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 OA symptoms.
• Promotional materials at strategic locations
• Appropriately targeted community initiatives particularly in relation to work related upper limb disorders (WRULD)
• 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
• Consider Rheumatological differentials where multiple joints are involved, there is significant joint effusion, or there is significant morning stiffnes.

Primary care

Patient presents to primary care with wrist and hand OA problem 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 painful non weightbearing joints . Refer to MSK web hub for lifestyle advice.
• Recommend relative rest if acute onset.
• Refer to MSK wrist and Hand OA 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 1st CMC joint injection if clinically appropriate and clinician skilled to provide.

Radiology:
X-ray not required unless fracture suspected. Patient with inflammatory OA often have normal x-rays. Any inflammatory symptoms should be referred to rheumatology.

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:

• Should include patient education on OA and lifestyle factors that can contribute to this.
• Activity modification strategies and a review of working practices should be included where a Work Related Upper Limb Disorder (WRULD) is suspected. Activity management and pacing strategies should be taught.
• Splinting options for 1st CMC joint OA can be considered as part of a package of care.
• Landmark guided corticosteroid injection may be considered as part of a package of care. for 1st CMC joint OA (other small joint injections to be performed under image guidance)

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.

Assurance of optimised conservative management:
To ensure conservative management pathways have been fully optimised for patients with wrist and hand tendon pathology i.e. medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.

Extended Scope treatment options:
Consider role of ultrasound guided injection

Onward referral options (following primary care)

• Consider bloods if spontaneous onset multiple joints to exclude systemic cause e.g Rheumatoid arthritis, Gout.
• Understand/manage expectations prior to referral- what are the goals of onward referral?
• Physiotherapy: patients will be offered 1:1 physiotherapy intervention.
• Referrals for secondary interventions to be initiated by ESP team following clinical review.
   

Onward referral options (following MSK physiotherapy)

• Medication management: refer to primary care team or Physio independent prescriber if medication optimisation required.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme, water based exercise oppertunities.
• 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: Referral on for trapeziumectomy, small joint replacement