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Microsoft word - final msk icats spine primary care management referral thresholds and management pathways_v 10.doc

MSK ICATS – Spine Primary Care Management, Referral Thresholds and Management Pathways v10 FINAL
Thresholds for
Primary Care
Management Pathway for the
Referral reason /
Primary Care Management
to initiate a
MSK ICATS clinicians (inc
Patient presentation
referral to BICS /
onwards referral)
Taken from the Map of Medicine:

Symptoms suggestive of cauda equina syndrome
(compression of the cauda equina). Back pain plus one
or more of:
o loss of bowel control (faecal or flatus incontinence) and unexpected laxity of anal sphincter CAUDA EQUINA
of bladder control (urinary retention or SYNDROME
o severe or progressive neurological deficit in the lower extremities or gait disturbance o saddle anaesthesia or paraesthesia (loss or change of perianal and perineal sensation)
Immediate referral to A&E or Orthopaedics

Thresholds for
Primary Care
Management Pathway for the
Referral reason /
Primary Care Management
to initiate a
MSK ICATS clinicians (inc
Patient presentation
referral to BICS /
onwards referral)
SUSPECTED SERIOUS PATHOLOGY
Acute motor deficit
1. Assessment and examination
- History
i.e. foot drop
- Examination and Assessment
2. If myotomal weakness
- Provisional / working diagnosis(es)
o Request urgent MRI scan 3. Review MRI scan report
o Needs surgery – refer on o Watchful waiting Management:
o Needs general physio – - Explanation of cause
- Pain relief:
o Needs ICATS review – o paracetamol may provide pain relief book appointment o while often recommended for non-specific back pain, there is no evidence that NSAIDs are more REFER ALL
effective in improving radicular symptoms than paracetamol or placebo o moderate analgesia (paracetamol and codeine) can also be tried if paracetamol fails to control pain, though there are few direct trials supporting its use for this indication o there is no evidence to support the use of muscle relaxants, diazepam, baclofen, antidepressants or cytokine inhibitors for relieving sciatica o there may be a significant risk of dependence when some of these medications are used for long periods. Thresholds for
Primary Care
Management Pathway for the
Referral reason /
Primary Care Management
to initiate a
MSK ICATS clinicians (inc
Patient presentation
referral to BICS /
onwards referral)
Dorsal / thoracic back Investigation:
1. Assessment and examination
pain
- History
- Examination and Assessment
2. Request MRI
With systemic
3. Review MRI scan report
(including IVDUs,
- Blood screen – full blood screen
o Needs surgery – refer on REFER ALL
renal and immuno-
o Watchful waiting Management:
o Needs general physio / - Refer to ICATS
manual therapy – refer on o Request haematology – o Medical referral – refer on Dorsal / thoracic back Investigation:
1. Assessment and examination
pain
- History
- Examination and Assessment
2. Management:
Without systemic
o Analgesia modification - If female > 60 years or Male > 70 years, do blood
o Facet injection Refer to ICATS if:
screen – full blood screen o Osteoporosis – refer to - If significant change in symptoms
Kathy Fraser at PRH • Request plain film x-ray o Interventional radiology • Request bone density scan if indicated Management:
- First six weeks manage in primary care
- Refer to General Physiotherapy / manual therapy
- Medical management of osteoporosis
- Analgesia
Thresholds for
Management Pathway for the
Referral reason /
Primary Care
Primary Care Management
MSK ICATS clinicians (inc
Patient presentation
to initiate a referral
onwards referral)
to BICS / ICATS
1. Assessment and examination
(cord compression)
- History
REFER ALL
i.e.
- Examination and Assessment
2. If myotomal weakness
loss of gait, loss of
- Provisional diagnosis
Exclusions:
o Request urgent MRI scan hand control
or progressive
3. Review MRI scan report
o Needs surgery – refer on o Additional neuro o Watchful waiting Management:
o Needs general physio – - Refer to ICATS / secondary care for MRI scan
- Explanation of cause
- Pain relief:
4. Needs ICATS review – book
o paracetamol may provide pain relief The above exclusions o while often recommended for non-specific back list require pain, there is no evidence that NSAIDs are emergency referral / more effective in improving radicular symptoms should be treated than paracetamol or placebo with special care o moderate analgesia (paracetamol and codeine) can also be tried if paracetamol fails to control pain, though there are few direct trials supporting its use for this indication o there is no evidence to support the use of antidepressants or cytokine inhibitors for relieving sciatica o there may be a significant risk of dependence when some of these medications are used for long periods Progression of symptoms is key to the urgency of
the referral.
Thresholds for
Management Pathway for the
Referral reason /
Primary Care
Primary Care Management
MSK ICATS clinicians (inc
Patient presentation
to initiate a referral
onwards referral)
to BICS / ICATS
NERVE ROOT PAIN (RADICULOPATHY)
1. Assessment and examination
- History
Refer only to ICATS
- Examination and Assessment
2. Management:
- Nerve root tension / signs
o Analgesia modification Acute (<6 weeks
since onset)
Management:
- Reassure patient
o If severe – request for - Advise patient to keep mobile
- Pain relief:
o Paracetamol may provide pain relief Otherwise manage in 3. Review MRI scan report:
o while often recommended for non-specific back pain, there is no evidence that NSAIDs are more effective in improving radicular symptoms than paracetamol or placebo o Tramadol (as likely to be least constipatory o Local Neuropathic Pain Guidelines may be a significant risk of medications are used for long periods - DO NOT give codeine (especially if suspected
disc prolapse. Secondary constipation and straining may exacerbate disc herniation.) Thresholds for
Primary Care
Management Pathway for the
Referral reason /
Primary Care Management
to initiate a
MSK ICATS clinicians (inc
Patient presentation
referral to BICS /
onwards referral)
1. Assessment and examination - History
physiotherapy in
- Examination and Assessment
the first instance
Chronic (>6 weeks
- Nerve root tension / signs
o Refer for manual therapy / since onset)
- Ability to work / ADLs affected?
Refer to ICATS if:
o Pain relief and education Management:
o If facet joint – injection - If pain is not severe, continue to manage in Primary
o If severe request MRI scan / o Reassure patient o Advise patient to keep mobile 3. Review MRI scan report o Self management plan o Education – Back Book
Paracetamol may provide pain relief
while often recommended for non-specific back pain, there is no evidence that NSAIDs are more effective in improving radicular symptoms than paracetamol or placebo
Tramadol
Local Neuropathic Pain Guidelines
there may be a significant risk of medications are used for long periods
DO NOT give codeine (especially if suspected disc
prolapse. Secondary constipation and straining may
exacerbate disc herniation.)
Thresholds for
Primary Care
Management Pathway for the
Referral reason /
Primary Care Management
to initiate a
MSK ICATS clinicians (inc
Patient presentation
referral to BICS /
onwards referral)

MECHANICAL BACK PAIN

Symptoms:
Mechanical back pain - Flare ups
- NONE –
manage in
Acute (<6 weeks)
primary care
- History
- Examination and Assessment
- If signs start to demonstrate neuropathic pain or
nerve root pain – follow nerve root pain pathway

Management:
- Reassure patient
- Exercise plan
- Self management plan
- Use patient outcome tool
- Pain relief:
is the first-line medication, although there is limited evidence regarding its efficacy: paracetamol alone does not provide sufficient pain control, offer: o NSAIDs and/or: o consider potential benefits and risks of these medications and patient preference when prescribing medications: o if NSAIDs or COX-2 inhibitors are prescribed consider the concomitant use of PPI's in patients with additional risk factors. (See Guidelines for Prescribing PPI's in adults, BSUH, October 2009) co-prescribing a laxative with opioids to counteract the constipating effects of opioids, as straining to defecate may aggravate back pain o aim for the lowest dose required for relief of o when prescribing opioids, short-acting agents given at regular intervals, rather than on a pain-contingent basis is recommended o evidence suggests that NSAIDs have some effect for short-term pain relief compared to placebo, but there are no benefits compared to paracetamol, narcotic analgesics or muscle relaxants Mechanical back pain Investigation:
1. Assessment and examination
- History
physiotherapy in
Persistent (> 6 weeks
- Examination and Assessment
first instance
2. Investigations
to < 12 months since
diagnostic uncertainty): Management: (Taken from Map of Medicine)
Refer to ICATS if:
- Develop a management plan to aid the patient in
understanding what to expect and their role and responsibilities in managing the pain. - Continue to offer reassurance and positive
messages that encourage the patient to return to o Look for inflammatory normal activities. disorders, sacroilitis, o Unable to cope spondylolisthesis, TB, - If signs of serious disease are still absent, consider
initially offering one of the following: o Physical activity and exercise programmes o Referral for manual therapy 3. Consider referring on to
rheumatology, orthopaedics, o Further drug therapy Medics, further physiotherapy / Functional Recovery Programme - Consider a different option from the list above if the
response to the first-line therapy is not satisfactory. 4. Consider referring for Pain
- Brief educational interventions aimed at reducing
Management Programme (PMP) sick leave and disability may be useful although NICE do not recommend education as a sole 5. Multi disciplinary and
biopsychosocial groups / functional programmes - Clinicians need to be aware of the importance of the
patient's employment – options for a ‘phased return' should be explored in each case.
- Patients dealing with disability and loss of
employment should be directed specific areas of support e.g. through an occupational health department and specially trained staff. Mechanical back pain Investigation:
1. Assessment and examination
- History
physiotherapy in
Acute on chronic
- Examination and Assessment
if not improved
2. Investigations to include (if not
(chronic patients with
after 6 weeks
done before / if diagnostic flare up)
Management: (Taken from Map of Medicine)
- Develop a management plan to aid the patient in
Refer to ICATS if:
understanding what to expect and their role and responsibilities in managing the pain. - Continue to offer reassurance and positive
messages that encourage the patient to return to normal activities. o Look for inflammatory o If refusal to go disorders, sacroilitis, - If signs of serious disease are still absent, consider
spondylolisthesis, TB, initially offering one of the following: o Physical activity and exercise programmes o Referral for manual therapy 3. Consider referring on to
o Further drug therapy rheumatology, ortho., Medics, further physiotherapy / Functional - Consider a different option from the list above if the
Recovery Programme (FRP) response to the first-line therapy is not satisfactory. o Unable to cope 4. Consider refresher / top up
- Brief educational interventions aimed at reducing
session(s) for Pain Management sick leave and disability may be useful although NICE do not recommend education as a sole 5. See persistent category above
- Clinicians need to be aware of the importance of the
patient's employment – options for a ‘phased return' should be explored in each case.
- Patients dealing with disability and loss of
employment should be directed specific areas of support e.g. through an occupational health department and specially trained staff.
- Explore psychosocial factors
Mechanical back pain Investigation:
Refer to ICATS if: 1. Assessment and examination
- History
Chronic (> 12 months) - Examination and Assessment
worsening and 2. Explore:
o Psychosocial factors Management: (Taken from Map of Medicine)
- Develop a management plan to aid the patient in
understanding what to expect and their role and o For diagnostic responsibilities in managing the pain. 3. Investigations to include (if not
done before / if diagnostic - Continue to offer reassurance and positive
messages that encourage the patient to return to normal activities. - If signs of serious disease are still absent, consider
initially offering one of the following: o Physical activity and exercise programmes o Referral for manual therapy o Look for inflammatory disorders, sacroilitis, o Further drug therapy spondylolisthesis, TB, - Consider a different option from the list above if the
response to the first-line therapy is not satisfactory. 4. Consider referring on to
rheumatology, ortho., Medics, - Brief educational interventions aimed at reducing
further physiotherapy / Functional sick leave and disability may be useful although Recovery Programme (FRP) NICE do not recommend education as a sole 5. Consider refresher / top up
session(s) for Pain Management - Clinicians need to be aware of the importance of the
patient's employment – options for a ‘phased return' should be explored in each case.
- Patients dealing with disability and loss of
employment should be directed specific areas of support e.g. through an occupational health department and specially trained staff. Thresholds for
Primary Care
Management Pathway for the
Referral reason /
Primary Care Management
to initiate a
MSK ICATS clinicians (inc
Patient presentation
referral to BICS /
onwards referral)
Symptoms:
To be managed in NONE Acute torticollis usually resolves within 24–48hours. Acute torticollis Occasionally, symptoms may take up to a week to resolve. Recurrence is common.
Investigation:
- History
- Examination and Assessment: Unable to rotate
Management:
Offer analgesia to relieve symptoms.
Advise gentle exercise within the comfort zone.
Intermittent heat or a cold pack to help reduce pain and
spasm. Maintain a good posture.
Advise against:
Routine use of a soft cervical collar. If pain on moving
the neck is severe, then wearing a soft collar for a few
days may help. It is preferable to keep the neck mobile
with gentle exercise.
brachialgia pathway Neck pain non specific: acute phase (first 6 - History
- Examination and Assessment
Management:
Reassure that neck pain is a very common problem and that the symptoms likely to resolve. Encourage the person to remain active Discourage wearing a cervical collar. Strongly discourage prolonged absence from work. Correct poor posture A firm pillow may provide comfort at night: 1. Assessment and examination
- History
- Examination and Assessment
6 weeks to 12 weeks Management
2. Explore:
Refer to physiotherapy Psychosocial factors Address any psychosocial factors, (Fear or avoidance beliefs, Associated anxiety and depression, Medico- legal issues, Family dynamics) Refer to ICATS if: 3. Investigations to include (if not
- History
- Examination and Assessment
physiotherapy and more than 12 weeks Management
Analgesia including trial of a low-dose tricyclic If seen previously Re-examine psychosocial factors periodically Refer to physiotherapy Consider referral to ICATS clinic. Suspecting serious o Bone Scan spinal abnormality Look for TB, other medical 4. Consider
rheumatology, ortho., Medics, further physiotherapy / Functional Recovery Programme (FRP) 5. Consider refresher / top up
session(s) for Pain Management Programme (PMP) Neck pain whiplash Manage in primary 1. Assessment and examination
care first 6 weeks
History of sudden or excessive neck extension, flexion, or rotation. Symptoms may be delayed for hours or 2. Explore:
days after the injury. Psychosocial factors The two most common symptoms are: physiotherapy after 6 weeks Disabling neck pain, with or without referral to the shoulder or arm – and headache. The person may also have: Refer to ICATS if Fatigue, dizziness, paraesthesiae. Nausea. Jaw pain 3. Investigations to include (if not
intractable pain and Posterior cervical sympathetic syndrome, including done before / if diagnostic headaches or facial formication (sensation of ants If nerve pain see crawling over the face). - History
- Examination and Assessment
Examine for signs of muscular spasm, point tenderness, and neurological problems in the upper or lower limbs. It is safe to assess for range of neck Look for TB, other medical Beware of have midline cervical tenderness (as this suggests a fracture or dislocation) or other serious 4. Consider
rheumatology, ortho., Medics, further Functional Recovery Programme Exclude spinal cord compression (myelopathyIf suspected refer to A&E. 5. Consider refresher / top up
Assess the presence of associated stress, anxiety, or session(s) for Pain Management depression and poor concentration. Look for 'yellow flags' that indicate psychosocial barriers to recovery and that suggest that the acute injury could progress to become a chronic problem. Management:
Provide reassurance that whiplash-associated disorder is usually benign and self limiting. Encourage early return to usual activities and early mobilisation. Explain that usual activities may initially be painful, but this is not harmful or indicative of ongoing damage. Discourage rest, immobilisation, and the use of soft collars, correct erroneous beliefs. to 1. Assessment and examination
- History
- Examination and Assessment
first instance and Management
previous 2. Explore:
Resist pressure to over-treat and over-investigate. Psychosocial factors Encourage and facilitate a return to normal activities. Refer to ICATS if Diagnose and treat anxiety and depression where they patient at risk of Do not sanction behaviours that promote disability. 3. Investigations to include (if not
done before / if diagnostic Do not enhance the person's expectations of a poor outcome and chronic disability. compensation claims and discourage the use of symptom diaries, as these encourage the person to focus on their pain and disability rather than their function and abilities. Continue education regarding behaviour and beliefs. Look for TB, other medical 4. Consider
rheumatology, ortho., Medics, further Functional Recovery Programme (FRP) 5. Consider refresher / top up
session(s) for Pain Management Programme (PMP) Referral reason /
Primary Care Management
Thresholds for
Management Pathway for the
Patient presentation
Primary Care
MSK ICATS clinicians (inc
to initiate a
onwards referral)
referral to BICS /
Spinal pain related to Advice? If unable to manage in primary care please refer all referral to gyneacology physiotherapy in the first instance (Central Registration – BGH). The patients will be screened by physiotherapy within 48 hours and if deemed inappropriate will be referred on the ICATS spine service

Source: http://www.bics.nhs.uk/EasysiteWeb/getresource.axd?AssetID=2826&type=full&servicetype=Attachment