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Interview with Dr Petrides by the British Osteopathic Association

In the Spotlight with Dr Simon Petrides MB BS DO DM-S Med Dip Sports Med FFSEM (UK&I)

Dr Simon Petrides has the unusual title of musculoskeletal, Osteopathic and sports physician which reflects the unique and ground-breaking nature of the medical career he has carved out for himself.

After studying medicine at Guys hospital in London in the early eighties, he worked for one year as a pre-registration house officer before taking the unusual decision to step off the medical career ladder in order to study Osteopathy on the shortened doctor's course at The BSO in London.

On completion of the course in 1988 he bought a small Osteopathic clinic in Milton Keynes which he has developed into a rare and innovative model of an integrated, multi-disciplinary musculoskeletal centre and sports clinic.  

The clinic now has 20 treatment rooms, a membership gymnasium, Pilate's studio, two injection fluoroscopy theatres and has expanded to include 4 other clinics located in Bicester, Croydon, Guildford and Brighton.

Practitioners range from specialist medical doctors to osteopaths, physios and an ayurvedic practitioner and the clinic runs programs such as an 'adolescent obesity' program and an 'exercise on prescription' program from NHS GPs. 

Simon's own speciality is based on his interest in the spine with assessment by video fluoroscopy and treatment of lumbar and sacroiliac instability by prolotherapy injections and he is regularly referred premiership footballers and international and Olympic rowers from GB Rowing.

He has a diploma in Sports Medicine and a diploma in Musculoskeletal Medicine and a few years ago was elected as a Fellow of the Faculty of Sport and Exercise Medicine. This year he was appointed medical officer at the London Olympic Games.

portrait-simon-petridesHe is Vice-patron of The British School of Osteopathy and Vice-president of The British Institute of Musculoskeletal Medicine (BIMM) - an organisation of doctors with an interest in examination treatment of the musculoskeletal system using non-surgical methods, primarily manual therapy and injection treatments. He is currently working with the BIMM and the GMC to design a robust 'Credentialing' system for doctors wishing to work in the field of musculoskeletal medicine.

Simon lives between Bedford and Northampton in a small village with his wife, Kate, and three children.

Q) Simon, you completed your undergraduate medical training at Guys hospital in London in the early eighties, did your first year as a pre –reg house officer and then did something rather extraordinary – you stepped off the medical path and decided to train as an osteopath? Why did you do that?

Interestingly, while realising I did not want to further my medical education in hospital medicine or general practice I met an osteopath by the name of Theresa Devereux who suggested that I may be in some demand as an osteopath with medical training.  Being young, free and single at the time meant that I could further embark upon more education as well as the usual advantages of maintaining the student lifestyle!  Theresa, who coincidentally approached me about this article, actually influenced my decision to immediately apply to the British School of Osteopathy for the shortened doctor's course.

Q) .....any regrets about choosing that path?

I have no regrets for choosing that path at all and I hope I have inspired other doctors to do the same in order to optimise the assessment and treatment using techniques learnt from the various Osteopathy schools and colleges in the country.  It has enabled me to forge a path parallel to most of my colleagues in NHS careers. I could detect the huge need for non-surgical treatment of the musculoskeletal system and the lack of enlightened doctors at that time.

Q) How have you found the world of Osteopathy compared to the medical world?

The osteopathic training enabled me to look at the function of the musculoskeletal system and it equipped me with the necessary tools to detect abnormalities in that function.  This skill is something which is difficult to learn and takes a lifetime to master.  Some doctors attend the London College of Osteopathic Medicine over one year and have also attained those skills - I work with some of these doctors at the British Institute of Musculoskeletal Medicine. 

Osteopathy enabled me to set up practice with patients understanding what I did but there was the inevitable antipathy from some orthodox practitioners but I strived relentlessly to bridge that gap and manage to establish a good relationship with the GPs and most hospital doctors in the area. 

The osteopathic world, I find, is a more relaxed way of establishing a career with the independence you get in private practice.  Having said that, if you wish to push the boundaries further, as I have done in integrating the two forms of medicine, there are many challenges to overcome.  Whilst sport and exercise medicine is a recognised specialty in this country, musculoskeletal medicine itself is not, the environment in which GPs work is changing all the time and musculoskeletal services are springing up around the country relying on GPs with special interests to run the triage(*) clinics. 

I feel that these doctors need further education to enable them to manage more of the musculoskeletal problems in the NHS rather than acting solely as triage services.  Some of these services have incorporated osteopaths and I have been encouraging the involvement of osteopathy locally but with little success unfortunately.

Q) Tell us more about 'The Blackberry Clinic'?

My vision was that of a multi-disciplinary, fully integrated, multimodal patient-centred model of an out-patient musculoskeletal and sports clinic.  The objective is to manage most patients who come into the clinic without referral elsewhere and to fulfil their expectations in improving their pain. 

The best way to achieve this is a holistic approach utilising a detailed history and examination followed by referral to the most appropriate practitioner for that patient.  The decision-making is not easy to describe and is not always based on the type of pain but often the personality of the patient. 

We have about 20 practitioners, ranging from ayurvedic medical practitioners to a consultant anaesthetist working in pain medicine.  I encourage complete integration of the therapists, such that many of them have established friendships and understand each other's work.  Patients are often allocated to one or two different practitioners or perhaps they are allocated to one type of therapy along with a personal training programme in the gym with our gym manager who specialises in rehabilitation programmes for patients with back pain.  These exercises incorporate the Pilates approach but many others besides.

I believe the main philosophy of clinic marketing is based around an 'internal marketing' approach such that all patients leave the clinic with inspiration and positive expectations.  Patients discuss their conditions regularly and discuss where they receive treatment, this I believe, is the most powerful way of achieving success.  A patient with a negative experience will discuss that issue with so many more friends than those who have a positive experience.  So, identifying unhappy patients is paramount.

Q) What is your role at the clinic?

My role at the clinic is that of clinic director and musculoskeletal and sports physician.  I am regularly holding meetings with the management team which involves a practice manager and finance director.  I also have a colleague, Dr Tom Saw, a musculoskeletal and sports physician who is making the transition from general practice to musculoskeletal and sports medicine.  He carries out similar techniques to me and is also seeing some of the elite athletes at the clinic. 

Q) Musculoskeletal services are springing up throughout the NHS - what in your view should an optimal outpatient musculoskeletal clinic look like?

I believe that the NHS are restricting themselves too much to using solely physiotherapists and GPs for managing a musculoskeletal service since all musculoskeletal conditions respond to a combination of treatments which include osteopathic, podiatry and chiropractic approaches along with an exercise-based rehabilitation.  Physiotherapists are becoming further trained in manipulation and injection therapy but it will be a long time before all physiotherapists are trained in this way.  So the optimal out-patient musculoskeletal clinic will involve a musculoskeletal physician or specialised GP along with an osteopath, physiotherapist and chiropractor working closely with podiatrists and an exercise rehabilitation specialist.  We all know that patients don't do their exercises so a class-based system encourages attendance and motivation resulting in better outcomes.

Q) What is your own personal treatment approach?

My own assorted training background enables me to assess and treat my patients in the optimal way.  My osteopathic training has been very influential, especially in manual assessment of dysfunction and introduction to manipulation.  I do not manipulate as often as previously since we have several osteopaths in the clinic.  Nevertheless I occasionally use my manual skills to introduce the patient to manipulative therapy and this also can establish whether it is the appropriate treatment for them.  Some of these patients will also be having injection treatment or oral medication to create a pain free window in which to establish a treatment regime.  The osteopathic philosophy of allowing the body optimal conditions in which to heal itself has been the basis of my approach with only judicious use of medication.  

Q) Can you explain more about your speciality using injection techniques with fluoroscopic guidance and the use of prolotherapy?

Injections using fluoroscopic (X-ray) guidance are the mainstay of my specialty in the Blackberry Clinic.

Prolotherapy is an injection of hypertonic dextrose sometimes with phenol and glycerol.  These mildly irritant injections are directed to the ligamento-periosteal junction in the intervertebral, iliolumbar and sacroiliac ligaments.  The irritation produced stimulates fibroblast mediated augmentation of normal connective tissue and collagen fibres thus stabilising the segments.  Instability is often concurrent with disc degeneration and sacroiliac joint dysfunction where pain becomes recurrent or stimulated by prolonged postures.  In these cases manual therapy has a temporary effect and prolotherapy can intervene stabilising the segment and reducing pain.  The injections are done under image guidance with a low dose X-ray unit called a fluoroscope or C-arm.  These use around 100th of the radiation used in a normal lumbar film.  Prior to prolotherapy treatment I often use video fluoroscopic kinematic assessment of flexion and extension movements to establish whether there is intervertebral segment instability. 

Patients with disc protrusions and nerve root entrapment can benefit from corticosteroid injection via caudal epidural, transforaminal or interlaminar epidural injection.  The reduction in inflammation around the nerve root can lead to a more successful rehabilitation programme using physiotherapy or osteopathy.

Other injections that can be used involve those of trigger points for myofascial neurosensitisation. 

We also include one of the latest forms of injection treatment for early to moderate osteoarthritis using hyaluronic acid which is a high molecular weight polymer and acts as lubrication for the joint stimulating synovial fibroblast cells to produce a more normal quantity and quality of endogenous synovial fluid.  These intra-articular injections have been shown to be effective especially in early to moderate OA of the knee but they have been promising in the hip and other joints. 

More recent types of 'prolotherapy' include using autologous blood injections for lateral epicondylosis and plantar fasciitis.  We have a tremendous success for this type of treatment in the clinic with almost no recurrence compared to a moderate recurrence rate using corticosteroid injections.

We are also developing the use of platelet-rich plasma which is obtained by venepuncture followed by centrifuge spinning to separate the platelet-rich section of the plasma.  These platelets produce growth factors that are heavily involved in reparative processes in tendon degeneration.

More recently 'autologous conditioned plasma' (ACP) has been used in intra-articular injections for early to moderate OA and the trials are awaited regarding the success of this procedure.

Q) How commonly are these treatments used and what is the evidence for how they work?

Regarding prolotherapy there are four clinical trials of high enough methodology to quote from the literature, two of which have demonstrated that prolotherapy is effective in back pain.  One trial demonstrated that it was successful but to the same extent as using normal saline and a fourth trial demonstrated a lack of effect. 

Unfortunately all trials on back pain have very low methodology scores and I personally feel that pursuing research in low back pain is a gargantuan task and evidence of efficacy of osteopathic treatment perhaps should be pursued in a less specific manner.  Due to the multi-factorial nature of back pain, as we know every patient is different and thus finding enough patients with exactly the same problem to enter into a clinical trial is next to impossible. 

Q) This seems to go right to the heart of the discussion about evidence for Osteopathic treatment yet there is clearly a need for scientific evidence to back up what we do. How do you think this can be overcome?

We should perhaps be looking at the effectiveness of osteopathic treatment within the National Health Service which can provide a large number of patients.  The objective would be to demonstrate the effectiveness of treatment along with the reduction in use of further medical resources such as analgesia and secondary referral.

Immense amount of resources need to be sourced in order to provide a clinical trial with sufficiently high methodological scoring for the medical establishment to take heed and using NHS musculoskeletal services with an osteopathic approach may allow a more objective assessment of outcomes demonstrating the cost-effectiveness of using osteopaths within the NHS.  Consequently there will be an increase in use privately. 

There are many musculoskeletal services in the process of 'going out to tender' but unfortunately the only organisations with enough resources to tender are large institutions who seem intent on only producing physiotherapy services with some input from a GP with special interest to provide triage.

Osteopathic treatment is much more complicated than a simple manipulative procedure so I believe that research should be carried out on a fully integrated patient-centred approach where each patient is taken individually and the optimal rehabilitation programme designed for them along with the appropriate therapies integrated into the programme.  Outcome measure can then be assessed on the whole process rather than breaking down the treatments into individual techniques.

Q) How did you get the post of medical officer at The London Olympic games and what was the experience like?

I spent two weeks at the London Olympic Games working in the polyclinic in the Athletes Village as a Sports and Exercise Medicine doctor with my specialty in musculoskeletal medicine and back pain.  I applied through the usual 'Games maker' system and was interviewed for the role.  I worked with many physicians who I had met over the years and some who I hadn't.  It was a delightful experience and I am very pleased to have been involved in one of the greatest sporting events in history.  We had no payment for those two weeks and we were allowed one meal during our shift with no payment for travel or accommodation but the whole experience was worth every 4 o'clock alarm call! 

One particular experience springs to mind.  I was presented with a weight-lifter from a small country who had a disc protrusion and was unable to lift the bar more than a few inches from the ground without searing leg pain.  His only competition was on the following day and we gave him the option of an epidural injection with no promise of success in such a short time. With full education about the possible side-effects he decided to go ahead and came 13th in the competition having lifted his expected weight.  This challenge was discussed among the doctors at the clinic.  We were out of our comfort zone regarding an epidural injection so soon before a competition but with the proper consent and information given to the athlete we were able to change his Olympic experience for the better.

Q) How central were Osteopaths to the Olympic medical team and how integrated were they with the doctors and other therapists?

I was working on the first floor of the polyclinic and along the corridor there was the physiotherapy department which incorporated one or two osteopaths and chiropractors at any one time.  On a couple of occasions I took an athlete down to the therapy area and located one of the osteopaths who I knew personally and handed the athlete over for appropriate treatment.  It was an exceptional facility to be able to treat the athletes immediately.  I held a short tutorial on back pain in the sports medicine centre and it was evident that some doctors were more aware of the benefits of osteopathy than others.  Let us hope that in future Olympics there will be a greater osteopathic contingent available for treatment of the athletes.  We had two MRI scanners and one CT scanner outside the door of the polyclinic and at one point one of the doctors pointed out to me that we had more scanners than we had thermometers!  One athlete that I saw had two MRI scans, a radiologist's report and discussion along with a return to my consulting room within 1 hour!  This is cutting edge management of elite athletes and it is rather unfortunately optimistic to expect this to be available in all areas of musculoskeletal medicine.

Q) What are your views on the future of Osteopathy and how it should move forward as a profession?

I personally feel that osteopaths should lobby NHS managers to be incorporated into musculoskeletal services.  Only in this way can the GPs become more aware of the benefits of osteopathic treatment and thus the patients also.  This knowledge will also stimulate the attendance of patients at private osteopathic clinics.  This lobbying will need to be done at a high governmental level since when decisions are made at these levels the information can cascade down to produce a frontline service which includes osteopathy. 

Q) On a final note, what would you say about building an osteopathic clinic?

 'It's not whether you have enough patients but find the right osteopath and then the patients will come'.

The Blackberry Clinic has been in existence for over 24 years and during that time we have had between 3 and 6 osteopaths at any one time.  Practitioners come and go, recessions come and go but the longer you are established in a single place then the more stable your level of growth as a practice ...  So the question an osteopath needs to ask themselves when deciding to set up practice is:

'Will I have enough patients and will I have enough patience!'

Simon will be giving a lecture on the topic of Fluoroscopy and prolotherapy at the British Osteopathic Association Convention at the Marriott Forest of Arden Hotel near Birmingham on 17 November 2012.

(*) triage –the first point of contact a patients has and who decides where they will be directed for treatment.

WITH THANKS TO DR SIMON PETRIDES

Interview by Theresa Devereux DO (non-practising Osteopath)