Healthcare providers are turning to technology to proactively support patients’ recovery and anticipate problems before they arise.

Pain is the body’s alarm system that prompts us to seek help, but imagine being able to anticipate a problem and respond before the pain becomes unbearable.

Dr Arrash Yassaee is Clinical Director of global health technology company, Huma, which builds evidence-based apps used by clinicians to remotely monitor patients recovering from surgery, such as Orthopaedic surgery, or with ongoing health conditions, such as diabetes.

“Using our smartphone app, patients input health data such as symptoms, questionnaires and vital signs. It can also make use of data that your smartphone is already gathering, like step count, to help clinicians make quicker, better decisions about their patients’ care,” explains Dr Yassaee.

Data-informed care

Patients may gain an added sense of empowerment as they can see and track the impact that changes in exercise, diet and medication or procedures have on their body.

The app data helps ensure interactions with healthcare professionals are more meaningful and can make accessing care more convenient.

It also gives clinicians timely, real-world insights so they can assess a patient’s care plan based on what the data presents.

The testimonials in this article represent the individuals’ own opinions, findings and/or experiences. Individual results will vary.

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Mr Roger Smith

Knee Replacement Patient

Technology is ushering in a new era of surgery where robotic-assisted software is driving personalisation.

Knee surgery should offer patients a new lease of life. However, research published in The Bone and Joint Journal suggests that 50% who undergo conventional surgery report some movement limitation¹, while around 20% are not completely satisfied.^2,3,4,5

Those statistics raised concerns for 62-year-old Roger Smith who, after decades of arthritic agony, saw knee replacement as his only option. “Physically and mentally, the pain completely drains you,” says Smith.

With the potential to be unsatisfied with the possible outcomes of conventional surgery, Smith sought alternatives which led him to computer-aided robotic surgery and the support of Dinesh Nathwani, Consultant Knee Surgeon at Imperial College Healthcare NHS Trust London and Cleveland Clinic.

Robotic-assisted surgery helps provide accuracy and personalisation

Robotics certainly doesn’t abdicate responsibility to machines. Instead, it uses technology, as we do in so many other areas of life, to enhance the surgeon’s ability to precisely plan and execute personalised knee replacements.^9,10,11

The CORI^◊ Surgical System is designed to help surgeons achieve more accuracy in bone resection and alignment through intraoperative planning, smart mapping (no CT, MRI, or preoperative imaging required) and full range-of-motion data collection.

The system allows the surgeon to collect patient-specific anatomic and kinematic data, and the system provides a 3D model of the patient anatomy. The surgeon can size, orient and align implant components virtually on a 3D model.

With improved implant position comes fewer revisions, which means less pain and better outcomes for patients than traditional surgery.

“Conventional systems have all been designed around averages, but there is natural variation among patients that is not addressed with conventional instrumentation,”^{6,7,8,12,13,14} confirms Mr Nathwani.

Once the reflective markers are placed, the surgeon registers anatomical landmarks and begins to personalise a plan for the patient using an intraoperative software. The precision milling process uses a bur guided by the system to reshape damaged bone. The system maintains high levels of accuracy by preventing the surgeon from going too deep from the proposed plan.

“I can work within a degree of accuracy which we have never had with conventional instruments,” says Mr Nathwani.

Increased demand for robotic surgery

Due to the improved accuracy, robotics-assisted partial knee surgery has been shown to result in fewer revisions and better patient outcomes compared with traditional surgery.^{15,16,17,18,19,20,21}

“Within three and a half weeks of surgery I was on a bike and within seven weeks I was bowling for Sussex over 60s,” says Smith who underwent a robotic partial knee replacement.

In Australia, the proportion of total knee arthroplasty operations conducted using computer-navigation rose from 2.4% in 2003 to 32% in 2019, according to the Australian Orthopaedic Association National Joint Replacement Registry.

In the UK, it’s just 4%, with cost and resistance to change being the major barriers.²² However, with a new generation of tech-savvy healthcare professionals coming through and patients who are actively asking for robotics, the best kept secret in orthopaedic surgery is finally getting the attention it deserves.

The testimonials in this article represent the individuals’ own opinions, findings and/or experiences. Individual results will vary.

^◊ Trademark of Smith & Nephew
All references can be found via this link

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Michael used to enjoy camping and wood carving, but he had to stop nearly all activities because he was in so much pain. Several nights a week, he couldn’t sleep at all. That all changed when he found a high-frequency spinal cord stimulation treatment.

Michael had been suffering from agonising pain in his feet and legs for 16 years. It required him to take pain medication three times a day. However, after trying HFX* for his painful diabetic neuropathy, he says: “I felt like my legs were 20 years old again!”

A relief from pain

In September 2021, Michael’s had a HFX trial, which was very successful, “I didn’t even want to take the temporary device off to get the implant because I experienced such relief!” he says. HFX therapy is available on the NHS and the service can be accessed through appropriate GP or secondary care referral. Since having the implant procedure in November 2021, he has experienced nearly 100% relief in his legs, and the pain relief in his feet is at 60%.”

Michael had been suffering from agonising pain in his feet and legs for 16 years. It required him to take pain medication three times a day.

Michael can walk and sleep well again. He can also push his wife in her wheelchair as she undergoes chemotherapy. He no longer has any trouble welcoming his dog onto his lap.

“There’s no sense in living with the pain. I wish I’d heard about it sooner,” says Michael, who would recommend the treatment to anyone.

Follow the link below to learn more.

*HFX is a comprehensive solution that includes a Nevro Spinal Cord Stimulation (SCS) system and support services for the treatment of chronic pain, including painful diabetic neuropathy, programmed with a frequency of 10 kHz

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Dr Ganesan Baranidharan

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

People with diabetes can often live in excruciating pain, yet spinal cord stimulation technology exists to offer them safe and effective relief.

People with diabetes are living with significant long-term pain that could be effectively and safely managed through spinal cord stimulation. Such people describe pain in their feet and legs as walking on broken glass. All too often, they are left to cope with ineffective painkillers. Yet, a new study, the largest of its kind, shows that high-frequency (10kHz) spinal cord stimulation can reduce this pain significantly maintained at 18 months, it also found that 63% of patients experienced improvements in motor, sensory, or reflex function in the same time period.

Technology for diabetes complications

Nerve damage or neuropathy is one of the long-term complications of diabetes. Over time, high blood glucose (sugar) levels can damage the small blood vessels that supply the body’s nerves, which can then become damaged and may even disappear. In the feet, this can manifest as loss of feeling, which can lead to injury or falls, or in other people, shooting or burning pain.

In spinal cord stimulation a small device is implanted near the spine, using leads to send electrical impulses to the brain, disrupting the pain ‘signals’ caused by nerve damage.

In some areas of the UK waiting lists for this specialist pain therapy are as low as 18 weeks to receive actual treatment, and candidates for SCS can often go home the same day.

Safe and effective pain relief

Experts with experience in this technology say that those with stable diabetes living with long-term and significant diabetes pain are usually suitable to use this device to gain safe and effective pain relief without any of the risks associated with pain medication. These experts also believe that this therapy, which is approved for use in the NHS by medicines watchdog NICE, remains off the “radar” of knowledge of most diabetic care teams, or is wrongly considered unsafe or ineffective.

However, studies show that 86% of people will see their pain reduced by 50% or more and the average pain relief at 18 months is 76%. Latest research shows that over seven in 10 individuals see significant pain relief continuing at 18 months, and at no extra risk of infection.

In some areas of the UK waiting lists for this specialist pain therapy are as low as 18 weeks to receive actual treatment, and candidates for SCS can often go home the same day. So why aren’t people accessing this therapy?

Finding effective treatment options

Dr Sarah Love Jones, lead clinician for Spinal Cord Stimulator Service in the Pain Clinic, North Bristol NHS Trust (NBT), believes that for too long diabetics have simply accepted painful neuropathy as part of their condition and do not push their healthcare professional to consider a referral. But it doesn’t need to be so, she says: “We know patients don’t want to live with this pain.”

Dr Ganesan Baranidharan, Lead Clinician for the Pain team at Leeds Teaching Hospitals and an Honorary Associate Professor at the University of Leeds, feels that existing diabetic check appointments are a golden opportunity to raise the possibility of SCS to suitable patients. Another solution could be to add it to the health checks that GPs are paid to deliver. He says: “There will be a lot of people out there that we can help.”

Read about the patient experience – follow the link below.

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A new tool is being developed to assist healthcare professionals in exploring back pain and spotting vertebral fractures in people with osteoporosis, which may have otherwise been missed.

It is estimated that 10 million people have back pain, which costs the UK economy billions of pounds each year (Versus Arthritis The State of MSK Health 2021). We are currently starved of the diagnostic tests needed for early detection, prevention and treatment of musculoskeletal (MSK) conditions like arthritis and osteoporosis.

Versus Arthritis funds research that will bring us closer to making MSK conditions preventable, treatable and ultimately curable. Recently, we prioritised investment in pain research, making a significant investment in the £24 million funding collaboration supporting the Advanced Pain Discovery Platform to drive step changes in the understanding and treatment of chronic pain across a wide range of conditions.

Osteoporosis is a common condition in which the structure of bones becomes more spongy and less strong. Anyone can get osteoporosis, but risk increases with age and women are about four times more likely than men to develop it.

Bone is a living tissue that is constantly renewing itself. Old bone tissue is broken down by cells called osteoclasts and is replaced by new bone material produced by cells called osteoblasts.

Osteoporotic vertebral fractures (broken bones in the back due to osteoporosis) are particularly important because they increase the chances of more fractures.

Anyone can get osteoporosis, but risk increases with age and women are about four times more likely than men to develop it.

Improving diagnosis

To help diagnosis of osteoporosis, researchers funded by Versus Arthritis, led by Emma Clark at the University of Bristol, have developed the Vfrac tool.

This tool consists of a checklist in a smartphone app which includes asking questions about the type of back pain the person is experiencing. It is designed to help doctors decide who needs to be referred for an X-ray. The app has been shown to improve the diagnosis of vertebral fractures, by helping medical professionals to make referral decisions based on how people are experiencing back pain.

Research findings

In newly published work, researchers tested the 15-question checklist in a group of women with back pain, some who have vertebral fracture and some who don’t.

They found that nearly all people with more than one vertebral fracture are diagnosed correctly using the Vfrac tool, and two-thirds of those with one fracture. This is a significant improvement compared to usual care.

Being able to now test this tool in a clinical setting brings us a huge step closer to supporting quicker diagnoses, and ultimately better targeted treatments for people with osteoporosis.

This article was originally published on the Versus Arthritis website

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Online pain management consultations are enabling specialists to liaise directly with patients from across the UK without them needing to make the journey into clinics.

A digital approach is offering a new dimension to chronic pain management for patients, with online consultations delivering timely guidance and advice on how people can continue with everyday activities despite their conditions.

Pain Management Consultant Dr Charlotte Small explains that most consultations do not require physical examinations, so she is able to see people from anywhere in the UK online, without them having to travel to a clinic.

“Patients can also find consultants with nationally-recognised expertise, or a special interest, in their condition,” she says.

Treatment plan

Alongside her NHS post in Herefordshire, Dr Small works for Leva Clinic, an online chronic pain management clinic.

She says: “We provide a multi-disciplinary assessment and treatment plan; working alongside specialist nurses, physiotherapists for musculoskeletal pain and psychologists.” The online service sees patients living with chronic pain, referred or self-referred, to the clinic for help to improve their quality of life.

“To do that, we have to understand how the pain impacts them, their work and their relationships, and what sort of person they want to be.”

Patients can also find consultants with nationally-recognised expertise, or a special interest, in their condition.

Education and support

With patients having undergone investigations, assessments and examinations by their GP or a specialist, they are assessed by a nursing team and triaged at the Leva Clinic.

“When they come to us, we put together a comprehensive multifactorial plan for them. That looks at medicine optimisation, which might be starting new medications for pain management, or more commonly stopping or reducing medicines such as opiates,” says Dr Small.

Education on pain can help support patients to manage their life with a long-term painful condition, guiding them through its impact on their sleep and mood, as well as looking at non-drug therapies such as acupuncture and heat and cold packs.

Survival mechanism

Consultants get to know how patients want to lead their life and their specific circumstances. “We look at realistic goal setting and reassuring, within reason, that what they want to do is safe and how to do it.”

Dr Small explains that pain is a survival mechanism to heal and avoid harm. However, chronic pain is an ‘aberration in that system’ and tells people what they are doing is harmful, when it is not.

Her approach is patient-centred, individual and tailored. Online consultations are similar to NHS face-to-face appointments, with the proviso that if a hands-on examination is required, the individual can be referred back to their GP or specialist.

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Dr Lorraine de Gray

Vice Dean of the Faculty of Pain Medicine of the Royal College of Anaesthetists

There is a significant and much needed requirement for training pain specialists doctors and upskilling non-specialist doctors to ensure pain services are available in the community.

Pain management is the responsibility of healthcare providers. The UK has a significant shortage of doctors trained as pain medicine specialists, with less than one specialist per 100,000 people.

The Faculty of Pain Medicine (FPM) of the Royal College of Anaesthetists is responsible for the training, assessment, practice and continuing professional development of specialist pain doctors in the UK.

Currently, most UK pain medicine specialists are anaesthetists. Recruitment from anaesthesia alone is not expected to meet the predicted workforce shortage in the next 20 years; anaesthetists also work in anaesthesia, perioperative and intensive care medicine.

Communication and empathetic consultation skills are the cornerstone of effective pain assessment, ensuring the biological, psychological and social aspects of pain are identified and managed. Pain doctors work in multidisciplinary teams including nurses, physiotherapists, occupational therapists, clinical health psychologists and pharmacists to help patients manage and live with their long-term pain condition.

The UK has a significant shortage of doctors trained as pain medicine specialists, with less than one specialist per 100,000 people.

Creating credentials for pain management

Together with the General Medical Council, we are at an advanced stage of developing credentialing for pain medicine specialists – the paramount reason is patient safety, clearly identifying doctors trained in the holistic practice of pain medicine. It is planned to facilitate doctors from other specialties training as pain medicine specialists.

We are also in discussions with Health Education England and NHS Education Scotland to develop a Credential for Advanced Health Care Practitioners in Pain Management. This will expand the workforce to deliver multidisciplinary community-based pain services, addressing patients’ needs at an earlier point in time, improving triage, access, appropriate communication, referral and integration with specialist pain services, with better and more cost-effective outcomes for the NHS and society at large.

The FPM is developing a patient focused Four Nation Pain Strategy to provide an overarching framework to deliver improved pain management across the whole healthcare sector including support to live well with pain. The aim is an integrated national, regional and local delivery system ensuring equality of gold-standard care for all, wherever they live. 

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Plasma therapy has the potential to reduce painful osteoarthritis and delay knee replacement surgery.

Painful knee problems are often the reason why older adults give up exercise or their favourite daily activities – and in the process often bring on more serious physical and mental health conditions. Yet, technology is now available to keep people moving and in less pain for longer.

Osteoarthritis (OA) is a painful joint condition commonly affecting the over-50s that causes swelling, tenderness, grating or crackling sounds when moving, most commonly in the fingers, thumbs, hips, knees, neck and lower back. At its most serious, OA will be treated by joint replacement surgery, from which full recovery can take several years.

New emerging treatment options

However, a new treatment is gradually gaining momentum in the UK that offers people with OA the hope of more pain-free years. In platelet-rich plasma (PRP) therapy, the patient’s own blood is manipulated to create a platelet-rich plasma “soup”, which is then injected into the injury site. Within the body, growth factors that naturally occur in these platelets work with stem cells to repair damaged tissue.

According to specialist knee surgeon Oliver Templeton-Ward, most people see significant improvements in pain and mobility after treatment. “With so few downsides, the vast majority of people are really pleased to have it done,” he says.

At its most serious, OA will be treated by joint replacement surgery, from which full recovery can take several years.

With a strong heritage of successful use in the USA, PRP is slowly finding its place within forward-thinking UK healthcare commissioners. In an ideal scenario, PRP is delivered in tandem with physiotherapy, providing a “first-stop” treatment option for people with arthritis that supports them towards improved joint health. Templeton-Ward says: “I would like to see primary care groups think of arthritis treatment as a journey along a pathway – rather than all or nothing.”

However, wider use of PRP remains handicapped by outdated experience of early-stage technology or lack of knowledge of its benefits. “There is a lot of good evidence out there for the use of PRP in mild to moderate arthritis. It is time to allay fears that this is hocus pocus,” he says.

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Dr Jane Quinlan FRCA FFPMRCA

Consultant in Anaesthesia and Pain Management, Oxford University Hospitals Trust
Honorary Senior Clinical Lecturer, University of Oxford

Better patient education will help people use, store and reduce their opioids more safely.

Opioids such as morphine and oxycodone are strong and effective pain medicines for pain after surgery. They are best used in combination with other ways of managing pain. Opioids are not without risk, with excessive opioid prescribing on discharge from hospital contributing to the community opioid burden.

Improving patient education

The British and Irish Pain Societies have collaborated with patient and professional organisations to develop a patient information booklet which supports patients to safely manage their pain once they have left hospital.

The information covers the whole surgical pathway, describing what patients can do to before their surgery to increase fitness and to set expectations about pain and recovery afterwards. It explains how medicines – both opioid and non-opioid drugs – work to relieve pain and gives suggestions for non-drug techniques for managing pain such as using distraction and exercise. It also provides a personal pain management plan that is jointly agreed by the patient and their healthcare team to achieve their recovery goals. 

Immediate opioid risks include “opioid-induced ventilatory impairment” which results from slow breathing, drowsiness and a loss of muscle tone in the airway. If left untreated this can result in death. Later opioid risks involve the continued use of opioids after the anticipated recovery period – “persistent postoperative opioid use” – which can result in dependence and addiction. The booklet guides patients to reduce and stop their opioids as the acute postoperative pain settles.

Further, where patients are prescribed more opioids than they need, there is the broader societal risk of diversion of unused opioids; or the devastating impact of accidental ingestion and overdose by children or pets if not stored out of sight and reach.

Opioids are not without risk, with excessive opioid prescribing on discharge from hospital contributing to the community opioid burden.

Raising awareness of harm

By informing patients and their carers about the risks and benefits of opioid medicine for acute postoperative pain it is hoped to reduce adverse events.

The five key safety messages are:

1. Lock opioids safely away. Keep them out of reach of children.
2. Reduce and stop opioids as your pain decreases.
3. Take unused medicines to a pharmacy for disposal.
4. Tell your carers to call 999 if they can’t wake you up or if your breathing is very slow. Ensure they tell doctors or paramedics you take opioids for pain.
5. Do not drive while taking postoperative opioids.

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Despite the availability of effective treatment options, neuropathic pain often remains untreated. Patient and healthcare provider awareness is essential to access these therapies.

Chronic pain is a major cause of disability worldwide. Neuropathic pain is a type of pain caused by an injury or disease of the nervous system. One in 10 people have neuropathic pain and almost half fail to get adequate pain relief with medications.

There is growing awareness and concern about the addictive potential of opioids and gabapentinoids. In 2008, the National Institute of Health and Care Excellence (NICE) recommended spinal cord stimulation (SCS) for routine use as an effective and cost-effective treatment for severe refractory neuropathic pain. Despite the guidelines, less than 1% of people with neuropathic pain receive an SCS therapy in the UK.

Benefits of spinal cord stimulation

Clinical trials and patient registries, such as the UK National Neuromodulation Registry, have shown significant improvement in pain, quality of life and reduction in medication following SCS implants. In UK practice, 75% of patients get at least 50% improvement in pain. As a consequence, they are able to reduce their opioids and gabapentinoid medications.

One in 10 people have neuropathic pain and almost half fail to get adequate pain relief with medications.

Improvement in quality of life

There are many causes of neuropathic pain. Persistent spinal pain syndrome (PSPS), where patients experience severe back and/or leg pain despite technically successful spinal surgery, affects more than 5,000 patients in the United Kingdom each year. There are 21,000 people who suffer from painful diabetic neuropathy in the UK and numbers are increasing.

Complex regional pain syndrome (CRPS) is a debilitating, painful condition in a limb that can result in severe disability and suffering. CRPS commonly arises after injury to that limb. However, there is no relationship to the severity of trauma, and in some cases there is no precipitating trauma at all (9%). Clinical trials have shown that early spinal cord stimulation treatment can improve pain, rehabilitation and function in these patients.

Cancer will affect one in two of us, and both the cancer itself and its treatment commonly cause pain. Despite the excellent palliative care in the UK, one in four patients have unrelieved or partially relieved pain. Uncontrolled pain and side effects of oral or injected pain killers can significantly reduce quality of life for these patients. The NHS funds highly specialised treatments such as continuous infusion of medications in the spine via an implanted pump to alleviate this pain.

The uses of neuromodulation are wide ranging and expanding. It is set to become a far more common treatment in the future. Patients and healthcare professionals need to access these treatment options in a timely manner.

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