HNY Policy and Pathway Repository - York

MSK and CCG co-working on public health:

• Media campaign promoting positive lifestyle change and MSK health
• Promotional materials at strategic locations
• Appropriately targeted community initiatives particularly in relation to work related upper limb disorders (WRULD)
• SEO of web hub

Diagnose clinically if:

• Patient has median nerve distribution pins and needles or numbness or whole hand paraesthesia and numbness which:
• Is worse nocturnally or on waking, is relieved by shaking of the hand
• Can be provoked by Phalen’s and tinnel’s tests.

Primary care

Patient presents to primary care with carpal tunnel syndrome.

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 e.g obesity for increased pressure carpal tunnel/ signs of work related upper limb disorders .
• Refer to MSK web hub for lifestyle /occupational factors advice.
• Recommend relative rest if acute onset. provide with night resting splint if available at practise and trial for 6 weeks.
• Refer to MSK Carpal tunnel syndrome page.

Pharmacological management:

• Synovitis of surrounding tendon sheaths and inflammation from 1st cmc joint implicated in evolution of CTS, consider Nsaids if evidence of associated tendon or 1st cmc joint pathology.
• Offer landmark guided carpal tunnel injection if clinically appropriate and clinician skilled to provide.
   

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.

1:1 treatment:

• Education
• Provision of night resting splints
• Nerve glider exercises
• Landmark guided corticosteroid injection may be considered as part of a package of care
   

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 upper limbpresentations or advanced disability.
• n.b. ESP's do not have direct access to nerve conduction studies, the decision to perform these or not will be taken by the consultant orthopaedic surgeon .

Assurance of optimised conservative management:

• To ensure conservative management pathways have been fully optimised for patients with carpal tunnel syndrome.

Extended Scope treatment options:

• Consider role of ultrasound guided injection

Onward referral options (following primary care):

• If patient has met POLCV criteria for onward orthopaedic management and wants to consider surgical management to orthopaedics.
• If patient has not met POLCV criteria (because injection or splinting not available at the practise) refer to MSK
   

Onward referral options (following MSK physiotherapy):

• Medication management: refer to primary care team or Physio independent prescriber if medication optimisation required.
• Complex condition management/ failure to respond to treatment:/ ultrasound guided injection required: refer to MSK ESP team in cases of diagnostic uncertainty,or if guided injection, or secondary care management is 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
• Condition management: refer to MSK Physiotherapy team.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Orthopaedic management: for consideration of CTS release