HNY Policy and Pathway Repository - York

MSK and CCG co-working on public health

• Media campaign promoting positive lifestyle change and MSK health and role of regular activity for low grade joint symptoms.
• Promotional materials at strategic locations
• Appropriately targeted community initiatives
• SEO of web hub

Diagnose Osteoarthritis clinically without investigation if a person

• Is 45 or over AND Has activity related joint pain AND Has either no morning joint related stiffness OR morning stiffness that lasts for no more than 30 minutes
• No history of trauma
• Mechanical symptoms (i.e. locking/ giving way) are not at the fore.

Primary care

Patient presents to primary care with lower limb OA.

Primary care team to optimise pre MSK management using the MSK web hub for patient education and management or alternative offline resources.

Non- pharmacological management strategies:

• Check BMI/ smoking/ exercise status:
• If lifestyle factors highlighted discuss as risk factors for MSK ill health/OA. Refer to MSK web hub for lifestyle advice.
• Refer to MSK web hub long term condition pages.

Pharmacological management
Optimise medication management as per NICE guidelines. Consider topical NSAIDS, oral NSAIDs plus PPI, Paracetamol. Address any maladaptive beliefs around medication useage in conjunction with MSK web resource

Offer joint injection if clinically appropriate and clinician skilled to provide.

Radiology:
X-ray is only indicated if the patient has clinical features do not fit the desription below or have not improved despite 6-8w of optimal conservative management.

Serial x-rays to monitor disease progress SHOULD NOT BE DONE.

MRI IS NOT INDICATED for degenerative hip or knee pain.
 

MSK physiotherapy 

Physiotherapy team to assist primary care in management of patients where web hub information and primary care strategies have not helped, where patients have self referred, or where patient is experiencing flair up.

All patients regardless of access point should have a discussion of expectations and functional goals to support planned management pathway.

Condition education groups:
Patient have the option of attending OA self management skills group or accessing a video presentation of the same information. The self management skills group will cover- what is arthritis? role of medication, role of exercise, role of lifestyle, activity pacing techniques.

Exercise and activity promotion course:
The MSK service will offer patients the oppertunity to attend a 6 week introduction to exercise and activity course. The aim of the course is to promote exercise and activity in lower limb OA to improve symptoms of the condition.***subject to best practise evidence r/w****

Flair up management:
The MSK service will offer 1 to 1 appointments for patients experiencing a flair up. This may include education, reassurance, therapeutic interventions including landmark corticosteroid injection for OA Knee.

MSK extended scope practitioner 

To support primary care and physiotherapy teams in managment and diagnosis of complex case presentations. To support patients in their decisions regarding surgery and ensure alternative treatment options have been explored and optimised.

Diagnostic uncertainty:
to utilise clinical skills and experience supported by diagnostic imaging and procedures to propose a primary diagnosis or diagnoses for patients with complex lower limb presentations or advanced disability.

Assurance of optimised conservative management:
To ensure conservative management pathways have been fully optimised for patients with lower limb osteoarthritis including: medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.

Support Arthroplasty decision making:
Support patients in their decision making (in conjunction with rightcare PDA) as to whether to proceed with surgery. Refer appropriately (either direct to List or orthopeadic opinion) to secondary care.

Onward referral options (following primary care):

• Understand/manage expectations prior to referral- what are the goals of onward referral?
• Condition management: MSK service- note patient must have engaged with online resources before making a condition management referral to MSK.
• Flair up management: MSK service- can offer 1 to 1 management for arthritis flair
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Complex condition management/ Arthroplasty: refer to MSK ESP team in cases of diagnostic uncertainty or if arthroplasty needs to be discussed.
   

Onward referral options (following MSK physiotherapy):

• Medication management: refer to primary care team or Physio independent prescriberif medication optimisation required.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme, water based exercise oppertunities.
• Complex condition management/ Arthroplasty: refer to MSK ESP team in cases of diagnostic uncertainty, or significant disabiltiy, or if surgery needs to be considered.
   

Onward referral options (following MSK extended scope practitioner:

• Medication management: refer to primary care team or Physio independent prescriber if medication optimisation required.
• If secondary care pain services are required make recommendation for that referral to GP.
• Consider role of DMARD's for OA management in discussion with primary care *** pending outcome of PROMOTE trial.
• Condition management: refer to MSK Physiotherapy team.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Orthopaedics: direct to list/ outpatient opinion.

Dermatome Map to be used in conjunction with GP Assessment for Acute Low Back Pain with radicular symptoms.