HNY Policy and Pathway Repository - Humber

The East Riding Musculoskeletal Physiotherapy service is an outpatient service providing assessment and management of all patients registered with an East Riding GP, aged 5yrs and over with a relevant musculoskeletal problem.

PATIENTS WITH RED FLAG SYMPTOMS OR SIGNS NEED URGENT DISCUSSION with the on call neurosurgery team via the referapatient system (www.referapatient.org.uk) or to be referred to the nearest Emergency Department. A referral to neurosurgery has to be accompanied with appropriate diagnostic imaging.

This includes cases with possible Cancer, Spinal Cord Compression, Spinal Infection or cauda equina syndrome.

• Raised temperature (associated with neurological findings or back/neck pain)
• Obvious deformity of spine (new or recent)
• Presentation younger than age 20 (Consider a referral to Paediatric Neurosurgery in Leeds or Sheffield is patient is under 16)
• Onset of symptoms following significant trauma (e.g. RTA; fall from a height)
• Past medical history of cancer
• Patients who are using systemic steroids
• History of HIV and/or drug abuse
• Patients who are systemically unwell
• Patients with unexplained weight loss
• Patients with inflammatory disorders such as ankylosing spondylitis
• New onset of bowel/bladder disturbances not related to pain / including saddle anaesthesia

Exclude Red Flag Symptons

PATIENTS WITH RED FLAG SYMPTOMS OR SIGNS NEED URGENT DISCUSSION with the on call neurosurgery team via the referapatient system (www.referapatient.org.uk) or to be referred to the nearest Emergency Department. A referral to neurosurgery has to be accompanied with appropriate diagnostic imaging.

This includes cases with possible Cancer, Spinal Cord Compression, Spinal Infection or cauda equina syndrome.

• Raised temperature (associated with neurological findings or back/neck pain)
• Obvious deformity of spine (new or recent)
• Presentation younger than age 20 (Consider a referral to Paediatric Neurosurgery in Leeds or Sheffield is patient is under 16)
• Onset of symptoms following significant trauma (e.g. RTA; fall from a height)
• Past medical history of cancer
• Patients who are using systemic steroids
• History of HIV and/or drug abuse
• Patients who are systemically unwell
• Patients with unexplained weight loss
• Patients with inflammatory disorders such as ankylosing spondylitis
• New onset of bowel/bladder disturbances not related to pain / including saddle anaesthesia

Please avoid referring simple MSK problems with a duration of symptoms less than 3-6 weeks. The vast majority will resolve with simple advice, analgesia and exercises that can be provided in primary care. Alternatively defer the patient to our website where clear advice, resources and rehab for MSK conditions can be found (www.chcpmsk.org.uk)

For all MSK patients

• Direct access to www.chcpmsk.org.uk for all patients with any MSK issue
• Specific resources for management of acute conditions
• The ER MSK website (www.chcpmsk.org.uk) also has healthy living, smoking, weight management and mental health advice links.
• Consider self referral via website or via Telehealth service 01377208300 (please note this is a Telephone service only)

Additional resources

• CKS | NICE

DO NOT REFER

• Any referral that does not have an MSK condition contained in the referral, and/or states is asymptomatic, with no loss of function
• Children under 5 years of age
• Patients requiring a home visit
• Provision of walking aid or equipment or mobility assessment as a standalone contact
• Neurological conditions eg CVA, MS, PD, MND, Peripheral Neuropathy
• Respiratory/CVS conditions eg Asthma, COPD, CCF
• Falls associated with fragility and falls through poor mobility
• Urinary Incontinence and vaginal prolapse including post-natal pelvic floor issues
• Diastasis Rectus post-partum
• Chronic Fatigue Syndrome as primary diagnosis
• Amputees of lower or upper limb
• Dizziness, vertigo and other vestibular conditions including balance disorders.
• Medically unstable patients or patients with suspicion of Red Flag/Sinister features on referral
• Bell’s Palsy
• Management of Primary Rheumatological Conditions once diagnosed including: PMR/Fibromyalgia and/or without specific MSK problem
• Hypermobility as primary diagnosis that are asymptomatic, and/or without specific MSK problem
• Temporomandibular Disorders
• Toe walkers or in-toeing gait as diagnosis, Developmental Coordination Disorder, Developmental Delay,
• Persistent/Chronic Pain as primary diagnosis
• Long Covid Rehabilitation
• Rehabilitation for patients without MSK conditions eg frailty or personal training requirements
• Provision of orthotic devises, splinting or orthopaedic supports 

IMAGING/RADIOLOGY

When referring into the MSK service, please do not tell the patient that they are being referred for a scan or other investigation or that they need to have a Physiotherapy assessment before being referred for a scan/investigation. We adhere to the guidance set out below. We assess all patients individually and only would suggest a referral for investigations based on clinical need and following a thorough assessment, to change pathway, if red flags are suspected or for surgical screening.

The East Riding MSK service clinical pathways align with NICE, iRefer and are consistent with:

HUTH spinal imaging pathway is based on NICE NG59 guidance.

HUTH USS imaging pathway is based on the Evidence-Based Interventions List 2 Guidance by The Academy of Medical Royal Colleges Evidence.

CORTICOSTEROID INJECTIONS

We do not offer standalone injections for patients. The ER MSK Service is not commissioned to provide an injection service as a stand alone intervention.

For referrals requesting standalone injections, the patient will be contacted, and informed ER MSK does not offer this, and they will be deferred back to the referrer if they do not wish to have a MSK assessment.

FOR SIGNPOSTING INFORMATION SEE ADDITIONAL RESOURCES SECTION 

Referral Criteria

Referrals accepted:

• Registered with an East Riding GP
• Aged 5yrs and over
• With a relevant MSK problem

Guidance for referrers

Referrals

ER MSK will offer:

Self Referral (without the need to be seen by a Healthcare Professional prior to referral) for over 18 years only

• Website referral form www.chcpmsk.org.uk  for all patients aged 18 and over registered with an ER GP
• Referrals via this route are to be triaged within 2 working days (48 hours inclusive of working day only Monday to Friday excluding Bank Holidays) to ensure aligned with Musculoskeletal orthopaedic approach to referral optimization.
• Patients self-referring via www.chcpmsk.org.uk  have the option to receive a Telehealth assessment utilising this option on the self-referral form.
• Telehealth referral via 01377 208300 for all patients aged 18 and over registered with an ER GP.
• Referrals via the Telehealth line or option on website self-referral form are offered a Telehealth appointment,  patients are offered their initial assessment in a timely manner of 1-5 working days following registration and no longer than 15 working days depending on service demand and capacity.

Referrals by Healthcare Professionals for 5 years and over via:

• Email referral via chcp.er-mskphysio@nhs.net  utilising agreed referral form for all patients 5 years of age and over registered with an ER GP
• Electronic Referral System (ERS) for all patients 5 years of age and over registered with an ER GP.
• Via SystmOne to SystmOne MSK Referral Portal

Referral options for appropriate patient management (opens in download arrow at top of the screen)

Clinical Guidance Communications

For all non-urgent MSK conditions, if an MSK cause is uncertain then please consider routine investigations to help exclude non-MSK causes prior to referral.

An MSK referral should contain enough relevant information to enable us to make a triage decision as to how the patient is best managed, without us needing to examine their medical records, or return the referral to you requesting further information. The following details should always be included where able:

• Area of pain/symptoms and working diagnosis/clinical suspicions
• History; including duration and onset (traumatic, insidious, occupational etc.) 
• Previous relevant treatment and investigations
• Relevant co-morbidities
• Patient expectations (eg. advice, physiotherapy, investigations, injections, surgery)
• Any cancer history or other clinical red flags
• Any specific post orthopaedic procedure protocols, instructions, follow up appointment dates or further investigations. Please note if referrals are sent without relevant Orthopaedic Protocols the referral may be rejected until this information is sent and delay timely care.