ACL Tears Can Do Real Damage to the Brain, Study Finds

ACL tears

Trauma to the anterior cruciate ligament, or ACL, has been found to also do real damage to the brain in a new study. It is already known that ACL tears can lead to some degree of permanent loss of joint function. However, the reason behind this isn’t clear.

The new study, published in NeuroImage: Clinical, was carried out by researchers at the University of Michigan. Here, we’ll look at what the new study found and how ACL injuries link to brain damage.

Latest ACL injury study

The latest study involved 10 patients who had undergone ACL reconstructive surgery. MRI brain scans were taken to assess brain activity.

The scans clearly showed areas of the corticospinal tract had experienced deterioration. This is the part of the brain responsible for relaying messages to the muscles. On average, the side of the corticospinal tract which correlated to the knee which received ACL reconstruction, was around 15% smaller than the other side.

As the pathway is smaller, it means less information can be passed onto the muscles from the brain. What this means for patients, is that there is a chance of re-injury, as well as issues with performance and a potentially slower recovery. It also means, even with physiotherapy, joint function might not return to normal.

The link between ACL tears and brain damage

This new small study isn’t the only one to look at brain damage caused by ACL reconstruction. A previous study, published in the Journal of Orthopaedics & Sports Physical Therapy, showed a lag in parts of the brain during recovery from ACL surgery.

The study revealed that those recovering from ACL surgery, relied on visual systems within the brain, rather than instinct when moving the knee. Confidence in using the knee reduced significantly, making it especially tough for those partaking in sports. In a bid to reduce the issue, therapists in Ohio are using strobe glasses to visually distract patients, forcing their brains to rewire back to their original state.

Researchers from the most recent study, believe the changes in the brain are as a result of a defence mechanism. They think the brain tries to reduce movement around the joint injury to aid its recovery. However, this is just a theory. What is known for sure, is ACL surgery doesn’t just affect the way the brain communicates with the body, but it also changes the brains building blocks too.

Even with the research that has been carried out so far, it is still unsure why ACL reconstructive surgery damages the brain. However, the research does provide more guidance on how patients should be treated.

Rather than just focusing on improving the range of movement in the joint and reducing swelling, a systematic review of treatments needs to be considered. Approaches such as re-wiring the brain for example, could work well to help the body adapt.

Overall, ACL injuries can have a significant impact on a patient’s life, particularly for those who partake in sports. This new research shows the damage that can occur and how it should potentially be treated.

FA Take Action to Reduce Incidence of ACL Injuries in Women’s Football

The FA is launching new studies to try and understand why so many female football players experience ACL injuries in the sport. The move comes after 12 players from the Women’s Super League and Championship suffered ACL injuries from the game.

Here, we’ll look at what studies are being carried out to address the worrying trend and what ACL injuries actually are.

The studies being conducted

Current research suggests that women are eight times more likely to develop ACL injuries as opposed to men. The FA want to discover why, carrying out an audit into the illnesses and injuries experienced in the top two tiers of women’s football. As an additional measure, they are also bringing in experts to provide clubs and players with strategies to prevent ACL injuries.

The studies are set to look at the demands placed on female players in the Championship and WSL. It is also going to look at other injury and illnesses female players face in the sport. These include irregular or no periods, alongside energy deficiencies and eating disorders.

Some experts believe that the increase in ACL injuries in women is down to hormonal variations during their menstrual cycle. The fatigue many women experience, can increase the risk of injury.

What are ACL injuries?

ACL injuries relate to a sprain or tear of the Anterior Cruciate Ligament. This is one of the main ligaments located in the knee. These types of injuries are common in sports which require sudden changes in direction and stops.

When an ACL injury occurs, you can typically feel or hear a pop in the knee. This can cause swelling around the area, and it may be too painful to place weight onto the knee. The severity of the tear or sprain can vary, determining which type of treatment should be used.

Why women are prone to ACL injuries

The reasons why women are more prone to ACL injuries isn’t fully known. However, experts do have a few theories.

The anatomy of women is different to men, so this is thought to play a role. For example, the intercondylar notch located at the bottom of the femur, is smaller in women. This could potentially cause issues with how the ACL moves, particularly during twisting motions. Women are also known to have larger hips, potentially affecting the alignment of the knee.

Biomechanics is another potential reason for increased ACL injury risk. While women’s knees are more flexible than a man’s knees, it does leave them prone to hyperextension of the knee. This puts additional strain on the surrounding ligaments.

These are just a couple of differences which could make women more susceptible to ACL injuries. While they may not always be preventable, it is possible to build up the strength and flexibility in the knee. Women who are considering getting into sports should therefore consider programmes which focus on building up knee strength and stability.

If an ACL injury is suspected, early treatment is crucial. If you suspect an ACL injury, call 0203 195 2443 for an appointment with London knee specialist Mr Jonathan Webb at the Fortius Clinic.

Prehab Before Your Procedure: How to Prepare for Knee Surgery

Prehab before knee surgery

Elective surgery has been hugely impacted by the Coronavirus outbreak and many patients now find themselves facing a lengthy wait for their surgery.

If you are waiting for your surgical procedure to be re-scheduled, there are things you can do to ease any discomfort or mobility issues you might be experiencing. Here, you’ll discover the benefits of prehab before your procedure and how you can prepare for surgery.

What is prehab?

Prehab, or pre-surgery rehabilitation, focuses on getting the patient fit prior to surgery. It is a method that has been used by many leading surgeons long before the lockdown was introduced.

It largely focuses on physical therapy, using exercises to improve strength, flexibility, mobility and physical health.

What are the benefits of prehab before knee surgery?

There are many benefits of partaking in prehab before your procedure. It is mostly used to improve the success rate of the surgery and to improve recovery. However, it can also provide invaluable benefits prior to the surgery too.

Did you know the right prehab could help to ease any discomfort and mobility issues you may be struggling with? The right exercises can strengthen your joints and muscles, helping to make it easier to remain mobile. They can also help to ease pain, greatly improving your day to day life.

By focusing on prehab now, you could reduce the need for rehabilitation after the surgery and get back on your feet faster. Several studies have shown that flexibility, strength and aerobic exercises undertaken by patients waiting for a hip and knee replacement, can reduce their need for rehabilitation by 73%. You will also see the benefits of prehab within just 24 hours after surgery.

You should find, with the right program, you can successfully ease any pain you might currently be experiencing.

Focusing on light, gentle exercises before knee surgery

Prehab for joint replacement surgery typically involves light, gentle exercises. Your physiotherapist should be able to put together a plan to specifically fit your requirements. However, there are some general prehab exercises you can try if you are struggling to get an appointment.

Mini squats are great and easy to perform. Make sure your feet are hip-width distance apart. Lower the body down slowly to a mini squat position. Your knees and hips should be at a 45-degree angle. Remember to keep your back straight and your kneecaps should be directly over your second toes.

Heel raises are another easy and gentle exercise you can try. Hold onto a bench or chair in front of you, then slowly start to raise the heels until you are on your toes. Slowly lower them back down again and repeat nine more times. You should aim to do two sets of 10 heel raises, one on each leg.

To ease discomfort and build strength in the hips, carry out standing hip abductions. Again, hold onto a bench or chair in front of you, making sure you are standing straight. Lift one leg out to the side and bring it slowly back down again. Repeat this move ten times on each leg.

Overall, waiting for surgery can be frustrating and debilitating. However, prehab can really help to ease any discomfort you might be feeling. It will also help to improve your recovery after the surgery.

For more advice on how to prepare for your knee replacement surgery during this current time, call Mr Jonathan Webb on 08450 60 44 99 or 0203 195 2443 for his London clinic.

Running addiction can increase your injury risk

runner's knee injury

Running is a popular form of exercise that can deliver a high level of benefits to the mind and body. You may have heard the term ‘runners high’, a phrase used to describe the euphoric feeling many people experience after a run.

As many gyms have now closed due to the Coronavirus, many people are turning to alternative forms of exercise such as running. However, according to a new study, a running addiction could increase your chances of developing a serious knee injury.

Here, we’ll look at what the study revealed and the types of injuries you could be exposed to.

Understanding the new study

The new study carried out by the University of South Australia, surveyed 246 recreational runners. They were aged between 19 to 77. It focused on how the mental outlook of a runner affects their physical injury risk.

It was discovered that those who were considered obsessively passionate about running, suffered the most injuries. This group of people often don’t leave enough time for their body to recover after running. In contrast, those who had a more relaxed and enjoyable view of running suffered fewer injuries. They were able to mentally detach from the activity, allowing them to take time off to recover when needed.

There was also a link between age and gender too. Women were found to have an increased risk of injury, while older people had a more relaxed attitude to running and were therefore less likely to suffer an injury.

Runner’s knee injury

One of the most common running injuries sustained by patients is runner’s knee. If you are experiencing pain in your knee area after running, this is the injury you likely have. It is caused by repetitive strain on the joint and it tends to be more common in women than men.

The two most common conditions to be labelled runner’s knee are ITB friction syndrome where the pain is over the outer side of the knee due to the soft tissues becoming inflamed and patella tendonopathy, which occurs when the kneecap tendon attaching to the tip of the kneecap becomes damaged due to repetitive strain. As Jonathan Webb explains: “It’s a bit like the equivalent of tennis elbow but in the knee. Both of these conditions will relate to an imbalance or lack of conditioning of the leg muscles, especially those around the hip that control the pelvis and leg as your foot hits the ground repeatedly.”

The most common symptom is a dull, aching pain behind or around the kneecap. It may hurt when you walk, squat, run or use stairs. Most commonly it occurs due to overuse, such as running too frequently without allowing the body adequate resting periods. However, it can also occur due to weak thigh muscles, arthritis or if you fail to warm up prior to exercise.

Treating running knee injuries

In most cases, runners’ knee can be treated successful without the need for surgery. Patients will need to rest, use ice to soothe the area, wrap it in a compression bandage and keep the leg elevated.

However, if the kneecap needs to be realigned or if the cartilage is damaged, surgery may be required.

Preventing runners’ knee

While runners’ knee is a common injury, it can mostly be prevented. Easing yourself into a new running routine is a good start. You should also ensure that you stretch well and stay in shape. Start gradually, rather than attempting to run a huge distance in one go.

While runners’ knee is treatable, it is obviously better to prevent an injury from occurring in the first place. The latest study highlights how your mental state can impact your risk for injury. As much as you may love running, make sure it doesn’t become an obsession otherwise you could pay for it later on.

New advice not to delay your knee replacement

knee replacement timing

It goes without saying that the decision to undergo a total knee replacement procedure is a decision not to be taken lightly, and there is a lot to think about before taking the plunge.

For many, it is uncertainty about the recovery period and its implications that play a role in making this decision: roughly six weeks before being able to resume a normal life, and anything from four months to a year to fully recover and feel the full benefit of the surgery. Consequently, many people are inclined to put off the procedure for as long as possible.

However, a report published in the Journal of Bone and Joint Surgery recently spelt out that knee replacement timing is everything. Leave surgery too late, and you run the risk of not reaping the full benefits of the procedure. Conversely, have it too soon and you may run into complications and ever require another replacement.

The study, conducted by the Feinberg School of Medicine at Illinois’ Northwestern University, deployed an algorithm that incorporates joint function, pain, radiographic assessment, and age to best determine the optimal time to have a knee replacement. It was based on information from 8,002 people who had or were at risk for osteoarthritis, who were followed up on for up to eight years.

According to the report, a lack of timing – and its knock-on effects – is rife. Around 90 per cent of patients with knee osteoarthritis are waiting too long to have the procedure, while 25 per cent of people who don’t yet need it are having the procedure done too soon, and consequently only experiencing minimal benefits.

Knee replacement timing: what’s the problem with waiting too long?

Well, while you’re waiting for the most convenient time to have your knee done, osteoarthritis doesn’t hang about. As it continues to flourish, the function of the affected area continues to deteriorate, which can impact upon exercise and activity, which inevitably leads to knock-on effects, both physical and mental. Not only that, but the longer they leave it, the less function will be restored when the procedure actually happens, and mobility levels are reduced considerably compared to those in patients who had the procedure done in a timelier fashion.

Knee replacement timing: what’s the problem with going too early?

Patients who have surgery too soon ramp up the risk of developing complications and increase the chances of having to undergo revision surgery somewhere down the line. And as any surgeon will tell you, revision surgery procedures can be more difficult, and often result in poorer outcomes.

While the researchers are more than aware that many people can’t just drop everything and go under the knife at the perfect moment, their hope is that their algorithm can be honed and adopted by the wider medical community to give future TKR patients the clearest advice for the best possible outcome.

To discuss your knee replacement options in more detail, call either our London or Bristol knee clinics:

Bristol: 08450 60 44 99 | London: 0203 195 2443

Link established between knee injury in early adulthood and onset of arthritis

knee injury and arthritis

If you’ve indulged in any long-term sporting activity, you’ve taken your fair share of knocks. And that’s OK when you’re younger – the body can take it, and damage can be healed. But are they storing up a welter of problems in later life?

According to a recent study conducted in Sweden, they probably are: the study, which was released at the end of last year, contends that young adults who have had knee injuries are much more likely to develop arthritis in the knee by middle age than their uninjured peers, especially if they have broken bones or torn connective tissue.

Six times more likely to suffer knee OA

The study, conducted by the researchers at the Lund University, analysed the data of almost 150,000 adults ages 25 to 34 – 5,200 of which with a history of knee injuries for almost two decades. Their findings? Compared to the people who never had knee injuries, those who did were nearly six times as likely to develop knee osteoarthritis during the first 11 years of follow-up, with more than triple the risk over the next eight years.

We already know certain risk factors that bring about osteoarthritis: they include being overweight, older, female or having a job that puts a lot of stress on the joints. When it comes to a history of knee injuries, however, the picture is muddier; we know it’s a risk factor, but we’re currently not sure whether certain types of injuries might be more likely to lead to osteoarthritis than others.

The research findings have helped to clear the waters a little. After 19 years of follow-up examinations, 422 of the study group who suffered from knee injuries (11.3%) went on to develop knee osteoarthritis. Compare this to the 2,854 (or 4%) of people without a history of knee injury who went on to develop knee osteoarthritis.

A matter of balance

Why is this? According to study leader Barbara Snoeker, it’s a matter of balance – or lack of it. “Injuries that occur inside the knee joint, for example in the meniscus or anterior cruciate ligament, may alter the biomechanical loading patterns in the knee,” she claimed. “Such injuries may lead to an ‘imbalance’ in force transmissions inside the knee joint, consequently overloading the joint cartilage and leading to increased risk of developing osteoarthritis, compared to injuries that mainly affect the outside of the knee joint, such as contusions.”

While medical experts around the world have already picked holes in the study – pointing out limitations such as a lack of data on patient’s body mass index (BMI), and how patients were rehabbed after their procedures – it’s clear that people who have suffered from knee injuries in early adulthood need to be looked at with a weather eye as they progress into middle age. Clearly, the quality of rehab that young athletes are receiving is a key factor – but so are lifestyle choices which are out of the hands of the medical community.

Don’t change a thing: no benefit found in adopting a new way of running

running knee injury

It may be midwinter, but we’re already a mere four months away from one of the biggest dates in the running calendar – the London Marathon. Which means that for the more serious runners amongst us, the training programme starts now.

The winter stretch is usually the less intense part of the year, physically, but it’s also the time that many runners focus on the fundamentals – especially the mechanics of running. And right at the top of the list of considerations is changing the way we run, especially if you’re a heel-to-toe runner.

We’ve all heard the stories about heel to toe being more dangerous than toe to heel, and how running on the balls of the feet can prevent sore knees, shin splints and other maladies, and many runners have switched to it, with the encouragement of coaches and medical experts. But a new review of the available data on running styles suggests otherwise.

Should you stay on the back foot?

The review, released at the beginning of the year by the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia, analysed 53 studies which looked at the impact of forefoot, rearfoot and flatfoot running patterns on injury, running economy and running biomechanics. Their conclusions: there is no evidence to suggest running on the front of your feet reduces injury risk or improves performance.

According to Dr Christian Barton, a La Trobe injury researcher and physiotherapist who led the study, the only major change that occurs when a runner changes from heel to toe to toe to heel is a shift in body weight from one area to another – but it doesn’t make the weight disappear.

Or should you stay on the ball?

“Our comprehensive review suggests that telling someone to run on the ball of their foot instead of their heel may make them less efficient, at least in the short term,” said Dr Barton. “Additionally, there is no evidence either way on whether running on the balls of your feet reduces injury.”

There’s always a massive temptation to tinker with – or even completely change – our running style, particularly when we’re going through a period of downtime but, in this case, the main message from the La Trobe report is ‘go for what you know’.

When it comes to running style, some experts say, there is no correct answer – the way an athlete runs is as unique as their fingerprint. And while there are certainly pros and cons in each main style, there is no such thing as the best technique. Because if there was, we’d all be using it.

And as Dr Barton pointed out, toe to heel running isn’t necessarily safer, either. “Running toe-heel might help injuries at the knee, where loads are reduced. However, it may cause injuries to the feet and ankle, where loads are increased,” Dr Barton said. “Put simply, when it comes to running style: If it ain’t broke, don’t fix it.”

Can you go skiing after a knee replacement?

skiing after knee replacement surgery

There’s always one on any skiing holiday: the poor soul who came a cropper on the slopes and has to spend the rest of the week incapacitated, staring out of the window, looking mournfully at the piste while sipping on a hot chocolate. No shame in being that person – it can happen to the best skier.

But what happens if you’re a regular skier and you have to go through a procedure as serious as knee replacement surgery? Are you going to have to stay on the sidelines forever?

If you are a regular skier and you’re thinking about knee replacement surgery, you might have even given the slopes a pass this season: total knee replacement candidates usually suffer from little to no mobility and experience a great deal of pain, and nothing puts pressure and strain on the knee as much as skiing does. But when the operation’s done, will you be able to return to your favourite winter hobby? Let’s try to address your concerns…

Skiing after knee replacement: are you experienced?

If so, there’s no need to panic, because most knee surgeons will encourage experienced skiers to get back on the slopes… eventually. If you know what you’re doing on the piste and are prepared to undergo a well-managed period of rehab, you won’t have to give up skiing (and that goes for virtually any sporting activity that doesn’t involve intensive running).

Skiing after knee replacement: your first on-piste experience

However, there’s a downside: you’re going to have to accept that you won’t be able to hop back on the slope and continue as before. Most importantly, you’re going to have to be a lot more selective about the days you go out and the terrain you ski on. Soft powder = good. Icy conditions = bad. And be extremely careful about obstacles, because fractures around the knee area can cause a wealth of problems for knee replacements.

Skiing after knee replacement: about recovery time

You already know that you can’t just get up and go about your regular business after total knee replacement: you’ll need the use of a walker or crutches for a few days, a cane for a few weeks, and – usually – you’ll be walking about unaided in about two or three weeks. Add another six weeks or so of physical therapy, you’re good to go for normal routine activities.

However, you’re going to need more recovery time if you’re aiming to be ready for the next skiing season. The minimum amount of time you should wait to ski after knee replacement surgery is three months, and you are advised to undergo a course of dry land training, in order to regain the adequate balance and strength for skiing. You’re also strongly advised to start on groomed surfaces for an hour or two at a time, to help get your endurance levels back up.

As a regular skier myself who has just undergone his own knee replacement, this is all positive information. I have every intention of returning to skiing but think I’ll be pushing it to even consider returning after three months, so I’ve set my sights firmly on next season.

If you’d like more advice on returning to skiing, or any other sport, after a knee replacement, call  08450 60 44 99 to arrange a consultation with Mr Jonathan Webb at either his London or Bristol knee clinic.

UK study finds listening to noisy knees can help with knee arthritis diagnosis

knee OA

If you’re hearing a snap, crackle and pop and you’re nowhere near a breakfast table, welcome to the world of knee crepitus. It’s a term for the sounds the joint makes, and in a lot of instances it’s nothing to worry about – it’s just tiny gas bubbles that have accumulated in the synovial fluid bursting, which is a natural occurrence.

However, certain sounds can also be the first indications of a damaged knee joint. So, the results of a new study from Lancaster University have caused a lot of people in the medical community to sit up and, well, listen.

The study in question, which was published in the medical journal PLOS ONE last month, has advanced the idea of a new way of diagnosing and assessing knee osteoarthritis, which involves attaching small microphones to the knee and detecting high frequency sounds from the joint components as the person being evaluated does nothing more strenuous than performing simple sitting and standing movements.

Sounding out knee OA

The signals – known as ‘acoustic emissions’, are then analysed on a computer in order to harvest data on the health of the knee. The analysis is based on sound waveforms during different movement phases. It’s the first technique of its kind in the field of knee OA analysis, and the results are encouraging to say the least: not only can the technique distinguish between healthy and OA-afflicted knees, but it also can be used in both a general practice and hospital setting.

The research project has been running since 2013 and has been conducted by a large multi-disciplinary team led by Lancaster University, with assistance from the Universities of Central Lancashire, Manchester and Cumbria, as well as the NHS in Lancashire and Cumbria. It has also leant upon the expertise of two businesses that specialise in technologies for acoustic sensing and cartilage measurement. And the goal is to create a fast, convenient and effective method of detecting the causes of knee crepitus – be they common-or-garden knee OA, chondromalacia patella, patellofemoral syndrome or any other knee-related injury

Faster, bigger, better?

“This work is very exciting because it involves scientists and clinicians working together as a team to develop an entirely new approach,” said Emeritus Professor Goodacre of Lancaster University, who led the research. “Potentially, this could transform ways in which knee OA is managed. It will enable better diagnosis and will enable treatments to be tailored more precisely according to individual knee condition. It will also enable faster, bigger and better clinical trials of new treatments”.

If all goes well, we could be seeing the development and production of a non-invasive and portable device which could be used by the medical community to detect any changes and possible ailments in a patients’ knee with minimal fuss or discomfort, providing a faster, more cost-effective, more convenient and more refined assessment than any other method available at present. We’ll definitely be keeping an ear to the ground on this one.

To arrange a consultation to discuss your knee OA options, including robotic assisted knee replacement, call us on 08450 60 44 99 for my Bristol knee clinic and 0203 195 2443 for my London practice.

Prehab before knee replacement could lead to better results

prehab before knee replacement

We’re all aware of the necessity of rehabilitation after knee replacement surgery, but what about the steps we can take before we even go under the knife? It’s something that’s been on my mind throughout the year, as I’ve been preparing for my own knee replacement procedure later this month. And according to a study in New York that was published in November, it seems that a ‘pre-habilitation’ programme – which involves being counselled by a peer coach – could really help patients and lead to a better, faster recovery.

The study found that using a peer coach – deemed as a patient who has already gone through the procedure and has been trained to provide personalised pre- and post-knee replacement support – can make a huge difference to a patients’ mind-set, can openly discuss what happens before, during and after the operation and steer them towards developing good habits.

It’s a methodology that has worked very well in other areas of medicine, particularly in the field of diabetes. And although the two issues are very different, the thinking goes that both issues require a radical change of lifestyle habits and a positive attitude – and nothing works better than having close contact with someone who has already been through the procedure.

Thirty-one patients were examined during the study, ranging in age from 65 to 89 – all of whom had undergone a knee replacement at least 12 months earlier with a good outcome. They were questioned on a range of issues, notably their experiences with a peer coach. The study group’s discoveries were as follows;

The fear factor

Many patients with osteoarthritis delayed knee replacement for many years, often until the pain became very bad. Not only that, but the majority had no idea about the best way to prepare for knee replacement surgery, and ultimately didn’t prepare at all.

Second-time patients are better prepared

Many of the patients were about to undergo their second knee replacement procedure – and this time they felt they had learned what was expected of them this time around. “Patients with high outcome expectations who had undergone a previous knee replacement learned from their first experience and reported feeling motivated to engage in physical activity for muscle strengthening before their second knee replacement,” said Dr Iris Navarro-Millan, principal investigator of the study. “They expressed that their own experiences made them more informed, self-efficacious and physically active to prepare for their surgery.”

First-time patients are prepared to listen

Understandably, the people undergoing knee replacement surgery for the first time were very keen to listen to other patients about preparation and recovery and being given the opportunity to talk to patients who had gone through the procedure removed a lot of apprehension about surgery.

A thumbs-up for peer coaching

Not only were new patients more than open to the idea of peer-coaching, but the study discovered that certain patients were already doing it off their own bat – and were finding it very rewarding. After all, doctors can only tell you what’s going to happen: people who have already undergone the procedure can tell you what to really expect.

So, what advice would I give you, as someone about to undergo surgery? Well, I’ve been seeing a personal trainer this year – partly to put off having to have the replacement for as long as possible, but now that surgery is imminent, to ensure my muscles are as good as they can be because when it comes to as swift a recovery as possible, you can’t have enough muscle.

Post-surgery, I’ll be able to give advice both as a surgeon and fellow patient. For more advice on knee surgery and robotic knee replacement, call 0203 195 2443 to arrange a consultation.