Shared learning database

University of Warwick/ University Hospitals of Coventry and Warwickshire
Published date:
November 2010

As the first physiotherapist on the new NICE Scholars programme I have outlined my Scholarship aims and objectives and how these have developed throughout the twelve month programme to improve the quality of patient care within trauma and orthopaedics.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

In 2008 'High Quality Care for All' by Lord Darzi outlined a proposal for NICE to implement a Fellows and Scholars programme. The aim of this programme was to develop a network of individuals, who would engage with NICE, and in turn promote the core values of NICE locally and nationally. The first intake for this programme took place in April 2010. As the first NICE Scholar from a physiotherapy professional background I set out to improve NHS care, within my clinical area, in two ways. The first was to increase awareness, understanding and implementation of NICE guidance and recommendations locally, achieved through collaboration with the communications team, departmental presentations, professional bodies, and integration with my teaching role on an MSc in Trauma and Orthopaedics, which is delivered by the University of Warwick. The Second was to integrate my clinical and research practice to deliver a project recommended by a NICE committee, to develop future guidance for the care of patients with musculoskeletal diseases. More specifically, these aims were supported through implementation of a specific interventional procedure research recommendation for autologous blood injection for tendinopathy. This provided a working example, from which to discuss what methodologies NICE use to develop the guidance, highlighting its transparency and inclusivity. Furthermore it provided an opportunity to link updates with the research project progress at departmental meetings with the opportunity for open discussion and questions about NICE, providing an ongoing forum for raising awareness and understanding. The objective was to set-up and implement a research project of direct relevance to NICE through collaboration with NICE, Warwick Medical School, University Hospitals of Coventry and Warwickshire NHS Trust and my professional body, the Chartered Society of Physiotherapy.

Reasons for implementing your project

Working alongside Mr. Matthew Costa, an orthopaedic consultant, we deliver a service for patients with Achilles tendon pathologies. Patients predominantly present with pain in the Achilles area which has led to subsequent disability and functional limitations. These painful tendon pathologies are called 'tendinopathies' and are the result of degeneration of the tendon, secondary to an imbalance between the protective/regenerative changes. Currently, there is no single best treatment option for Achilles tendinopathy, as highlighted by a Cochrane review, but a simple exercise that eccentrically loads the calf muscles is the 'standard' treatment option offered to patients in the first instance. However, patients often do not complete this programme due to the pain associated with the exercises and time commitment required. An alternative treatment available to manage this pathology is autologous blood injections. In January 2009 NICE published guidance on the use of autologous blood injection for tendinopathy. They highlighted three published articles that all reported positive findings; however they were all case series designs and none were assessed in relation to Achilles tendinopathy. It was concluded that further research was required in the context of randomised controlled trials. The combination of this clinical context combined with my individual, and the departments commitment to promote and implement evidence based practice and develop research proposals in response to local and national requirements, led to the aims of the NICE Scholarship application and the specific project that is of direct relevance to NICE, which proposed the following: Is there a difference in patient reported functional outcome scores (VISA-A scores) and compliations at six months between patients managed with autologous blood injection compared to patients managed with an eccentric loading programme?

How did you implement the project

Funding was provided by the Chartered society of Physiotherapy. Once relevant approvals were in place, all patients presenting to the Achilles tendon clinic with a mid-substance tendinopathy were provided with an information sheet, which explained that all patients taking part in the research would be randomly allocated to one of two groups. Group one would receive an autologous blood injection and group two would receive a twelve week eccentric training programme. After collecting baseline information, both groups would then be followed up at six weeks, three months and six months. At these points any complications would be recorded and they would be asked to complete a patient reported functional outcome measure (VISA-A), which was the primary outcome measure. A total of twenty patients would be enrolled into this pilot randomised controlled trial.

Key findings

The project achieved monthly recruitment targets. There were 22 patients approached to take part in the research, of which 20 consented. Follow-up of these patients is planned to be complete by April 2011. This project was developed in response to a local need and a national requirement outlined by NICE for further research. The final results of this project will inform the design of a larger study which will provide invaluable information on which to base decisions regarding the future provision by NHS trusts of autologous blood injections for Achilles tendinopathy.

Key learning points

For other organisations struggling to change their practice and get NICE recommendations into practice, a learning opportunity such as the NICE Fellows and Scholars programme is invaluable. This is because the programme allows individuals to locally foster an environment that encourages others to engage with NICE. It has been an important driver for change from within the department because that person's 'NICE project' has been developed by the department, so they have embraced the associated methodology to feel a sense of 'ownership' over the process. Furthermore the NICE advocate acts as a link for representatives of NICE to raise awareness and knowledge through invitation to departmental meetings, which would not have normally occurred. Through these activities individuals in my place of work have then been made aware of educational materials available to them, provided by NICE, which further overcomes barriers to change through increasing understanding. For other Allied Health Professionals considering this opportunity the main consideration is the time commitment involved and the twelve month time scale of the Scholarship, for project planning. Identification of a clinical project mentor in addition to the mentor provided by NICE was imperative to the completion and delivery of the initial Scholarship aims.

Contact details

Rebecca Kearney
University of Warwick/ University Hospitals of Coventry and Warwickshire

Secondary care
Is the example industry-sponsored in any way?