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.
• Health promotion regarding Work related upper limb disorders.
• 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 and has some observable reduction in joint range.
• No history of trauma
• Mechanical symptoms (i.e. locking) are not at the fore.

Primary care

Patient presents to primary care with elbow 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.

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

Radiology:

• X-ray not required prior to referral

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 physiotherapy:

• To explore education around osteoarthritis, discuss activity management strategies, signpost to medication advice, and provide specific exercise based interventions.
• Flair up management: The MSK service will offer 1 to 1 appointments for patients experiencing a flair up.
• If corticosteroid injection indicated consider whether this can be done Landmark or wether USGI is indicated.
   

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 elbow 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.

Ultrasound guided injection:

• To provided guided injection into elbow joint for symptom management, where this is not possible by landmark guidance.
• Support decision making regarding orthopaedic intervention
• Support patients in their decision making as to whether to proceed with arthroscopy/ elbow replacement surgery. Refer appropriately 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 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/ OK procedure needs to be discussed.
• Urgent orthopaedic opinion (via ED) should be sought for acutely locked elbow due to IA loose body.
   

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/Ultrasound guided injection/ orthopeadic options: refer to MSK ESP team in cases of diagnostic uncertainty, or significant disabiltiy, or if further intervention needs to be explored.

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.
• 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.