University Hospitals Bristol and Weston NHS Foundation Trust was a winner in this year’s British Society for Rheumatology Best Practice Awards, achieving recognition for an innovative project to help empower osteoporosis patients and drive down the number of hip and spine fractures.

DEBILITATING spinal and hip fractures are becoming a growing problem as the population ages. They’re devastating and painful for patients and are proving increasingly costly to the NHS and social care. The rheumatology unit at University Hospitals Bristol and Weston NHS Foundation Trust was seeing an increasing number of osteoporosis patients asking questions about thin bones, including how to avoid them, what food they should eat and what exercises they should do.

The team, led by consultant rheumatologist Dr Shane Clarke, developed a survey in 2015 for patients coming to the osteoporosis clinic and those having a bone density scan.

Dr Clarke explains: “We didn’t know what the best way to help our patients would be. Our survey helped us to understand that patients wanted to be able to improve their knowledge and learn practical tips to help manage their condition. Half of respondents were keen for regular hourlong sessions and the others wanted half-day sessions, so they didn’t have to come back and forth to the hospital.”

The team, including osteoporosis clinical nurse specialist Terrie Stocker and consultant Dr Matt Roy, developed a six-week course with each 60-minute session divided into two.

Dr Clarke says: “The first half would deal with one aspect of thin bones, such as nutrition, diagnosis of osteoporosis, how to interpret DXA results and fracture risk, what medications are available, their advantages and potential adverse events.  The second half was devoted to tailored group exercise.”

Physiotherapist Katrina Hutchins developed exercises to improve patients’ core strength and a 12-station activity circuit including tai-chi, Pilates, strengthening and balance exercises, relaxation, and a practical session on getting up off the floor after a fall. Dr Clarke said: “The whole idea was to see whether we could encourage people to carry on with the exercises at home once they’d completed the course.”

The half-day courses allowed them to include a session with a dietitian and support from an occupational therapist. The team partnered with the Royal Osteoporosis Society (ROS) who supported them with administration, signposting patients and providing trained volunteers who came into clinics to talk to patients.

Once four of the courses had been run over the first year, the team brought 37 “alumni” patients back together to reflect on what had gone well, what needed to change and to find out how many were still exercising.

Dr Clarke said: “They retained most of their osteoporosis knowledge, but their confidence in continuing to exercise had waned. After the review we altered the balance of the courses to focus on a medium-term aim to continue exercising at home. By the time of the second alumnus meeting, which was very well attended, the majority had continued to exercise regularly.”

More than 200 patients have now been through the courses and hip fracture rates locally have reduced. As well as the Best Practice Awards, the team has been particularly recognised for Outstanding Patient Involvement.

Dr Clarke says: “The main thing is that people who go through the course feel less frightened by fractures. What we’re trying to do is get people to go out and have a good quality of life, rather than sit at home worried about breaking bones. This award win is great for the team, but it’s a clear reflection on all the hard work put in by our Royal Osteoporosis Society volunteers too.”

The team recognises that men were underrepresented on the courses. It’s now working on a new venture to get more regular exercise into the community, particularly to include older men. The team is linking with Gloucester County Cricket and cricket writer Scyld Berry to introduce cricket games between residential homes in Bristol using specially manufactured softballs that can’t cause fractures, once the pandemic is over.

Dr Clarke said: “It’s about engaging people to continue exercising into their 70s, 80s and 90s – the health and social benefits are beyond doubt.”

Reproducible service model

Chair of the judging panel and British Society for Rheumatology president, Dr Elizabeth Price, believes the project stood out from the crowd. She said: “It’s such a simple idea and it really captured my imagination. It delivers education and practical help with appropriate exercise in a group setting for those with osteoporosis. The team has worked collaboratively with the Royal Osteoporosis Society and developed a very cost-effective, reproducible service model.”

Four volunteers from the charity Versus Arthritis, who all have lived experience of arthritis and accessing health services, helped judge the entries. They gave the team full marks for exceptional patient involvement, highlighting that patients were central to the design of the project and commended how patient feedback helped shape improvements.

Dr Clarke’s advice to other clinics is that you need to survey your patients: “It would be nice to say if you introduced this everywhere it would work, but each area is different. Do the survey and get buy-in from patients. After each course, we always collected information from patients aiming to make the content more relevant and helpful for subsequent groups. Getting it right for your local community is what it’s all about.”

The challenge

Osteoporosis affects more than 3 million people in the UK, and more than 500,000 people a year receive hospital treatment for fragility fractures resulting from osteoporosis1.  Patients who are at high risk of fracture require targeted education to explain their condition and what steps they can take to self-manage it through medication and exercise.

Education programme

Participants gain knowledge to help them understand their osteoporosis and the practical steps they can take to reduce their risk of a fragility fracture and minimise the effect a fracture might have on their daily life if they do break a bone.

Exercise programme

Promoting the ROS ‘Strong, Steady and Straight’ guidelines, for exercise in patients with osteoporosis, participants gain practical experience and confidence in doing exercises that improve bone strength as well as balance and stability that can reduce the risk of falls.

1) NHS. Overview: Osteoporosis. 2019 ( conditions/osteoporosis)

Article from TalkBack, winter | 2020 (BackCare)

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