators 4

Pathway for low back pain needs careful planning 8

Better care for people using opioids for pain relief 15



Cover image: dronepicr

We welcome articles from readers, but reserve the right to edit submissions. Paid advertisements do not necessarily reflect the views of BackCare. Products and services advertised in TalkBack may not be recommended by BackCare. Please make your own judgement about whether a product or service can help you. Where appropriate, consult your doctor. Any complaints about advertisements should be sent to the Executive Chair. All information in the magazine was believed to be correct at the time of going to press. BackCare cannot be responsible for errors or omissions. No part of this printed publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the copyright holder, BackCare. ©BackCare

BackCare BackCare, Monkey Puzzle House, 69-71 Windmill Road, Sunbury-on-Thames TW16 7DT Tel: +44 (0)20 8977 5474 Email: info@backcare.org.uk Website: www.BackCare.org.uk Twitter: @TherealBackCare Registered as the National Back Pain Association charity number 256751. TalkBack is designed by Pages Creative www.pagescreative.co.uk and printed by Gemini West, Bristol.

The sedentary workplace a big cause of backpain 18

How weather affects longterm health conditions 20 TALKBACK l WINTER 2019


PRESCRIPTION processing is to become digital by default as the final phase of the Electronic Prescription Service (EPS) is rolled out across the country. The latest improvement to EPS – known as Phase 4 – allows prescriptions for all patients to be sent using the more efficient system, not only for those who had chosen a regular “nominated” dispenser. Electronic prescriptions will save the NHS £300m by 2021. EPS saves the NHS time and money by reducing the amount of paper processing required by GPs, pharmacists and the NHS Business Services Authority.

Patients will see little or no change to the process of being prescribed medicines by their GP, or how they request and collect them from their community pharmacy. Those without a nominated pharmacy still receive a paper copy of their prescription listing what has been prescribed, but this will also contain a barcode. Pharmacy staff will then scan the barcode to download their electronic prescription from the secure NHS database – the NHS Spine. Dr Ian Lowry, director of Digital Medicines and Pharmacy at NHS Digital, said: “Every prescription that is sent electronically saves money for the NHS by

Image: pressfoto/Freepik

Electronic prescriptions to save NHS £300m over three years

increasing efficiency. The system is also safer and more secure, as prescriptions can’t be lost and clinicians can check their status online.”

University runs CPD anatomy updates for practice educators PHYSIOTHERAPY staff at the University of Leicester (UoL) have developed an initiative that aims to increase engagement with local educators by offering them continuing professional development opportunities. The university’s physiotherapy course team, led by Professor Simon Barry, provided a free CPD anatomy update event to practice educators from University Hospitals Leicester, Leicester Partnership Trust and Kettering General Hospital. The event was held at UoL’s medical school dissecting room, which provides access to a range of cadaveric and plastinate material. On the day, 30 MSK practice educators attended for a three-hour anatomy update session. Professor Barry said: “The session was supported by a digital workbook, which was available on wall-mounted iPads. The workbook was designed to guide, question and challenge participants as they reviewed a range of professionally prepared upper and lower limb cadaveric prosection specimens. “Plastinated specimens were also available, which clearly demonstrated all the major joints and allowed participants to see and feel arthrokinematics in action.” The day provided an opportunity to get a visual perspective on human MSK anatomy


Nikki Baker and Simon Barry from the musculoskeletal course team, in the medical school dissecting room for those who had not had the benefit of access to a dissection lab in their training or working life. One of the attendees said: “To have a meaningful exchange about the tissues, hunt for specific structures across the different models and appreciate how differently these all can be positioned and therefore present in our patients, was very valuable.” Pip White, professional adviser at the Chartered Society of Physiotherapy, added: “This is a great example of a university building innovative links with local physiotherapists who provide clinical

education to our student members throughout the east midlands. “I visit UoL students at the beginning of their programmes and recognise the pressure on placement providers. It is great to see the university fostering links across the profession and supporting educators by creating ongoing support for professional development.” Physiotherapy course providers who are interested in arranging for their staff and students to visit the UoL for an MSK anatomy update can contact Professor Barry at sjb164@le.ac.uk.


Rise in obesity among reception-aged children OBESITY prevalence among reception-aged schoolchildren in England increased in the past year, new statistics show. The National Child Measurement Programme, England – 2018-19 report indicates that the prevalence of obesity in four and five-yearolds rose from 9.5% in 201718 to 9.7% in 2018-19. This equates to 58,000 children. Among year 6 pupils, aged 10 and 11, obesity prevalence of 20.2% in 2018-19 (121,000 children) remained similar to the previous year (20.1%). The National Child Measurement Programme – overseen by Public Health England and analysed and

reported by NHS Digital – measures the height and weight of more than one million children in England a year and provides robust data on the number of children in reception and year 6 who are underweight, healthy weight, overweight, obese or severely obese. In 2018-19, 22.6% of reception children and 34.3% of year 6 children were either overweight or obese. Obesity prevalence was at least double for children living in the most deprived areas compared to those living in the least deprived areas. In reception, 13.3% in the most deprived areas were obese compared to 5.9% in the

least deprived. Severe obesity prevalence was almost four times as high in the most deprived areas (3.9%) than the least deprived areas (1.0%). Obesity prevalence among reception-aged children ranged from 5.4% in Richmond upon Thames to 14.2% in Knowsley. In year 6, it ranged from 10.7% in Richmond upon Thames to 29.6% in Barking and Dagenham. In both age groups, obesity prevalence was higher for boys than for girls. For reception-age children, 10% of boys were obese compared to 9.4% of girls. Among year 6 pupils, 22.5% of boys were obese compared to 17.8% of girls.

Obesity in context Around three quarters of reception children were a healthy weight (76.5%). In year 6 it was around two thirds (64.3%). Severe obesity prevalence was higher in year 6 (4.4%) compared to reception (2.4%). The proportion of underweight children was higher in year 6 (1.4%) than in reception (1.0%). www.digital.nhs.uk

THE 11th BritSpine multi-disciplinary scientific conference and exhibition, held across three days, will bring together experts in spinal conditions, research and treatment from across the world to expand knowledge and promote networking. BritSpine 2020 takes place from 1-3 April 2020 in Glasgow, at the SEC (Scottish Event Campus), with pre-conference courses on 31 March, including Spine Masterclass, Industry Rep Masterclass, and the National Backpain Pathway – Clinical Network Annual Meeting. BritSpine has developed a programme on a wide range of topics to do with spinal care and research, with keynotes, debates, updates and paper sessions from both UK and International Faculty, and also provides a great opportunity to meet with peers in the spinal community. n Information on the conference programme, speakers and fees can be found at www.BritSpine.com/registration

Image: Pressfoto/Freepik

Conference to cover research on spinal conditions



Making physical activity a practical choice for you

Selling the benefits of muscle strength A PROJECT to find the best ways to promote the benefits of maintaining and improving muscle strength for people visiting their physiotherapist is being co-ordinated by the Chartered Society of Physiotherapy (CSP) in association with Sport England and the Centre for Ageing Better. The 15-month initiative will explore people’s understanding and perceptions of the importance of regular strength and balance activities, and create messaging and approaches that will help more people meet official activity guidelines. These guidelines recommend all adults do activities that challenge the muscles at least twice a week. Despite the importance of strengthening activities, research has revealed very low levels of awareness that strengthening activity is even needed on a weekly basis. Indeed, only 9% of adults surveyed were aware of the requirement, with 34% of the


respondents doing fewer than two days a week of muscle strengthening exercises. The initiative will look at the role physiotherapy staff can play in encouraging more uptake of strengthening activities, both directly with patients and in developing and promoting public facing materials, such as strength-based apps or training programmes. The initiative is made possible through National Lottery funding via a £150,000 grant from Sport England. Andy Maud, a National Partnerships Lead for Health and Inactivity at Sport England, said: “Regular strength, balance and flexibility activities can help to make all movement easier, improving our ability to perform normal daily tasks and enjoy active lives. “We’re excited by the potential of this partnership to develop and test new creative ways of communicating the importance of strength for physical function. It forms an

important part of our longer-term drive to start changing how we talk about getting active, in a way that inspires people to make sport and physical activity a practical choice for them.”

Messaging The project comprises two key phases: insight and creative. The insight phase will feature focus groups, surveys and deskbased research. The creative stage will see the testing of a range of messaging concepts to encourage people to do more strengthening activities each week. CSP staff will manage the project, reporting to an advisory board made up of key stakeholders including physio and patient representatives. Input from professional networks and the consultants’ group will also be gained as the project progresses. Sara Hazzard, CSP Assistant Director


Image: Freepik

Women and over-55s drive new activity statistics Image: Freepik

and balance of Strategic Communications, said: “This work has the potential to deliver a greater understanding of people’s fears and motivations when it comes to strengthening and find ways to help them lead independent, active lives.” Jess Kuehne, Senior Programme Manager (Healthy Ageing) at the Centre for Ageing Better, said: “Many of us don’t realise the huge difference that improving our strength and balance can have to our wellbeing, especially as we age, and very few of us meet the recommended weekly guidelines for muscle strengthening exercise. “We need to do much more to make sure physiotherapists understand how they can help individuals meet the guidelines and communicate their importance to people across the country.” www.csp.org.uk www.sportengland.org www.ageing-better.org.uk

THE highest levels of activity have been recorded by Sport England’s Active Lives Adult Survey, with one million more people physically active than when the survey began. Based on data gathered from 180,000 respondents (aged 16+) in the 12 months from May 2018 to May 2019, 1,015,700 more people are active compared to when the survey started, in 2015. That takes the total number of active people – those doing at least 150 minutes of moderate intensity physical activity per week – up to 28.6 million. The number of inactive people – doing fewer than 30 minutes of moderate intensity physical activity per week – is down to 11.2 million, a decrease of 131,700 since 2015 and the lowest figure ever recorded by the survey. The results show that this improvement has been driven by women and older adults – groups that Sport England has focused on in its Towards an Active Nation strategy; with campaigns such as This Girl Can; with the £10m fund that supports people aged 55+ to get active; along with the £3m investment into parkrun. For women, weights, interval and gym sessions have seen a significant increase in popularity, while there are

142,000 fewer inactive women than 12 months ago and an additional 254,200 more active women – taking the figures to 5,948,100 and 14,103,900, respectively. While for older people, running, weight sessions and gym sessions have grown in popularity, with 100,700 fewer inactive adults aged 55+ and an additional 506,700 more active in the last 12 months – leading to totals of 5,592,400 and 9,137,800, respectively. Tim Hollingsworth, chief executive at Sport England, said: “We can’t be complacent. Within the overall positive picture of these figures is a sobering reality – if you are well-off you are far more likely to be active than if you’re on a low income or less affluent.

Inequality “While there are complex barriers that stop less well-off people from getting active, this is an unacceptable inequality and one we’re starting to address in the work we are doing across the country – including piloting programmes in 12 local areas to tackle inequality,” said Tim. “Being active has positive benefits for mental and physical wellbeing, strengthens communities and helps build confidence and resilience.” https://www.sportengland.org/



Reducing the burden of MSK by bringing


People with MSK conditions usually need a range of interventions such as manual therapy, exercise-based services and self-management support

Image: Freepik

The impact of musculoskeletal ill-health on individuals, health service providers and the economy is widely recognised. The NHS Long Term Plan states that, along with mental health and respiratory, “musculoskeletal conditions are responsible for a substantial amount of poor health and place a substantial burden on the NHS and other care services.”

Why the pathway for the treatment

REFERRALS for spinal surgery are increasing year on year and a growing number of patients are waiting longer than 18 weeks from referral to treatment. Wide variations exist in surgical rates between centres, and there are a significant number of treatments with a poor evidence base. A clinical team of 30 specialists in the diagnosis and management of lower back pain and I have devised a complete end-to-end pathway for the management of lower back pain. The objective of this is threefold: first, to rapidly identify and refer potentially serious pathology; second, to provide expeditious access to interventions such as nerve root blocks or surgical discectomy where indicated and, third and most importantly, provide effective and timely care for sufferers with acute low back pain to improve outcomes and reduce disability.

Back pain is the largest single cause of disability in the UK, with low back pain alone accounting for 11% of the total disability of the UK population. CHARLES GREENOUGH, National Clinical Director for Spinal Disorders, explains the importance of the National Back and Radicular Pain Pathway. I would like to see every Clinical Commissioning Group (CCG) in the country commission through this pathway to reduce delays, remove ineffective treatments and help patients to lead a fuller more active life, reducing disability and chronic pain. And by making the treatment pathway more evidence based and more coherent, this management will be less expensive than the current

management. The volume of spinal surgery is spiralling – the NHS in England spends £200m a year on spinal surgery and there are currently about 10,000 adult patients each year that have elective spinal surgery. However, there is a large variation in practice with inconsistent indications. In addition, there are large numbers of patients being given injections with low evidence of effectiveness.


health and care professionals together IN ORDER to help those developing cost effective services for good MSK health on a local level, ARMA (the Arthritis & Musculoskeletal Alliance) has produced a document that sets out a core offer in five areas: Underpinning framework, Services, Prevention, Mental Health and Personalisation. Primary Care Networks should ensure that an Integrated Care Services (ICS) framework is in place to address MSK in the community. The document states: “An ICS brings together local organisations to redesign care and improve population health, creating shared

leadership and action. They are a pragmatic and practical way of delivering the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care.”

Interventions People with MSK conditions usually need a range of interventions such as manual therapy, exercise-based services and self-management support. This can only be provided effectively if there is a multidisciplinary team available in the community. The high incidence of people with MSK conditions having multiple other long-term conditions makes

a multidisciplinary approach doubly important. Expanded neighbourhood teams will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, and AHPs such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector.

Pathways The guidance recommends that local MSK services be organised and commissioned in pathways – including pain medicine, orthopaedics, rheumatology and hospital/ community therapy services – enabling patients to be rapidly

directed to the appropriate point on the pathway. This means that everyone who acts as a first point of contact for patients should understand how these interventions are provided and referral routes. The NHS says it will increasingly be more joinedup and co-ordinated in its care, breaking down traditional barriers between care institutions, teams and funding streams to support the increasing number of people with long-term health conditions, rather than viewing each encounter with the health service as a single, unconnected “episode” of care.

of low back pain needs proper planning Reducing these ineffective but costly injections alone would save the NHS £9m a year. From a review of the service it was clear that there were two main issues impacting on this area of work. l The current pathway of management for low back pain is not planned, has little reference to the evidence base and contains very significant delays at every step l Large variation in surgical indications and rates between centres, which is unexplained. This in turn drives large variation in activity and cost between CCGs. In addition, we found problems with waiting list management and fragile clinical teams relying on one or two individuals working in isolation. The National Low Back Pain Pathway is a complete end-toend pathway for lower back pain and radicular pain which

Image: jcomp/Freepik

Retraining healthcare professionals to de-medicalise simple back pain starts at the GP surgery and moves through primary care and, if indicated, through to secondary care. All clinicians using this new pathway will be applying right care/right time/ right place principles, supported

by a public health awareness campaign. The focus will be on the promotion of selfmanagement and improving understanding of how to manage, limit and prevent back pain. This will reduce ongoing

pain and disability and in turn reduce the need for patients to be referred into secondary care. To support the pathway, standardised patient literature will be used in conjunction with retraining of healthcare professionals to de-medicalise simple back pain. Altering population beliefs about back pain is a recognised highly effective way for reducing back-related disability. Patients will experience a planned care pathway, including those who need a high intensity combined physical and psychological treatment programme. Only after completion of the whole pathway will consideration be given to surgery for axial back pain (eg fusion surgery). Disability and chronicity will be reduced and ineffective therapies such as injections will be addressed. www.ukssb.com/improvingspinal-care-project http://arma.uk.net



Video gaming: everything to play for? The global growth in the popularity of eSports – electronic sports – involving organised competitions using video games, has seen a corresponding growth in musculoskeletal injuries of the neck, back, and upper extremities.

IN THE United States, eSports is gaining acceptance at professional, collegiate and high school levels – with the accompanying uniforms, practices and coaches that can be found in traditional sports – while the top tournaments carry high value cash prizes. However, there is a lack of information for physicians about the health concerns and appropriate treatment of eSports athletes. Because of the sedentary nature of the sport and accompanying poor posture, eSports athletes are likely to have musculoskeletal injuries of the neck, back, and upper extremities. Publishing in the Journal of the American Osteopathic Association, doctors from the departments of Family Medicine, Osteopathic & Manipulative Medicine and the NY College of Osteopathic Medicine1, examine the current evidence on related health concerns including musculoskeletal conditions, and look at the osteopathic

physician’s role in promoting health and reducing injury in this new gaming phenomenon. Practice for collegiate eSports can be three to five hours of gameplay a day, and many athletes (as they are classified) continue to play at home. ESports athletes are seated throughout gameplay; therefore, the injury profiles and health concerns are more likely to resemble a desk worker than, say, a footballer.

Guidance With the unique characteristics of eSports intensified at professional and elite amateur levels, physicians need specific guidance on how to assess and treat injuries. Furthermore, there are clear parallels for the millions of gaming enthusiasts here in the UK who are committing long hours to this sedentary activity. Approximately 35% of collegiate eSports athletes report neck or back pain while gaming. Research examining posture while gaming revealed

Why eSports players are regarded as athletes ESports require manual dexterity and quick reaction times to achieve victory. Players at a professional level can perform up to 500 action moves per minute (APMs) compared with 10 for a novice. Neck and back dysfunction Cause • Forward head displacement • Stress of cervicothoracic junction and intervertebral discs • Back rest-induced flattened lumbar lordosis


Intervention • Stretching • Strengthening exercises for postural control • Osteopathic cranial manipulative medicine • HVLA (cervical) • Muscle energy • Soft-tissue mobilisation (lumbar) • Mobilisation for lumbar segment

that within 30 minutes of play, there was forward displacement of the head compared with the spine. Remaining in a forward head position for prolonged periods of time stresses the cervicothoracic junction and paraspinal muscles, which causes regional imbalances in muscle tension. Every inch of forward head displacement is associated with a 10-pound increase of force torque in the cervical extensors. The increase in force perpetuates a cycle of further forward head displacement and muscle strain. Therefore, in addition to cervical strain, eSports athletes are at an increased risk of cervicogenic and tension headaches. In the lower back, slumping posture increases forces on the intervertebral discs and can result in herniations. Furthermore, seats with backrests, which are common in gaming chairs, promote flattened lumbar lordosis and posterior pelvic tilt causing increased muscle tension in the paraspinal muscles and weakness of the transversus abdominus. Appropriate interventions for eSports athletes with neck pain include stretches, strengthening exercises and osteopathic manipulative medicine (OMM). When prescribing exercise to this population, stretches and strengthening should focus on muscles associated with postural control, such as the back, abdomen and neck. Strengthening exercises and stretches can decrease pain and improve range of motion. Cervical postural manipulation was found to increase lordosis and cervical extension range of motion and decrease forward head posture in the cervical

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Millions of gaming enthusiasts are committing long hours to this sedentary activity

Next generation eSports athlete?

function and mental health. Playing video games longer than three hours is associated with shoulder pain and is likely a result of poor posture while gaming. Sitting for five minutes in the forward head posture position caused a significant decrease in shoulder external rotator strength. Additionally, more than 30%

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spine. High-velocity, lowamplitude (HVLA) and muscle energy techniques were found to decrease neck pain. In patients with chronic low back pain, soft-tissue mobilisation, muscle energy techniques, and mobilisation for lumbar segment techniques twice per week reduced pain intensity and improved physical

of collegiate eSports athletes report pain in the hand or wrist. Playing video games requires quick, repetitive movements involving the fingers, hands and wrists. These repetitive movements result in hypertrophy of the flexor tendons in the carpal tunnel and increased crosssectional area and swelling ratio in the median nerve. The increase in pressure begins within 30 to 60 minutes of keyboard use and is exacerbated by an accompanying ulnar deviation of the wrist. Video games that involve a joystick can result in de Quervain tenosynovitis. Wrist exercises can help alleviate wrist and hand pain. To help prevent upper extremity injuries and decrease strain and stress when playing, it is paramount to counsel eSports athletes on proper posture. Several OMM techniques can effectively address shoulder somatic

dysfunctions associated with prolonged gaming. The fascial distortion model was found to increase shoulder range of motion and HVLA thrust manipulations, and highamplitude, low-velocity thrust mobilisations were found to improve shoulder recovery after injury. By applying the tenets of osteopathic medicine, the authors conclude that physicians can provide comprehensive care to address the unique concerns of the eSports athletes and others in the gaming community. Proactively exploring and addressing these concerns will promote health, prevent further injury, and likely improve performance. 1) Hallie Zwibel, DO, MPH; Joanne DiFranciscoDonoghue, PhD; Amanda DeFeo, OMS II; Sheldon Yao, DO. An Osteopathic Physician’s Approach to the Esports Athlete: the full article can be found on the website of the Journal of the American Osteopathic Association. https://jaoa.org



Devising better systems of working between the NHS A NEW four-year study funded by the National Institute for Health Research (NIHR) aims to enhance how researchers and health and social care services can use existing data to improve the care and quality of life for care home residents, families and staff. The £2.2m DACHA study (Developing research resources and minimum data set for care homes’ adoption and use) is led by the University of Hertfordshire. The study team will review how health and social care systems work and explore the evidence on how to

integrate data and test what a minimum dataset would need to be the key resource for all those working in and for care homes. The findings have the potential to deliver a step-change in how we understand the needs of the care home population. This could be a resource that supports the provision of high quality care across the country, they add. Claire Goodman, Professor of Health Care Research, NIHR Senior Investigator at the University of Hertfordshire, who is leading the study, said: “A more consistent approach

is needed to support integrated working and ensure that planning for future needs of residents is based on the best evidence. By bringing together existing data systems, creating a minimum data set and further researching care home residents’ needs, we can make recommendations likely to improve residents’ quality of life.” She added: “Long-term continuing care for older people is principally provided by care homes, with approximately 420,000 people in England and Wales living in a care

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Calculating the full value of clinical research

THE value of clinical research to the NHS, the UK economy and jobs market has been evaluated in a new report, which provides an assessment of the economic impact of the National Institute for Health Research Clinical Research Network’s (NIHR CRN) activities to support clinical research in England. It shows that over the threeyear period to 2018/19, clinical research supported by the NIHR


CRN generated an estimated £8bn of gross value added (GVA) and 47,467 full-time equivalent (FTE) jobs for the UK. The report, produced by KPMG UK’s Economics team using data from a range of sources, also provides an insight into the benefits and income that NHS providers gain through undertaking commercial contract research – studies sponsored by life sciences

companies and delivered alongside NHS care. It provides an analysis of the value of payments to NHS trusts for delivering commercial research studies. It also estimates how much NHS providers save through using medicines provided as part of commercial studies, where the company bears the cost of the medicine, in place of the standard NHS treatment.

The report also states that, for each patient recruited on to a commercial trial supported by the NIHR CRN, on average NHS providers in England received an estimated £9,200 from life sciences companies, and on average saved an estimated £5,800 per patient (where trial drugs replaced the standard treatment). www.nihr.ac.uk


S and care homes Image: rawpixel.com/Freepik

home. Residents and staff rely on the NHS for medical care and the role of social care is gaining recognition as an essential part of care provision for this ageing population. This underlines the need to develop reciprocal systems of working between the NHS and care homes. Our aim is to create new ways of working and doing research in and with care homes, so that the outputs benefit not only the researchers, but also the residents.� www.nihr.ac.uk

Integrated care for people with multiple long-term conditions MORE than eight million people in England live with three or more longterm health conditions. Improving integrated care can have a huge impact on how they manage their health and wellbeing and how they encounter the health and care system. A one-day event at The Kings Fund in London in February will explore the experience of people who live with

multiple long-term conditions and how outcomes can be improved. Delegates will share case studies of different approaches and innovations in care delivery and how they can fit into different disease pathways. Tuesday 4 February 2020, 8.30am4.30pm, The King’s Fund, London W1G OAN. www.kingsfund.org.uk/events

Improving the knowledge of headaches PATIENTS with headaches and migraines are being recruited for a survey being undertaken by Osteopaths for Progress in Headaches and

Migraines (OPHM). The survey is a part of the Education and Assessment for Competency in Headaches (EdACHe) project, supported by the Osteopathic Foundation (OF). The project will assess the current level of the working headache knowledge among osteopaths. It will create suitable online training based on this assessment along with a training course which itself will in turn be assessed. To complete the survey, visit the OPHM website. www.ophm.org/edache

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Stem cell treatment for Arachnoiditis I WAS diagnosed with adhesive Arachnoiditis and have been researching for something that might fix this condition. A neurosurgeon in Ohio may have found something that appears to be working. He pulled blood from my bone marrow, spun it down and then injected 10cc into my spinal canal and the balance into my IV. I have had many surgeries over the years and with each one lost a little bit more of me. Left toes and the bottom of the foot had no feeling, the sides of my legs as well and my entire lower back. No rectal feeling or control including urinary function. On the second day after the injections, my wife tickled my left foot for the first time in over 20 years. She scratched my lower back and I could feel it. There have been no more electric shocks down my legs. What more to come in the next days, weeks and months? I eagerly look forward where before I dreaded the future. I am aware of the placebo effect and am only talking about things that have been documented as no longer functioning, so I think this treatment certainly deserves consideration as others have failed. Jerry Borsh, Sacramento, US n Arachnoiditis is a pain disorder caused by the inflammation of the arachnoid, one of the membranes that surrounds the nerves of the spinal cord. It is characterised by severe stinging, burning pain, and neurological problems.



A NEW osteoporosis medication called Romosozumab, used to treat postmenopausal women at high risk of breaking a bone, has been approved by the European Medicines Agency (EMA). Romosozumab – sold under the brand name Evenity – is a bone-building drug that not only increases bone formation but to a lesser extent reduces bone loss. However, it may not be suitable for people with a history of heart attacks or strokes. The Food and Drug Administration (FDA) approved the medication in the US back in April after safety and efficacy data from two clinical trials, involving more than 11,000 women with postmenopausal osteoporosis, showed that it could lower the risk of a new spinal fracture by 73%. Use of the medication in the UK was initially denied in June due to concerns about why the medicine appeared to increase the risk of heart and circulatory problems. However, the EMA has now decided to give regulatory approval for Romosozumab following an appeal, provided that its use is restricted to women with no history of heart attack and stroke. The EMA said: “The Agency finally concluded that if restricted in this way, the benefits of Evenity would outweigh its risks in postmenopausal women with severe osteoporosis who are at a high risk of fracture. Additional measures and studies are foreseen to follow its use in practice and to ensure that the medicine is used correctly.” Given that osteoporosis causes one in two women to experience a fracture in her lifetime, UK approval of the medicine is considered very positive, and means that healthcare professionals and patients will have more choice in clinically effective osteoporosis treatments. Alison Doyle, head of clinical practice and operations at the ROS, said: “We welcome the approval of this highly


effective drug. It is important to remember that, as with any medication, there are side effects that need to be considered and Romosozumab may not be suitable for everyone. However, it is a highly effective drug that will benefit many people. “It has taken 15 years of research to get to this point, and it’s been nine years since the last osteoporosis drug was approved. With no other new treatments on the horizon, this really is a positive step and provides improved patient choice.” She added: “Drugs aren’t the only

solution though. We also need to better understand the causes of osteoporosis, which is why our Osteoporosis and Bone Research Academy is working with patients, research clinicians and academics in the field to advance our knowledge and ultimately find a cure for osteoporosis.” The recommendation will now be reviewed by the European Commission (EC), which has the authority to approve medicines for use throughout the European Union. A decision by the EC is expected by the end of the year. https://theros.org.uk

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New osteoporosis medication is approved for the UK

Image: Yanalya/Freepik


More patients are becoming dependent on opioids

Better care for people using opioids for long-term pain A NEW study is set to help improve care for people using opioids for long-term pain, by testing a way to train pharmacists to support these patients. The five-year PROMPPT trial1 will focus on patients using opioid drugs, a group that includes codeine and morphine. Although opioids can be very effective for short-term pain, for many people they are not helpful in the long-term – with a recent Public Health England report finding that more patients are becoming dependent on the drugs.

The study is funded by the National Institute for Health Research’s (NIHR) Programme Grants for Applied Research scheme and led by researchers at Keele University. It will be seeking views from patients, pharmacists and GPs to help design a new way for clinical pharmacists to work with teams in GP surgeries to review patients who are taking opioids long term. This new approach could involve pharmacists helping patients to stop or reduce their use of opioids if appropriate

and supporting them in coping with long-term pain. One issue is that people don’t realise their pain medicines are opioids or know about the risks associated with long-term use. The research team has set up an online discussion forum for patients called the Q-PROMPPT blog, so that participants can take part via the internet, as and when they want to. Commenting on the initiative, Health Secretary Matt Hancock said: “We are in the grip of an over-medication crisis and it is vital that we help people find

alternatives to addictive opioids to manage their pain. This government-funded study will help pharmacists and health professionals better support their patients and help move them on to more effective treatments.” www.nihr.ac.uk www.keele.ac.uk https://promppt.co.uk 1) Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams.

“I put on weight, couldn’t sleep, my skin condition worsened...” LOUISE Trewern has lived with pain for most of her adult life. She said: “I used opioids for more than 12 years. At first, they helped me to cope better and to carry on looking after my children and running my home.” But the benefits were not long-lasting.

She said: “Even on opioids my pain would get worse and my dose was increased. That worked for a while, until it didn’t, and my dose would be increased again. “At the same time, my skin condition became worse, a cold would put me in bed for a week and I put on weight. I

nodded off in the day, even in the middle of a video-call with my grandson but I couldn’t sleep at night. “Taking part in this research is an amazing opportunity for me and others like myself who live with pain to improve the care that we receive.”



As rugby fans eagerly await the start of the Six Nations in February, ULRIK SANDSTRØM, team chiropractor at Leicester Tigers Rugby Club and member of the British Chiropractic Association, brings us a glimpse of how elite squads prepare for internationals.

Image: creativeart/Freepik

How top teams avoid injury

Image: creativeart/Freepik

THE intensity of international games is 20-30% more intense than a week-to-week rugby match, even at premiership level. After big weekend games such as those we saw in the recent World Cup, the rest of the weekend is dedicated to letting the players rest and treating any injuries. Maximising training opportunities in the week before the next match will be instrumental in making sure that all are strong and resilient enough to deliver their best performances.

These tactics will be in part forward dominated and power-based, but also reliant on the creation of space and use of pace. Outside of core training, the teams’ diet will be highly regulated to ensure maximum energy release, and players will be receiving additional care and treatments where required, which at Leicester can include anything from a light massage, to a combination of chiropractic and physiotherapy.


The team will be put through moderate training on Thursday. Players will be training at about a 60-70% intensity to help them prepare and also prevent injuries. “A lot of people assume that stretching helps to prevent injuries, but it doesn’t,” said Ulrik. “We don’t tend to stretch our players at all before a game or during training. Warming up – doing what you’re about to do at a lower intensity – however, is really important. Warm-up drills might be individual for each player, and they might all have their own routines or workouts.”

The focus needs to be on “rebooting”. Following a couple of days of light, low-intensity training and treatment, the players will today experience a full training session, testing their strength and conditioning to make sure they’re strong enough to deal with the impact of the next game. When it comes to strength and conditioning, the medical team has a very clear idea of the loads each player can handle, and so today will be about finding the balance where players are bearing enough to make them strong and resilient, but not so much that they get injured.

Wednesday Today, the team’s focus will shift towards developing tactics and plays to help them beat their competition. This requires a thorough understanding of your team’s strengths and weaknesses – and the tactics they are likely to employ.



Friday Often referred to as the “team run”, the players will be at the ground, familiarising themselves with the surroundings and walking through their plays. With the big game just a day away, they won’t be doing any high impact training that could overload them so much that they injure themselves.

Image: creativeart/Freepik


before big matches

The most common injuries in rugby

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BECAUSE rugby is a running sport, you tend to see a lot more hamstring and groin injuries than in other sports. You also see more high impact injuries in rugby due to the nature of the game. I deal mainly with spinal injuries and complaints, so I see a fair few “stingers”. Stingers are essentially traction injuries of the nerve

Hamstring and groin strains can originate from a lower back or pelvic issue bundle coming from the neck and are usually caused by tackling someone. I’m finding myself getting more and more involved in concussion injuries, too, as they’re often neck related. I also see a lot of lower back disc issues as well as hamstring and groin strains which, interestingly, tend to originate from a lower back or pelvic issue that isn’t working correctly. Most injuries occur in the game rather than training, and particularly in the first part of the second half. So, between 40 and 60 minutes is the highest peak in injuries. I put this down to the fact that players

are fatigued because they’ve had a full first half and then 15 minutes of cooling down and then they’re straight back out, playing at full intensity again. A lot of our players will sit on static bikes keeping warm during half time to keep their legs ticking over as a preventative measure. Also, in game time, backs players tend to get more injuries than forwards, whereas in training, forwards tend to get more injuries than backs. In training the backs generally don’t get hit as hard as they would during a game, but forwards do get involved with live scrums, lineouts etc, which carry more risk. https://chiropractic-uk.co.uk

Movement mechanics and the lower back FORMER Saracens physiotherapist James Moore is now intensive rehabilitation unit manager at the British Olympic Association. He offers this tip for staying safe: “The low back can be very vulnerable. When you go back to basics the spine is really a large spring that is designed to transfer force around the body. It is not designed to be the primary force producer. “This primary force production should come from the shoulders and hips so effective mobility and flexibility for both your hips and shoulders, coupled with good strength through your available range of motion, can take a lot of pressure off your spine and therefore can protect it.” www.csp.org.uk



Technology and sedentary lifestyles

MORE than 70% of chiropractors have treated patients with injuries linked to sedentary lifestyle habits, such as screen time (78%), commuting (88%) and sitting for too long (93%). Technology has been found to have the biggest growing impact on people’s back health, according to a recent survey by the British Chiropractic Association (BCA). Similar numbers (68%) of chiropractors have seen an increase in children with issues linked to screen time, in the last five years in particular. In a very extreme case, one BCA chiropractor reported that a child as young as four had complained to their parents of back pain, linked to using a tablet device for hours each day.


Easy changes to everyday life can make a significant difference Lower back pain was revealed to be the most common complaint chiropractors treat among all their patients, as a growing number of people replace regular exercise with sedentary habits. This fits with statistics across the world which suggest that low back pain causes more global disability than any other condition. Catherine Quinn, president of the BCA, said: “Almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, and it is increasing – disability due to

back pain has risen by more than 50% since 1990 so it’s no coincidence that our findings echo similar reports from other researchers and organisations in the chiropractic profession. “Our members are seeing more and more cases of back and neck pain among a much younger age group, which is a sign of how our lifestyles are changing. Back and neck pain can develop at any age and is usually not serious. However, many of us are spending more time being sedentary, whether sat at a desk, watching TV or

using tablets in the evening. Research shows us that this lack of physical activity is a major risk factor for lots of health concerns, including back pain, and that intensified efforts and initiatives are needed to address the burden of low back pain as a public health problem.” The BCA’s findings follow on from a recent report by the Royal College of Paediatrics and Child Health, which revealed that fewer than 10% of British teenagers meet the recommended guidelines for sleep, exercise and screen time. In addition, it found that more than three-quarters of teenagers spent more than the recommended two hours a day interacting with screens. One respondent to the BCA’s


Image: tirachardz/Freepik

are ‘the biggest cause of back pain’

Dos and don’ts at your desk Image: Freepik

survey suggested they often see the onset of back problems in children around the age of 11, when they go to secondary school and their parents have less control over their phone use and screen time. Catherine Quinn continued: “Our lifestyles have completely changed in the last 20 years, with advances in technology like mobile phones and smart devices meaning we’re spending less time on the move and more time looking at screens. We now spend so much more time at a desk working from a laptop or computer, too. All this is having a direct impact on our general back health. “With young people particularly, it’s important to remember that their bones and skeletons are

still developing. So habitual behaviour, like bending your head over your phone, is more likely to lead to postural issues. “Easy changes to everyday life can make a significant difference, but if your pain doesn’t reduce or is prolonged, you should see a health professional for guidance.” Regularly changing posture and remaining seated for no longer than 30 minutes at a time are two simple ways to prevent or reduce pressure on the back. Research by Arthritis UK also proves that physical activity can reduce the risk of developing joint and back pain by 25%; a claim supported by the BCA, with 68% of its members believing that exercise is the single most important element for maintaining good back health.

WITH devices and new technologies now a staple in homes and workplaces, the BCA shares its top tips for keeping mobile and your back healthy. Sit up: If you’re watching TV or using a computer or mobile device for a prolonged period, sit comfortably with your back supported in the base of the chair. Sitting with your head forward adds strain on your neck and back, so sit with your head directly over your body. Get moving: Your back loves to stay active, so try to move around every 20-30 minutes, whether at home or at work (an easy trick is to stand up every time you’re on the phone). Being active is also a great way to keep back pain at

bay, but don’t be tempted to go straight in, full throttle with high endurance-based activities, especially if you haven’t exercised in a while. You can gradually build up your exercise load with swimming, walking or yoga which can be less demanding on your body, while still keeping you physically active. Check your workspace: If your job primarily involves sitting at a desk and staring at a computer for hours at a time, make sure your desk is set up to support a comfortable position. This is different for everyone so if you don’t feel comfortable in your current set up, try altering the height of your chair or screen. https://chiropractic-uk.co.uk



How the weather can affect MANY people living with arthritis report that they experience a change in their symptoms due to the weather. Research published by Manchester University and funded by Versus Arthritis, indicates that people with long-term health conditions can be up to 20% more likely to suffer from pain on days that are humid and windy with low atmospheric pressure. The Cloudy with a Chance of Pain study, led by consultant rheumatologist Professor Will Dixon, is a smartphone-based study to investigate how weather affects long-term

People reported greater discomfort on humid and windy days health conditions including arthritis and fibromyalgia. Thousands of people with differing health conditions across the UK took part in the study over 15 months. Predominantly,

participants were people living with arthritis. Participants were asked to record their daily symptoms and other factors that affected their pain levels (such as how well they have slept or how much exercise they have done) with an app on their smartphones, while GPS in their phones provided accurate weather reporting. A sample of 2,658 people who recorded their experiences on most days for six months or more showed that people experienced greater discomfort on humid and windy days, whereas dry days were least likely to be painful. The charity spoke to some of the people who took part in the study to find out what this research means to them...

Managing symptoms

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Arthritis sufferers experienced more discomfort on humid and windy days

Nora Boswell, 70, was diagnosed with osteoarthritis five years ago. After deciding to take part in the study, she is now using the findings to help her plan her days and manage her symptoms. She said: “I have knee arthritis and multiple aches and pains but couldn’t really pin down what made them worse and the thought of continued deterioration was daunting.” Nora decided to take part in the Cloudy study as she thought it was an interesting and much more in-depth way of researching her causes of pain. She found the Cloudy app easy to use

Emotional wellbeing a key factor in managing Lisa, 50, has been living with osteoarthritis for 10 years and began to experience the symptoms four years before she was officially diagnosed. TALKBACK l WINTER 2019

LISA was working in an officebased role at the time and found it hard to come to terms with the fact that her arthritis was affecting her ability to work. As the pain got worse, Lisa decided to leave work and focus on managing her pain and living well with her arthritis. She said: “At the time, I wasn’t aware that the pain I was experiencing in my neck and shoulders was related to arthritis. So, my diagnosis did come as a complete shock.”

“Arthritis has stolen my independence but over time I’ve learnt to accept this” Up until her diagnosis, Lisa had worked in office-based roles for many years. Her employer arranged for an ergonomic specialist to assess her needs. “I was provided with a new working environment, that was catered very specifically to my needs at the time.

“Despite being incredibly grateful to my employer for the support I received, the ergonomic equipment only bought me short-term and partial relief. I would spend hours at my desk and often be in a lot of pain. It was difficult to explain to my colleagues, as to


long-term health conditions Ankylosing spondylitis

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Participants responded via an app on their smartphones and was impressed by the broad spectrum of influences it was able to track, saying “it helped me to think properly about my dayto-day life.” The results helped her to discover that inactivity raises her pain levels and on the dull, damp and grey days, she finds it difficult to stay motivated. Nora says, “forewarning of such weather will ensure I set strategies in place to keep myself active and, I hope, alleviate the effect of the weather to some extent.” Nora also finds that exercise lowers her pain levels. “This made me think more about how to help myself. For example, on long car journeys, I have devised an

“in-car-work-out” doing leg, arm, neck and body exercises to keep my muscles from stiffening up but keeping the movements minimal so as to not distract the driver.” Carolyn Gamble, who has ankylosing spondylitis (see box), said: “So many people live with chronic pain, affecting their work, family life and their mental health. Even when we’ve followed the best pain management advice, we often still experience daily pain.” Having taken part in the study, she added: “Knowing how the weather affects our pain can enable us to accept that the pain is out of our control, it is not something we have done or could have done differently in our own self-management.”

Ankylosing spondylitis (AS) is a type of arthritis that mainly affects the back, by causing inflammation in the spine. This can make your back, rib cage and neck stiff and painful. It often starts in the late teens or 20s. In response to the inflammation, the body produces extra calcium around the bones of the spine. This can make extra bits of bone grow and cause your back and neck to be more stiff. In rare cases, some of the bones of the spine may link up, or fuse together. In serious cases this can make the spine curve forward more. You can reduce the risk of this happening, if you: l keep active l have effective medical treatment l try to maintain a good posture. While it mainly affects the neck and back, it can cause pain and stiffness elsewhere in the body, including in the hips, shoulders and feet. We don’t yet know what causes ankylosing spondylitis. To some extent it’s related to your genes, but the condition isn’t passed directly from a parent to their children. You can’t catch it from anyone else.

arthritic pain and decision to leave work

Continued on page 22

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them I looked perfectly fine on the outside.” Two years after her diagnosis and at the age of 46, Lisa made the decision to leave work. “It was a hard decision. I’ve never been a quitter and at the time, part of me felt that I was giving up too easily. But in my heart, I knew my body couldn’t cope with the pressures of being in an officebased environment and having ‘I wasn’t aware that the pain I was experiencing in my neck and shoulders was related to arthritis’



Emotional wellbeing a key factor in managing from page 21

to sit at a desk for hours at a time. “After I stopped working, the pain in my neck reduced significantly. However, the pain spread to other areas of my

body and in subsequent years the doctors confirmed that I also have osteoarthritis in my feet and hands.” Lisa often struggles to sleep: “It’s difficult to find a comfortable position to sleep when you’re experiencing pain

in your neck and arms. I was taking a nerve control tablet to assist with this, but the effects were short-lived and I was concerned about increasing the dosage. “The pain in my neck and arms means that simple

household chores have become extremely difficult. Instead of cleaning my house in a couple of hours, it now takes me a week, as I have to break down the chores into smaller chunks, so I can manage the pain.”

WE KNOW that a healthy diet and lifestyle is good for us; exercise is one of the best things you can do to improve your symptoms of arthritis. So, why do we hear about runners developing knee problems? Can injury increase the chances of later developing osteoarthritis? The Centre for Sport, Exercise and Osteoarthritis Versus Arthritis, based at Nottingham Universities Hospitals NHS Trust, working alongside the Universities of Nottingham, Oxford, Southampton, Bath, Loughborough and Leeds, is aiming to answer these questions. To do this, the centre brings together researchers with expertise in osteoarthritis and sports medicine, nutrition, orthopaedics, bone and cartilage biology and physiotherapy. The key research questions include: l Can we identify specific activities that are related to osteoarthritis symptoms in athletes and exercisers? l Can treatments like physiotherapy, which help to prevent and manage osteoarthritis, help to keep people active throughout their lives? l Can we identify the effects of exercise on quality of life for those currently with (or at risk of developing) osteoarthritis?

Running For most people who do moderate exercise, there’s no increased risk of osteoarthritis, and they benefit from a healthy lifestyle choice without a great risk of injury. However, many people believe lots of running will have a damaging effect on joints, in particular the knees. With the help of parkrun, the research


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Do sports increase the risk or

centre is recruiting volunteers for the HALO study (health of adults’ longitudinal observational), to follow a group of runners over 15 years, observing the amount of running they do and any injuries they have, to see if these factors impact their joint health later in life. This research could help to find out if there’s any truth behind the link between running and osteoarthritis in the knee and could lead to new advice or clinical practice.

MSK health in the military The research centre is also exploring musculoskeletal conditions in military personnel. Recent advances in imaging and surgery have shown that hip pain can often occur before osteoarthritis develops. Since hip pain is common in young military personnel, the MILO (Military Hip Rehabilitation Outcome) study looks at the link between military training (and the


arthritic pain and decision to leave work The benefits of exercise Lisa has found exercise to be very beneficial, in terms of managing the pain and improving her emotional wellbeing.

“I’m feeling the benefits of exercise in so many ways. Since I’ve been focusing on exercise, I can manage the pain better. “I particularly enjoy taking part in regular Pilates and yoga classes, although I

was advised not to lift heavy weights or play racket sports that could put pressure on my neck and shoulders. “My advice to anyone with arthritis is to keep moving. I know everyone says that, but

take it from me, I’ve seen such positive changes in my life since I’ve been exercising in a focused way. “It really is the small things you notice that make the biggest difference to how you feel.”

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help improve osteoarthritis?

Examining military training and the physical forces it imposes on the body physical forces it imposes on the hips) and pre-arthritic hip pain. Since starting, this study has developed and tested an exercise programme for military personnel, with participants showing improved physical function of the hip. To see how beneficial this rehabilitation programme could be, it is now being compared to other treatments in a larger clinical study. The Bio-Mil-OA study (Biomarkers and Joint Pain in Military Osteoarthritis, also run by researchers at the centre) explores the link between battlefield trauma and osteoarthritis, to see if trauma increases the risk of developing the condition. This study is part of the much larger government funded ADVANCE Study, a collaboration between researchers and the

Defence Medical Rehabilitation Centre to study long-term physical and psychological effects of battlefield casualties.

Prevention and better treatments Based on its findings, the research centre helps to develop plans to help prevent, assess and treat sports injury. One of the studies has shown that intense physical activity in adolescence can lead to changes in shape of the hip joint (which increases the risk of later developing hip osteoarthritis), particularly in adolescent males who play competitive sport. These findings have allowed clinicians to suggest preventative treatments or exercises to help.

Value of exercise Ultimately, it is important to remember the value of exercise. Reports suggesting that all runners have knee problems can make people lose confidence in exercising, and often don’t mention the wider health benefits of regular exercise. We Are Undefeatable is one campaign from Sport England that is helping people with long-term health conditions to build physical activity into their lives, so that everyone can enjoy the benefits of exercise. www.versusarthritis.org www.cloudywithachanceofpain.com www.sportsarthritisresearchuk.org www.parkrun.org.uk www.advancestudydmrc.org.uk www.weareundefeatable.co.uk




Profile for BackCare

TalkBack, winter | 2019 (BackCare)  

TalkBack is the quarterly magazine of BackCare, serving those with a personal or professional interest in back pain with news, views and edu...

TalkBack, winter | 2019 (BackCare)  

TalkBack is the quarterly magazine of BackCare, serving those with a personal or professional interest in back pain with news, views and edu...

Profile for backcare