Managing Pain - Q1 2021

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Managing Pain Read more at www.healthawareness.co.uk

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People suffering from chronic pain have very low quality of life indicators.

SCS could help many more neuropathic pain patients than it currently does.

Dr Arun Bhaskar, President, British Pain Society

Dr Ganesan Barani, Consultant in Anaesthesia and Pain Medicine, Leeds Teaching Hospitals NHS Trust, Honorary Clinical Associate Professor, University of Leeds

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Helping pain patients access better care

IN THIS ISSUE

04 Robotics are leading the way in arthroplasty surgery.

I

~ Mr Paul Manning, Chief Medical Officer, Circle Health Group

06 Many people living with pain struggle to get healthcare practitioners, employers, even family and friends to believe that their pain is real. ~ Antony Chuter, Chair, Pain UK

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WRITTEN BY

Dr Arun Bhaskar President, British Pain Society

People living with chronic or persistent pain see a significant negative impact on their daily life, more needs to be done to make pain management a priority.

n the UK, 8 million adults and around one in five adult Europeans report moderate to severe pain that is disabling, 40% of them reported inadequate management and haven’t had specialist treatment.

People suffering from chronic pain have very low quality of life indicators (EQ-5D) and there had been studies where the baseline scores of patients with chronic pain were considerably lower than those admitted with stroke.

Making pain a priority Chronic pain patients are twice as likely to visit the GP surgery and five times more likely to attend A&E. In the UK, patients with chronic pain attend nearly 5 million primary care appointments per year. This is attributed to persistent symptoms contributed by poor understanding of the problem, resulting in unnecessary referrals, investigations and ineffective treatments.

Despite affecting a significantly large number of people, pain is not deemed as a priority like cancer or heart disease; hence only a small fraction of the health and social care budget is allocated for managing these patients.

Chronic pain and mental health issues contribute to more than half the sick notes in the UK. People with persistent pain are seven times more likely to quit their job and claim longterm incapacity and disability benefits.

Thus, chronic pain is not only a physical and psychological condition, but also an emotional, social, economic and humanitarian issue.

Chronic pain patients are twice as likely to visit the GP surgery and five times more likely to attend A&E. Learning about pain through life experiences There is room for optimism. The revised definition by International Association for the Study of Pain acknowledges pain as a personal experience influenced by various factors and a person’s report of an experience as pain should be respected.

It also states that the concept of pain is learnt through life experiences and though it usually serves an adaptive role, it may have adverse effects on function and social and psychological wellbeing.

Improving collaboration in pain care There are plans to integrate health and social care as well as better collaboration between various specialities and primary care. Hopefully the GIRFT (Get it Right First Time) initiative will ensure that the patients receive appropriate treatment without undue delay.

Until we listen to the patient and devote time and effort in understanding how the pain is affecting them and had negatively impacted on their life, we would be failing to help them. It is also our responsibility to raise awareness, so that adequate funding is allocated to deal with these complex issues.

Can the Evoke® System help you reduce your chronic pain?

The Evoke Closed-Loop Spinal Cord Stimulation System is designed to measure your spinal cord's response to stimulation and make automatic, real-time adjustments intended to maintain a consistent level of therapy.

Learn more about Closed-Loop Chronic Pain Therapy (CLT)™ by scanning the link with your phone. www.saludamedical.com Saluda and Evoke are registered trademarks of Saluda Medical Pty Ltd. Copyright © 2021 Saluda Medical CLIN-MKT-008161_EU Rev 1.00

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An innovative new hope for chronic pain patients: Closed-loop spinal cord stimulation A new type of spinal cord stimulation technology is improving the quality of life for selected neuropathic pain patients. Is this a breakthrough in chronic pain management?

INTERVIEW WITH Dr Serge Nikolic Consultant in Pain Medicine and Neuromodulation, Clinical lead for Neuromodulation, St Bartholomew’s Hospital and The Royal London Hospital

INTERVIEW WITH Dr Sarah Love-Jones Consultant in Pain Medicine and Anaesthesia and Lead Clinician for Spinal Cord Stimulator Service in the Pain Clinic, North Bristol NHS Trust

INTERVIEW WITH Dr Ashish Gulve Clinical Lead Consultant in Pain Management, The James Cook University Hospital

WRITTEN BY Tony Greenway

Paid for by Saluda Medical

Improving neuropathic pain long term Dr Sarah Love-Jones, Consultant in Pain Medicine and Anaesthesia and Lead Clinician for Spinal Cord Stimulator Service in the Pain Clinic at North Bristol NHS Trust, cautions that it won’t benefit all chronic pain patients. “For example, SCS isn’t suitable for those with mechanical back pain or fracture pain,” she says. “This is why potential candidates should first be assessed by a team of multidisciplinary specialists.”

Those who could benefit from SCS therapy include patients who have undergone technically successful back or leg operations, but still experiencing significant back, leg or arm pain.

SCS was developed over 50 years ago and has been proven safe and effective in treating chronic pain yet it still has it limitations. Unlike a similar technology used to treat cardiac dysfunction, all therapies currently stimulate the spinal cord without listening to the signals that return. Cardiac pacemakers

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hronic pain is a much bigger problem than most people realise, notes Dr Serge Nikolic, Consultant in Pain Medicine and Neuromodulation, and Clinical Lead for Neuromodulation at St Bartholomew’s Hospital and The Royal London Hospital.

“For the 550 million people around the world who live with chronic pain, the consequences are far-reaching,” he says. “It can limit an individual’s dayto-day function, mobility and quality of life, and in extreme cases lead to isolation, loneliness and complete withdrawal of social interaction, which has an enormous impact on family life. A person with chronic pain may be unable to work, which can cause financial and mental health issues; plus, their complex needs can place a profound economic burden on welfare and healthcare systems. So, any treatment that can improve chronic pain is to be welcomed by those affected — and by society as a whole.”

“Thankfully, a treatment called spinal cord stimulation (SCS) can be effective in reducing this pain.

SCS therapy uses a small, implanted device that transmits electrical pulses to the spine and in doing so selectively intercepts chronic pain signals travelling to the brain. In most cases this results in a significant improvement in function, mobility, sleep and overall quality of life” says Dr Nikolic.

Any treatment that can improve chronic pain is to be welcomed by those affected — and by society as a whole. use electrocardiograms to control a patient’s therapy. In SCS, there has not been such a parallel and all systems are open-loop and fixed-output. The patient has to manually adjust their therapy based on subjective feedback.

A new SCS system is available, which overcomes these limitations. The new closed-loop system is the only SCS system designed to measure the spinal cord’s response to stimulation in the form of the evoked compound action potential (ECAP) and make automatic, real-time adjustments millions of times per day. For the first time, the system delivers consistent therapy so that patients can focus less on their pain and return to living life, sleeping better, and potentially reduce their medications.

Benefits of closed-loop SCS therapy Dr Ashish Gulve, Clinical Lead Consultant in Pain Management at The James Cook University Hospital in Middlesbrough, carried out the first closed-loop implant in the UK when it became commercially available 18 months ago. “The patient was a young lady who had a young family

and was taking three different types of painkilling medication,” he says.

“Before the implant she scored her pain as a six to seven out of 10 — if 10 is the worst pain you can think of. Yet a year after her implant she was reporting excellent pain relief, with a pain score of zero to one out of 10, and experienced an improvement in her overall quality of life.”

Closed-loop spinal cord stimulation provides a lot of optimism for the future of managing chronic pain. Dr Nikolic says: “This is the first time that we can observe the spinal response to this therapy and, more importantly, automatically adjust the treatment so it is kept at its optimum level that patients find helpful long term. We at Barts have now implanted more than 20 patients over the past year with very promising results.”

He says: “The closed-loop spinal cord stimulation treatment is available on the NHS and the service can be accessed through appropriate GP or secondary care referrals.”

The Evoke® Closed-Loop System is the first and only closed-loop spinal cord stimulation system.

In a recent NICE briefing, comments from clinical experts suggested Evoke could reduce hospital follow-up visits because of improved pain management over time, reduce the use of pain management medication and reduce the reliance of clinicians on subjective feedback from patients.

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Joint pain matters – why you should ask for help

INTERVIEW WITH

Mr Paul Manning Chief Medical Officer, Circle Health Group

Recent events have shown that there has never been a better time for collaboration between the private sector and the NHS.

I

’ve found it pretty remarkable to see what we’ve achieved over the past year. At the beginning patients were reluctant to go anywhere near a hospital, but we’ve managed to keep COVID compliant thanks to our focus on creating ‘green’ sites, where we have rolled out a very successful testing system alongside remote diagnostics support to ensure we could stay open for acute and vulnerable patients” says Mr Paul Manning, Chief Medical Officer at Circle Health Group.

While BMI healthcare facilities (Circle Group acquired BMI in 2019) have been used in collaboration with the NHS, the group are keen to stress to all patients that they are very much open for other treatments once again.

My message to anyone would be of reassurance, if you’re suffering from joint pain, ask for help. Whether on the NHS or private, you’ll receive great quality care.

Mr Manning adds, “As a consultant orthopaedic surgeon I’m incredibly happy to see that not only are we fully open but we continue to innovate – which is in part led by the demand from our patients. Increasingly, private care is chosen because of its speed of access and availability of innovative treatments, and crucially, the quality of care in both sectors remains the same.”

With the addition of robotics to arthroplasty surgery (restoring a joint in the knee or hip for instance), Mr Manning believes that this type of technology is leading the way.

He adds, “I’m delighted with the inclusion of robotics in orthopaedics, surgeons are already reporting shorter lengths of stay and earlier mobilisation alongside a better range of movement.

This is really exciting for me. My message to anyone would be of reassurance, if you’re suffering from joint pain, ask for help. Whether on the NHS or private, you’ll receive great quality care.”

How knee and hip operations are becoming better thanks to robots Robotics in the operating theatre isn’t something new, but even in the middle of a pandemic these small, handheld devices are helping to revolutionise joint pain in orthopaedics.

T INTERVIEW WITH Mr Simon Jennings Consultant Orthopaedic Surgeon, BMI Clementine Churchill Hospital

SPREAD WRITTEN BY Gina Clarke

wo medical practitioners who currently use robotics in their surgeries are Mr Simon Jennings, Consultant Orthopaedic Surgeon at the BMI Clementine Churchill Hospital and Mr Craig White, Consultant Trauma and Orthopaedic Surgeon at BMI Woodlands Hospital.

For Mr Jennings, his journey into robotics started several years ago. He says, “When I was first shown the sort of machines on offer it was nothing like I’d imagined. We all watch these movies with massive robots but actually the device is very small – I was amazed the first time I saw it in action.”

Using robotics is a complete change in concept, although it’s the same operation it’s being done in a totally different way.

A minimally invasive approach There’s good reason why medical professionals are getting excited over robotics, as not only do they re-calibrate in realtime, but are also perfect for reassuring patients who want a minimally invasive approach.

Mr Jennings explains, “Using robotics is a complete change in concept, although it’s the same operation it’s being done in a totally different way. There is less cutting and, in my experience, the device is far more accurate than the old fashioned system of jigs as now we can fine-tune to fit the patient. It’s made a knee replacement an absolute joy for me as I get to do it spot on and the patient is up and about much quicker.”

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Back on the golf course: How robotics helped my knee recovery ©DRAGONIMAGES

Improving outcomes For Mr White, the feedback the hip navigation surgery allows means from his personal experience the patient often has a better recovery and overall outcomes. He adds, “The navigation and robotics give you feedback visually on a screen – as well as audio feedback. If you stray out of the zone, the system won’t allow you to engage the tool. The robot will literally stop you from leaving the zone.”

If you stray out of the zone, the system won’t allow you to engage the tool. The robot will literally stop you from leaving the zone.

Mr White also referenced the movies when it came to his robotic inspiration. “It’s certainly nothing like you imagine, this is more of a handheld tool. When I tell my patients, they often think I’ll be sat in a chair doing nothing but that’s not the case. And if the tool fails? Well, that’s easy, the surgeon will fall back on their years of experience and training. Robotics and navigational tools are just that – instruments to help gain better results.”

Both consultants believe that there will be better outcomes to come with the use of integrated robotics in orthopaedics, and in their experience so far it points to quicker recovery and higher patient satisfaction rates.1,2,3 For the world of orthopaedics, robotics has been revolutionary.

References: 1.Gregori A, Picard F, Bellemans J, Smith JR, Simone A. Handheld Precision Sculpting Tool for Unicondylar Knee Arthroplasy. A Clinical Review. Paper presented at: 15th EFORT Congress; 2014; London, United Kingdom.

2. Smith JR, Picard F, Rowe PJ, Riches PE, Deakin AH. The Accuracy of a Robotically-Controlled Freehand Sculpting Tool for Unicondylar Knee Replacement. XXIV Congress of the International Society of Biomechanics; 4-9 August, 2013; Natal, Brazil 3. Gustke K, Golladay G, Jerry G, et al. Increased satisfaction after total knee replacement using sensor-guided technology. Bone Joint J. 2014;96-B(10):1333-1338. https://pubmed.ncbi.nlm.nih.gov/25274917/

As a golfer, skier and all-round active person, when 73-year-old Nathan Fraser began to struggle with walking he knew he had to do something.

INTERVIEW WITH

Nathan Fraser Patient

A INTERVIEW WITH Mr Craig White Consultant Trauma and Orthopaedic Surgeon, BMI Woodlands Hospital

s his knee began to get more and more painful, Nathan saw his GP where he realised major surgery was ahead, alongside pain, discomfort and a long recovery.

However, after researching the procedure and the adoption of new robotics techniques, Nathan was keen to press ahead. He says, “All my life I had heard about technology innovations, and when I saw the video on the website of how it worked it was quite enlightening.”

I was told that I could continue to take painkillers after being released from the hospital but found I didn’t need them.

Instead, I focused on my exercises.

That was in March 2019, as he prepared himself for a few days stay in hospital and, what he thought would be, a long and painful road to recovery, Nathan was surprised to find that he was back home much sooner than expected. He adds, “I was told that I could continue to take painkillers after being released from the hospital but found I didn’t need them. Instead, I focused on my exercises.”

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by Smith+Nephew. Smith+Nephew is a portfolio medical technology company.

These articles’ subject matter and contributors were proposed by Smith+Nephew but determined by Mediaplanet. The articles’ content representssolely the personal views of the contributors.

Continuous rehabilitation The physiotherapy routine was established with Nathan by experts while in hospital and something he carried on with religiously when at home. He says, “I would encourage any patient in pain to have the operation, but they must commit to the physiotherapy. Soon, I was able to walk to the physio and then the next milestone was nine holes around the golf course at six weeks – the pain had gone!”

Disclaimer: Patient-specific experiences and outcomes will vary.

There’s nothing artificial about our intelligence.

*RI.HIP Navigation available on Kick

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How new neuromodulation implants treat chronic pain Technological advances are offering patients discreet, targeted, pain relief to help improve their quality of life.

Helping people living with pain to be heard

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iscreet electrical implants are helping a growing number of patients cope with chronic pain.

The approach, known as neuromodulation, uses a device to deliver electrical impulses to interrupt pain signals to the brain and reduce the feeling of pain.

Two particular approaches are offering drug-free solutions: the spinal cord stimulator (SCS) implanted in a person’s back, sends electrical stimulation to specific spinal locations to treat chronic pain typically associated with the back and legs; while the more recent evolution of the peripheral nerve stimulator (PNS) delivers relief via electrodes on the nerve at the source of pain, below the head, in an arm or leg, for example.

Direct pain relief PNS offers a more patient-friendly dimension by working directly at the nerve responsible for the pain. Dr Andrea Trescot, Chief Medical Officer at Stimwave Technologies, explained that PNS is delivered through a needle, usually implanted under local anesthetic and powered by an external transmitter.

The patient wears an antenna over the skin which activates the device, avoiding the complexity of internal batteries and extension leads of the traditional SCS approach.

“The implanted, micro-device is passive and only activated when the antenna is placed over it and the transmitter is turned on,” she adds.

“There is no maintenance; all that is required is that the patient sees their pain team in the hospital for reprogramming appointments or check-ups.”

“The patient wears the transmitter and antenna when they need it or wish to. This varies by patient and what best fits their lifestyle.’’

Quality of life The wearable antenna and transmitter are removed when showering, or swimming, without interrupting pain relief as there is a gradual “wash in-wash out” to the way the electrical therapy is delivered.

The system is for any nerve area below the head and designed to help give patients freedom from chronic pain, potentially come off strong pain-relief medication and be able to enjoy improved activity, exercise and quality of life.

INTERVIEW WITH

Dr. Andrea Trescot Chief Medical Officer, Stimwave Technologies

WRITTEN BY

Mark Nicholls

Paid for by Stimwave Technologies stimwavefreedom.com

Taking pain seriously as a condition in itself could improve the lives of people living with pain and save jobs.

G INTERVIEW WITH

Antony Chuter Chair, Pain UK

WRITTEN BY

Linda Whitney

etting the right treatment for pain is often difficult or impossible.

However, for many people living with pain, the problem starts before that: they struggle to get healthcare practitioners, employers, even family and friends to believe that their pain is real.

“Many people living with pain, which is pain lasting over three months, feel unheard and can be passed from one specialist to another for months or years, while living with pain and its consequences,” says Antony Chuter, Chair of the charity Pain UK. Chuter, who lives with pain himself, says: “I lost my job, my relationship and my home as result.” He is not alone, in the UK currently 28 million live with pain.”

Barriers to access “Access to pain diagnosis is a postcode lottery and waiting lists for pain clinics can be long,” says Chuter. “Many clinics are run by specialists who, while they would consider themselves generalists, also often have an interest in particular conditions or treatments, so if your pain is outside their area of interest you may not get the best care – and you don’t get a choice of clinics.”

Treatments do not eradicate the pain in most cases, though they may reduce it. “There have been no new licensed pain treatments for years,” says Chuter.

“Clinicians are taught that pain is a diagnostic for other conditions, rather than as a difficult human experience.”

However, for many people living with pain, the problem starts before that: they struggle to get healthcare practitioners, employers, even family and friends to believe that their pain is real.

Pain UK are looking to create a Pain at Work Charter where organisations will pledge to listen, believe, adjust and offer understanding for people living with pain. To help fund this and the other essential works of Pain UK, visit painuk.org/donate

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How spinal cord stimulation can improve your quality of life Spinal cord stimulation therapy can reduce chronic neuropathic pain in some patients. Yet not everyone who might benefit from it is being treated.

E INTERVIEW WITH Dr Ganesan Barani, Consultant in Anaesthesia and Pain Medicine, Leeds Teaching Hospitals NHS Trust Honorary Clinical Associate Professor, University of Leeds

Written by: Tony Greenway

lectrical stimulation to reduce chronic pain isn’t new, notes Dr Ganesan Barani, Consultant at Leeds Teaching Hospitals. In fact, it’s centuries old.

“In 46AD, people would tie electric eels onto their heads if they had migraines, or stand on electric eels if they had sciatica,” he says.

Thankfully, electrical stimulation is rather more sophisticated these days.

Take spinal cord stimulation (SCS), which has been routinely used for decades to treat patients who suffer from chronic neuropathic (or nerve) pain caused by accident, injury or disease. With SCS, a small device is placed under the skin. This delivers a mild charge to nerves along the spinal cord, which modulates the pain signals going to the brain.

“Neuropathic pain presents as a stinging, shooting or burning or pins and needles,” explains Dr Baranidharan. “If you have a back operation but your sciatica still persists, or you recover from shingles but still experience pain, or any surgery and have pain in the

scar area, you may be a candidate for this treatment.” However, SCS does not work for patients with nonneuropathic pain.

Meeting an unmet need for chronic pain patients Dr Barani — who is also President of the Neuromodulation Society of UK and Ireland (NSUKI) — believes that SCS could help many more neuropathic pain patients than it currently does. “For every 100 patients who could be offered SCS, we are only reaching out to around four or five of them,” he says.

“There is a huge unmet need. We’ve told medical teams to send us their nerve pain patients, but our implant numbers have not risen over the years.

So now we want to reach out to the patients themselves.” European expert group has developed an online tool (scstool.org; used by both doctors and patients) to reveal those individuals who may be suitable for SCS therapy and those who may not be.”

It’s never too late to seek SCS treatment. “I implanted a patient

If you have a back operation but your sciatica still persists, or you recover from shingles but still experience pain, or any surgery and have pain in the scar area, you may be a candidate for this treatment. yesterday who had been in pain for the last 25 years,” says Dr Barani.

“Although the SCS implant is not 100% guaranteed to help — no intervention can promise that — we find that seven out of ten patients do benefit from it. Of those seven, two will have significant reduction in their pain and perhaps no pain at all. Two to three will have 50% pain relief. Two to three will have less than 50% pain relief, but still report that their pain is better compared to what it was before, and their quality of life has improved.”

Approximately 100 million people across Europe suffer from chronic pain.

“Every day tasks are a struggle” Spinal Cord Stimulation therapy can give them new reasons to hope.

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What you can do to manage your pain while waiting for surgery While waiting for surgery, it is important for patients to remain in the best shape they can, in order to achieve the best outcomes.

WRITTEN BY John Skinner Vice President, British Orthopaedic Association

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s we emerge from the pandemic, patients living in pain from arthritis and other bone and joint conditions have waited far longer than we would have wanted for diagnosis and treatment. Many patients will be anxious about what the future holds and uncertain as to what support is available.

The roadmap for the return of musculoskeletal services is clear.

Elective surgery is resuming in nearly all parts of the country and services are being ramped up in a way that is safe for patients and staff. Behind the scenes, surgeons and other healthcare professionals are working to prioritise the patients most in need of early treatment.

In the meantime, it is important for patients to remain in the best shape they can, in order to still achieve the best outcomes from treatment.

Here are some common questions around pain management and support available: 1. How do I start making healthier choices?

The Chartered Society of Physiotherapy website provides excellent tips and tools to help you to start making healthier choices.

There are exercise videos tailored to those with bone and joint conditions and general advice on health and wellbeing.

2. Why is my weight so important?

Being overweight puts more stress on joints. Even small amounts of weight loss can dramatically reduce the forces going through your joints and improve pain.

3. Will exercise damage my joints more?

Exercise is very unlikely to worsen joint damage. Even gentle exercise helps to maintain bone strength and

In the UK, 8 million adults and around one in five adult Europeans report moderate to severe pain that is disabling, 40% of them reported inadequate management and haven’t had specialist treatment. ~ Dr Arun Bhaskar, President, British Pain Society

to keep your heart and lungs in the best shape. It is important to try to do something every day, even if it’s just going for a short walk. For those who have had hip or knee replacement procedures cancelled, the free ‘Joint School’ app can help you to find the right exercises to do at home.

4. My painkillers aren’t working Simple painkillers are usually most effective when taken before pain reaches crescendo and most tablets require time to work. If you’re waking at night with pain, you may benefit from taking a tablet last thing at night, even if not in pain at the time. Work with your doctor or pharmacist to find the best regimen for you and your lifestyle.

5. Don’t forget mental wellbeing Mind has excellent resources to help you take charge of your mental wellbeing. They even have resources specific to COVID-19 and explain how mental health and physical activity interact.