Sint Maartenskliniek - Pain Management magazine

PAIN MANAGEMENT

Zeroing in on the pain Driving forward with neuromodulation RealHealth Institute

1ST EDITION / SPRING 2019

The Sint Maartenskliniek was founded by the Congregation of the Choorstraat in 1936.

In their honor, there is a bronze statue of these little nuns at the main entrance of the hospital.

February 2019

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contents

8

Zeroing in on the pain

Driving forward with local anesthetic nerve block

Neuromodulation

20

An average of 80 Sint Maartenskliniek patients receive the treatment each year

26

Dear reader

4

Virtual Reality: A new age for pain care

6

Zeroing in on the pain

8

A popsicle in bed

11

World leadership in treatment of posture and movement-disorder pain

12

Facts & Figures

14

Opioids: Not just an American problem

16

Neuromodulation

20

Raising the bar on treatment quality

24

RealHealth Institute

26

Backing app

32

Patient interviews

34

RealHealth Institute

An innovative pain treatment focuses on reducing the consequences of chronic back pain Concept and coordination Hidden Champion b.v. Design Reclameloods Rotterdam Copywriting Hidden Champion b.v.

Photography Manon Bruininga, Dennis Vloedmans, Inge Hondebrink Postaddress Sint Maartenskliniek - PO box 9011 - 6500 GM NIJMEGEN

www.maartenskliniek.nl

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DEAR READER

February 2019

Mark Van Houdenhoven

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DEAR READER, Please accept a warm welcome to our first edition of PAIN MANAGEMENT, the magazine of Sint Maartenskliniek’s Pain and Anesthesiology Department!

For many years, I have been very proud to oversee the great work of my colleagues in the area of pain management – a field of expertise that can significantly improve the lives of people everywhere.

From our clinic in the eastern Netherlands, we have pioneered a range of treatments and approaches that have become internationally recognized and driven forward clinical progress.

Now, through this magazine, we want to show the world our great work. From neuromodulation (read about this on page 20) and our RealHealth program (page 26) to our local anesthetic nerve blocks (page 8) and our use of virtual reality technology (page 6), this magazine outlines some of the most innovative treatments and tools we have developed and continue to apply. Every day, hundreds of patients in the Netherlands and beyond enjoy a better quality of life thanks to treatments like these.

Moving forward, we ready to further raise the bar of our pain treatments (see page 24), such as by continuing to collaborate with our partners, nationally and internationally (see page 12). By zeroing in on pain, and by developing more innovative and effective treatments, we can help to make the world a better place – and that’s what keeps us going!

I hope you enjoy reading our magazine.

Yours sincerely, Mark Van Houdenhoven Chairman of the Board of Directors

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February 2019

Since late 2017, Sint Maartenskliniek has been pioneering a novel treatment

VIRTUAL REALITY: A NEW AGE FOR PAIN CARE

By Natasja Maandag, Anesthesiologist and Pain Specialist

VIRTUAL REALITY

For over a year, the Department of Anesthesiology and Pain Treatment at Sint Maartenskliniek has been applying innovative new technology to the age-old problem of post-operative pain. By allowing patients to engage with virtual reality technology, the recovery period after surgery can be made more effective and entertaining.

Virtual Reality has offered many new

In late 2017, we began a pilot with post-operative

opportunities for society as a whole, but

patients who used Virtual Reality technology to

in medical care it is a particularly exciting

distract them from their surroundings and their

technology. At Sint Maartenskliniek, we first used

physical state, which often involved pain and

this technology in our rehabilitation department

discomfort. By using this non-invasive, non-

in the form of the GRAIL walking simulator, which

pharmaceutical treatment, patients were able

helped patients to get back on their feet – after a

to escape into a new dimension and forget their

stroke, for example.

pain, which could help both their physical and mental recovery.

A new world of possibilities The pilot proved to be very successful, with patients often remarking that they wished their virtual reality could last longer, so we have decided to roll out this treatment more formally.

These other-dimensional experiences involve a wide range of different activities; from visiting the city of London and swimming with dolphins to taking a walk in the forest or visiting the seaside.

For bed-ridden patients, these experiences are

Natasja Maandag

incredibly liberating.

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“Crucially, patients have more than one sense stimulated at once, as they also wear headphones.”

The key idea behind this treatment is that we

treatment, and the more feedback we receive, the

should evoke positive emotions in post-operative

better we can make the virtual reality experiences.

patients. By making them feel happier, and more

Although we’re very happy with this treatment,

at ease with the changes that have taken place

we’re continuing to optimize and improve its

in their body during surgery, we can drive them

application.

back to better health faster than would otherwise be the case. Crucially, the patients have several of

What’s coming next? Well, in the coming years,

their senses stimulated at once, as they not only

we would love to scale up our application of this

see a different landscape in front of them, but

treatment and – in particular – make it available to

they also hear music and sounds via headphones.

more types of pain patients. The possibilities are

Introducing an interactive component further

endless – the only limits are our imaginations!

enhances effectivity.

More VR ahead Our use of virtual reality for pain treatments is still relatively new, but we’re confident that this technology will prove very important moving forwards. The more patients that use this

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ZEROING IN ON THE PAIN

February 2019

Driving forward with local anesthetic nerve block

ZEROING IN ON THE PAIN

By Ivar Bruaset, Medical Manager and Anesthesiologist

Over the years, Sint Maartenskliniek’s Department of Anesthesia and Pain Treatment has pioneered forms of local anesthetic nerve block treatments, which offer significant advantages in treating acute post-operative pain compared to generalized pharmaceutical pain relief treatments.

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A

s many doctors will know, the right choice is

An ESRA-approved training institution

not always the easy choice. When it comes

In view of the high quality and the high volume of

to treating acute pain in post-operative patients,

our local anesthetic nerve block treatments, the

the easier choice is often to rely on analgetics or

European Society of Regional Anesthesia & Pain

“painkillers”, which are quick to deliver and work

Therapy (ESRA), which is a sister society of the

relatively well. By contrast, nerve blocks, which

US’s ASRA, granted us a training licence for this

provide pain relief by injecting local anesthetic

treatment. As such, doctors come from all over

near targeted nerves to block sensation, takes

Europe to learn more about how to apply local

longer to apply per patient and requires extra skill.

anesthesia treatments at our clinic in Nijmegen.

However, the evidence of the advantages of this second type of treatment is clear. Nerve blocks

“Patients can even

can provide faster recovery, less operative pain and fewer post-operative complications over

apply local anesthetic

general anesthesia treatments. Overall, by taking less medication, patients can avoid common

treatments themselves

potential side effects of pain relief medication, such as drowsiness, upset stomachs, and

at home, which gives

dizziness.

them greater ownership

At Sint Maartenskliniek, we tend to take a

over their condition.”

holistic view on patient care and recovery. Our Department of Anesthesia and Pain Treatment looks at the full picture of patient wellbeing, and how we can contribute to this. We have been pioneering and optimizing local nerve block treatments, and we are the only hospital in the

In fact, at Sint Maartenskliniek, we have also

Netherlands to be using this treatment option on

helped to develop special local anesthesic nerve

such a large scale and for such a wide range of

block treatments that the patients can apply

patients.

themselves. By using an elastomeric infusion pump, we can deliver our best care to patients in

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February 2019

the comfort of their own home, which gives them

patients in their own home has proved very

great ownership over their own health. In turn, this

successful, so I’m confident that the future ahead

can help their psychological state, and drive them

is very bright. My advice for hospitals and doctors

to better health as quickly as possible.

who are considering using local anesthetic nerve

Moving forward, we’ll keep on optimizing this

block treatments? Just do it!

technology and innovating in line with patient requirements. Over the past four years, providing

ZEROING IN ON THE PAIN

local anesthetic nerve block treatments to

“We’ve managed to

achieve fantastic results,

reducing the typical postoperative hospitalization period for foot and ankle

surgery patients from four days to one night.”

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“Treating” post-operative patients

A POPSICLE IN BED A dry mouth and a bad taste – it’s a recognizable feeling for many patients just waking up after surgery.

Traditionally, patients at Sint Maartenskliniek received a glass of water in our recovery room but, since November 2017, this has been replaced by a popsicle, known popularly in the Netherlands as “a rocket”.

“Post-operative recovery is aided by the fluid and sugars of the popsicle,” explains Bauke Schretlen, a nurse in the recovery room. “The patients love them! The easily digestible flavored ice helps to prevent possible nausea and also soothes throat irritation. Research at other hospitals has even shown that patients who consume these frozen treats have less need for painkillers.”

“We do not tell you in advance, so for most patients it’s a great surprise to get the popsicle,” says Bauke. “We get a lot of enthusiastic reactions, even from patients who are over 80 years old. The nice thing is that everyone knows the rocket, but few people know which three flavors are in it.

They find this out through experience. And no, I’m not going to give away the secret!”

“Post-operative recovery is aided by the fluid and sugars of the popsicle.”

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February 2019

International partnerships are the key to progress

WORLD LEADERSHIP IN TREATMENT OF POSTURE AND MOVEMENT-DISORDER PAIN

WORLD LEADERSHIP IN PAIN TREATMENTS

By Kris Vissers, Professor Pain and Palliative Medicine and Anesthesiologist

To drive forward research, understanding and treatment of chronic pain due to posture and movement disorders, Sint Maartenskliniek partners with a range of international scientific societies. In a world where multidisciplinary approaches are more common than ever, these partnerships are increasingly important.

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Since the 1970s, chronic pain has been considered

These partnerships and collaborations have four

a disease in its own right. In fact, it is a disease that

main objectives: (1) to improve training and education

has a huge effect around the world: it affects as many

in the field of pain, (2) to build higher volumes of

as one in five adults globally, and has a devastating

patient data, (3) to foster international networks for

economical and personal impact.

patient care, and (4) to help create more cost-effective patient treatments. In a world where having different

At Sint Maartenskliniek, we are dedicated to improving

perspectives and skillsets is key, these partnerships

the quality of life of many different chronic pain

enable us to widen our scope of understanding and

patients, and we use a wide range of innovative

raise the standards of our treatments.

treatments and approaches to this end. In particular, we focus and develop programs for three particular

As part of these collaborations, our partners send

types of chronic pain: (1) lower back and leg pain, (2)

trainees to Sint Maartenskliniek from all over the world,

knee pain, and (3) chronic pain caused by movement

and we are able to learn from each other and grow

disorders, which includes paraplegic patients and

hand-in-hand. Ultimately, the aim is to improve patient

amputees.

care, not only in Sint Maartenskliniek, but all over the world. It takes between five and ten years to see the

As an institution that strongly believes in evidence-

full effects of these exchanges, which makes me very

based approaches, we undertake many studies and

excited for what is to come.

pilot programs to explore and research these types of pain. In addition, we partner with several leading national and international scientific institutions, societies and academic associations to drive our programs forward and deliver higher-quality pain

“Through our international partnerships, we are able to widen our scope of understanding and raise the standards of our treatments for chronic pain.�

treatments that are backed by evidence and eligible to be covered by reimbursement institutions.

Better together Specifically, in different ways and through different means, we partner with the RealHealth Rehabilitation Program, the European Society of Regional Anesthesia & Pain Therapy, the Comprehensive Center of Excellence in Pain Practice, the European Pain Federation EFIC, the World Institute of Pain, and the European Society for Medical Oncology.

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February 2019

OUTPATIENT SATISFACTION RATINGS

FACTS & FIGURES

Sint Maartenskliniek compared to Dutch average

2016

2017

2018

8.62

8.83

8.61

8.15

8.24

8.22

NPS SCORE

SINT MAARTENSKLINIEK

DUTCH AVERAGE

2016

66.7%

100%

38.3%

likely to recommend

NR.1

for ‘likely to recommend’ for the last 3 consecutive years among CQ index hospitals

100%

2017

68.3%

100%

44.8%

100%

2018

67.1%

100%

41.1%

100% SINT MAARTENSKLINIEK

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DUTCH AVERAGE

FACTS & FIGURES UNITED KINGDOM

SINT MAARTENSKLINIEK PAIN TREATMENT CENTRE

THE NETHERLANDS GERMANY

FRANCE

ITALY

SPAIN

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February 2019

Addiction in Europe is on the rise

OPIOIDS: NOT JUST AN AMERICAN PROBLEM

By Bart van den Bemt, Medical Manager and Senior Pharmacist

OPIOIDS: NOT JUST AN AMERICAN PROBLEM

With the world media rightly highlighting the scale of the American opioids crisis, it’s easy to lose sight of the fact that this problem extends beyond North America. Pharmacist and clinical pharmacologist Bart van den Bemt explores the issue of opioid addiction in the Netherlands, and outlines Sint Maartenskliniek’s investigative efforts to tackle the problem.

Despite the bad press and negative public opinion

year on year. On average, every Dutch pharmacy

of opioid drugs, it is important to remember that

has two or three opioid addicts in regular

these medications are among the most effective

attendance.

in the treatment of moderate and severe pain; they provide crucial pain relief to chronic and

In my opinion, over the last 15 years, this problem

acute pain patients all over the world, every day.

has been driven by three main changes: (1) the

What’s more, in the Netherlands, 95% of post-

release of opioids with more pharmacologically

operative patients no longer use opioids one year

addictive profiles, (2) a growing negative

after surgery, having successfully used the drugs

perception of other painkillers, such as NSAIDs

– just for a short period – for pain relief.

(non-steroidal anti-inflammatory drugs), and (3) the changing of pain quality parameters in

Nevertheless, continued use of opioids can

hospitals, in which reducing pain is sometimes

lead to physical dependence and ill health on

more important than looking after the complete

a personal level, and devastating wide-ranging

patient wellbeing.

effects on a social level. In the United States

Sint Maartenskliniek:

alone, some 382,000 citizens have overdosed on them since 2000 – it’s not for nothing that it has

A revolutionary study

been classified as a national emergency. While in

With the issue of opioid addiction clearly on

the Netherlands we are not yet at that level, we

the rise in the Netherlands, our team at Sint

should not ignore that the problem is growing

Maartenskliniek in Nijmegen, the Netherlands,

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“At Sint Maartenskliniek, we have undertaken a special program to study the causes and effects of opioid addiction in post-operative patients.�

Bart van den Bemt

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OPIOIDS: NOT JUST AN AMERICAN PROBLEM

February 2019

decided to undertake an important program to

Among the key questions we hope to answer

study the effects and causes of opioid addiction.

are: can we predict which patients will become

Since 2018, we started to closely monitor a

addicted to these drugs? Can we intervene even

dynamic cohort of patients who are treated with

before surgery? What is the clinical and societal

opioid medication. Each year, we will study at least

impact of their addiction?

5,000 patients.

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We hope that the results of this special program

States to maximize the impact of our research.

and study, which is unique for its size and scope,

The first results of this study will be available in

can help prevent opioid addiction in hospital-

the second half of 2019 – so watch this space!

related admissions – not only in the Netherlands but also further afield. In fact, we are actively collaborating with our partners in the United

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DRIVING FORWARD WITH NEUROMODULATION

February 2019

An average of 80 Sint Maartenskliniek patients receive the treatment each year

DRIVING FORWARD WITH NEUROMODULATION

By Leon Vonhรถgen, Anesthesiologist and Pain Specialist

Neuromodulation is the alteration of nerve activity through the targeted delivery of electric stimulation, often through the invasive implantation of an electrode device in the spinal canal, on the spinal cord. The Anesthesiology and Pain Treatment Department of Sint Maartenskliniek has been delivering this niche treatment to chronic lower back and leg pain patients for over 14 years, with some strong results.

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N

euromodulation is not exactly new:

be adjusted to the specific requirements of each

doctors have been experimenting with

patient. While the treatment rarely removes

this treatment since the Second World War,

pain completely, many patients agree that their

when electromagnetic stimuli were applied to

sharp pain is replaced by a less intense tingling

wounded soldiers as a means to relieve intense

sensation, which results in improved overall

pain from battlefield injuries. Since then, this type

physical wellbeing.

of treatment has evolved greatly and, although neuromodulation is still considered a last resort

At Sint Maartenskliniek we have been applying

in the relatively few medical facilities where it is

this treatment since completing its trial period

applied, it can deliver significant improvements to

here in 2004 and, as such, we were one of the first

patient quality of life.

institutions to offer neuromodulation for lower back and leg pain patients in the Netherlands.

Specifically, neuromodulation works by delivering

Because of the high price of the electrode device

a counter electric signal to the electric pain signal

and the invasive nature of the treatment, our

being emitted by the body, thereby producing

patients undergo an extensive physiological,

a net result of no signal, as shown in the graph

psychological and medical screening process.

Electric Nerve Signal

below. The strength and effect of this signal can

PAIN FROM PATIENT

NEUROMODULATION

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February 2019

Pioneering the all-in-one model Since we began applying the treatment, we have become one of the neuromodulation leaders in the Netherlands because of our high volume of patients and our highly efficient surgical procedures. For the procedure to be considered a success, our patients need to experience a 50% reduction in average pain, which we achieve in most cases. In particular, we are one of the few institutions to deliver neuromodulation through an all-in-one electrode device, rather than through DRIVING FORWARD WITH NEUROMODULATION

a device with a separate, rechargeable battery that requires a second round of surgery. Through our all-in-one method, we reduce the possibility of surgical complications and improve our overall success rates.

Moving forward, we aim to optimize our neuromodulation treatment through closer cooperation with our spinal surgeons and, more specifically, by developing better prediction models to forecast the success of the treatment.

With our strong track record for this treatment so far, we have every reason to be optimistic for the future.

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February 2019

Sint Maartenskliniek’s ambitious vision will pave the road forward

RAISING THE BAR ON TREATMENT QUALITY

By Mark Van Houdenhoven

VIRTUAL REALITY

As the American politician Bill Bradley once said, “Ambition is the path to success. Persistence is the vehicle you arrive in.” Below, Mark Van Houdenhoven, Chairman of the Board of Directors at Sint Maartenskliniek, explains how Sint Maartenskliniek is building on its ambition to raise the bar on treatment quality and become an international reference point in pain management and control.

The Dutch have a long heritage of

Our ambition as a clinic is to continue raising the

entrepreneurship and pioneerdom. In the 17th

bar of pain treatments, maintain our position at

century, the Dutch Golden Age was a period

the cutting edge of progress, and become the

where – thanks to our spirit of adventure and

best pain treatment center in Europe. No small

love of innovation – the Netherlands became

ambition, I realize, but one that I feel is fully

a world leader in trade, science, technology

achievable given our talented team and our strong

and art. Around the world, our small nation

organizational culture.

was recognized as the reference point for

One step at a time

improvement and development.

While our ambition is strong and our desire to I see a lot of this same entrepreneurial spirit

have a positive social impact is even stronger, we

at the Sint Maartenskliniek, and specifically at

must also understand that progress is made day

our Department of Anesthesiology and Pain

by day, step by step, little by little. We can’t just

Treatment. Our values of excellence, innovation,

decide to be the best – we need to build on it by

entrepreneurship and human centricity are the

continuing to believe and act on our core values,

pillars on which we build progress and shape the

while putting in a lot of hard work, of course.

future of our clinic. They guide us in what we do, and allow us to anchor our treatments, programs

Personally, I am fully engaged with our mission

and organizational approaches on strong

and vision as a pain treatment center because of

foundations.

how much of a positive impact we can have.

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“Our ambition as a clinic is to continue raising the bar of pain treatments.”

We make a real difference to real people’s lives.

People with pain – chronic or otherwise – can have a very low quality of life. But by applying our evidence-based treatments, and by continuing to partner with Radboud University Medical Center to research and develop new avenues of treatment, people can enjoy a higher quality of life and return to work quicker and in better condition.

And this is really what I find both so energizing and so humbling about working in the medical field, and of working in pain treatment. Our efforts change the course of people’s lives in the most fundamental ways. This is great – but we can always do better, of course. So, let’s keep going and let’s make the world a better place!

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February 2019

An innovative pain treatment focuses on reducing the consequences of chronic back pain

REALHEALTH: BEYOND PAIN ITSELF

By Desirée Engelbart, Head of RealHealth and Pain Management Center, Sint Maartenskliniek and Marieke Soree, Project Leader RealHeath Sint Maartenskliniek

REALHEALTH: BEYOND PAIN ITSELF

For over a decade, Sint Maartenskliniek has offered a special off-site treatment program for patients with chronic lower back pain. Called RealHealth, this program teaches patients to cope with their pain physically, mentally and socially – an approach that has produced excellent results so far.

RealHealth was first developed in the early- to

of between 10 and 12 years, with each program

mid-2000s by consultant spinal surgeon John

lasting two weeks.

O’Dowd, anesthesiologist and pain specialist Charles Pither, and a team of expert psychologists

What does the program do?

and physiotherapists. This innovative treatment

Unlike many other chronic pain treatments,

program for chronic lower back pain patients

RealHealth focuses on trying to make life easier

began as a residential treatment program and

and better for the patients rather than tackling

was designed to tackle the consequences of pain,

the cause of the pain itself. By taking this holistic

rather than the pain itself, by helping patients feel

approach, which encourages patients to accept

more comfortable with the issues surrounding

their pain and channel their energy into trying to

their discomfort.

take positive steps in line with their wider goals, RealHealth has delivered impressive short-term

In October 2006, the first RealHealth program

and long-term benefits to patients.

in the Netherlands commenced at an off-site location of the Sint Maartenskliniek, Nijmegen,

In fact, over 80% of RealHealth patients claim that

where the original RealHealth concept had been

their quality of life has improved. The economic

further developed and adjusted. Since then

impact of these improvements, while difficult to

we have accepted three groups of roughly 10

calculate, is likely to be significant, as RealHealth

people per month into the program, all of who

patients often find it easier to return to work and

have suffered lower back pain for an average

have more socially integrated lives.

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“Since the start of the program, over 3,000 patients have been treated

by RealHealth in Nijmegen.”

Desirée Engelbart

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February 2019

More specifically, our RealHealth program views

understand the program. We are always trying

the various pillars of a patient’s wellbeing – their

to optimize the various aspects of the program,

physical and emotional health, and their social

and we continue to adjust content to improve

interactions – not as separate areas requiring

our results. In fact, the more patients that come

separate attention, but rather as interconnected

through the program, the more data we have and

and interdependent elements. By applying

the better our program optimization can be.

evidence-based treatments that take the patient’s full wellbeing into consideration, life quality can

Moving forward, we hope to extend the scope

be dramatically improved.

of RealHealth to other types of chronic pain treatment, and open another facility in the

REALHEALTH: BEYOND PAIN ITSELF

More RealHealth ahead

western part of the Netherlands, near Amsterdam.

The current program has worked well for over a

In addition, we have recently implemented

decade, but we are not complacent in how we

a process to fast-track patients by offering

Marieke Soree

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“80% of patients say their quality of life has improved thanks to RealHealth.”

How can the RealHealth program help?

consultations in the outpatient clinic of the Sint Maartenskliniek in Woerden. All evidence-based

• Reducing the impact of lower back pain

programs take time, but we are convinced of the added value and the positive effect that

• Improving confidence

RealHealth has on our patients, and we’re sure

• Enabling the regain of trust in one’s body

that the best is yet to come. Here’s to many more

• Enabling work reintegration

years of RealHealth!

• Reducing reliance on pain medication •P romoting relaxation and improving the ability to move •U nderstanding one’s physical and mental limits •R estoring balance between work family - social life - sport

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February 2019

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February 2019

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An e-health tool to deliver key information earlier

BACKING APP

Much of the content of the RealHealth program has been carefully developed over the past 12 years with a view to

improving the situation of chronic lower back pain patients, most of whom have suffered from pain for over a decade.

Nevertheless, much of the program’s content is applicable to

early-stage patients; those who potentially may become chronic sufferers but are not yet there.

For these patients, Sint Maartenskliniek is developing the Backing App, which uses the advice and insights of the

RealHealth program as tools to mitigate further possible pain

and discomfort. As part of the app, patients must record a video

to describe their issues, which triggers a response system within the app and makes relevant content available to the patient.

A prototype of the app has now been developed, and a finalized version will be available for patients to use on their devices in 2019. Stay tuned!

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INTERVIEWS PATIENTS SINT-MAARTENSKLINIEK February 2019

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PAIN MANAGEMENT

INTERVIEWS PATIENTS “I first came to the Sint Maartenskliniek for

agrees. Obviously, I don’t want to keep being

an operation in 1976. Since then, I have been

hospitalized but, if I do, I will keep coming

an ambassador for their pain treatments

here!” Thijs

and healthcare in general. The doctors and nurses don’t treat you like a number or a task

“I’m loving my virtual reality experiences,

they need to complete, they take the time to

they are so much fun! Before breakfast, I took

help you and it is always a cozy feeling to be

a trip down to the beach and then a walk in

here. As a patient, I not only want innovative

a city environment. Because of the operation

treatments and high-quality technology, I

on my foot, I’m unable to walk, so it’s very

also want to feel personally cared for during

liberating to feel that I still can through this

my hospital stay. Nothing is so healing as the

treatment. It definitely took my mind off my

human touch.” Willem

pain. Normally, I would have to spend a lot of money to have these experiences in real

“This is my fifth time in the Sint

life, so I have to make the most of my ‘mini-

Maartenskliniek. Although I live near

vacations’ while I am here!” Amber

Amsterdam, which is a long way from Nijmegen, I chose to come here especially because of the reliability and the quality of the pain treatments. The brand of Sint Maartenskliniek stands for patient peace of mind and my personal experience is that this is definitely a deserved reputation. My wife

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www.maartenskliniek.nl