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 Vonhögen, 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
