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Case study: Greater than the sum of the parts: how NIHR Programme Grants for Applied Research is supporting knee pain research

Professor Rachael Gooberman-Hill’s programme of NIHR research is developing a new approach to help the thousands of people each year who experience long-term pain after knee replacement surgery, with multidisciplinary work driving her approach.

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Greater than the sum of the parts: how NIHR Programme Grants for Applied Research is supporting knee pain research

Author: Professor Rachael Gooberman-Hill

My research inspiration

In my own research I’ve been focused on long-term conditions for some years. Within this I became interested in painful conditions, because they are so common and are such an area of great need. Osteoarthritis is a leading cause of pain and disability, affecting millions of people globally - many people have osteoarthritis in their lower limbs, particularly their knees. Many people with severe knee pain because of osteoarthritis have a total knee replacement, which involves replacing the painful knee joint with an artificial joint. Over 75,000 total knee replacements take place every year in the NHS.

We noted some years ago that some people who had joint replacement surgery were not happy with their outcome. Sometimes this was because of ongoing pain.

Our systematic review found that perhaps as many as one in five people who had a knee replacement had long-term pain afterwards. This means that roughly 15,000 people in the UK every year will have long-term pain after knee replacement surgery.

We saw immediately that this was an issue that needed to be addressed, particularly as people have these operations to relieve their pain, and so to have pain afterwards is very hard indeed.

I work with an interdisciplinary team looking at research into long-term conditions and their treatment. This includes pain in the joints and arthritis.

Our research tries to understand how to improve care and treatment for the many thousands of people each year in the UK who have pain after knee replacement surgery.

We worked together as a team to bring our ideas together into a solid research plan, and were fortunate to receive an NIHR Programme Development Grant. The grant enabled us to start to develop a ‘complex intervention’ for people with pain after knee replacement and our work included qualitative research and a literature review.

We also used the time on the development grant to build a diverse team, including methodologists and clinicians, all of whom bring crucial and unique skills. As we work on pain and surgery it was particularly important that the team includes people with expertise in these areas.

The team also includes statisticians, qualitative researchers, trial experts, health economists, pain specialists, orthopaedic surgeons, psychologists, specialists in evidence synthesis, patient and public representatives, and allied health professionals. The team is really inspiring to work with, we all learn from one another and all of us want to make a difference to healthcare.

Receiving a £2 million NIHR funding award

We were then awarded nearly £2 million through NIHR Programme Grants for Applied Research (PGfAR) for a five-year programme of research into better post-operative prevention and management chronic pain after total knee replacement.

As part of STAR - Support and Treatment After Replacement, we have designed a new approach to care for and support people with long-term pain after knee replacement. This involves inviting people with pain to attend a specialist clinic. At the clinic a trained healthcare professional spends time assessing the person’s knee pain and then refers them onto existing services in the NHS. This might include a referral back to their surgeon, or to a pain specialist or to their GP. The approach is focused on helping people to access care for their pain as well as possible.

We are now finding out whether this works, and whether it is cost effective. To do this, the STAR research programme includes a multi-centre randomised trial that is evaluating the new approach that we have developed. We hope the research will inform guidance on care for people with pain after knee replacement.

We have several publications in this research area, and our patient and public engagement work has received awards and recognition over the years. Personally I received the British Pain Society Medal in 2016 - I was both surprised and honoured by this.

I’m keen to continue research into topics that matter to people and that are best addressed through multidisciplinary approaches. I think that technology has great potential but that we also need to think about processes in healthcare systems so that care is optimal and so that healthcare professionals and patients are all satisfied.

The role of NIHR Programme Grants for Applied Research

The NIHR funding we received from PGfAR was vital to enable us to cover the costs of running research, including personnel and the costs of doing the research ‘on the ground’.

I’m also a panel member for PGfAR. Sitting on the panel has provided a fascinating opportunity to learn about different topic areas, and it’s been good to see how many other teams around the UK also work well as interdisciplinary groups.

I think a particular strength of PGfAR is the way in which it enables research to be more than a pathway to a trial. In STAR, for instance, we analyse routinely collected data and cohort studies, as well as undertake evidence synthesis, qualitative research and a trial. All of these are crucial to the work that we’re doing, and the whole really is greater than the sum of the parts.

Rachael Gooberman-Hill is Professor of Health and Anthropology and Director of the Elizabeth Blackwell Institute for Health Research at the University of Bristol. She leads the STAR research programme to improve treatment for long-term pain after knee replacement, supported by an NIHR Programme Grants for Applied Research award. She also leads work in the NIHR Bristol Biomedical Research Centre, including its Qualitative Research Network.