COVID-19: MSK service guide

Service Updates - July 2020

Lumbar Spine Pathway-Physiotherapy led service is now running as normal.

Beacon Medical Group MSK: Reinstatement of services in line with national guidance to restore services safely from the 1st July 2020.

The triage element of the services will continue as normal as no face to face contact is required. Video consultation allows for patients who do not require face to face contacts to be reviewed remotely to the practice. For this service there will be few situations were face to face appointment is not required due to the nature of the patient's symptoms assessment will likely be required for all patients.

Scope

This information provides guidance on the management of MSK patients across Plymouth and West Devon during the Covid-19 pandemic. The information is based on National Guidance

National guidance

This guidance is to help primary or community care practitioners recognise serious pathology which requires emergency or urgent referral to secondary care in patients who present with new or worsening musculoskeletal (MSK) symptoms. Serious pathology as a cause of MSK conditions is considered rare, but it needs to be managed either as an emergency or as urgent onward referral as directed by local pathways.

Urgent and Emergency Musculoskeletal Conditions Requiring Onward Referral

Helpful information about MSK Physio:

UHP Adult and Paediatric MSK & specialist outpatients (including Lumbar Spine) are still operational offering either: Face to face where there is an urgent need for clinical intervention, 'Attend Anywhere' virtual clinic or telephone assessments.

All Therapy outpatient services provided by UHPNT are being run in the same way as usual (Physio / Occupational Therapy (OT) / Speech & Language Therapy (SLT) & Dietetics).

Red Flags

Consider serious pathology as a differential diagnosis if a person presents:

  • with escalating pain and progressively worsening symptoms that do not respond to conservative management or medication as expected
  • systemically unwell (fever, weight loss)
  • with night pain that prevents sleep due to escalating pain and/or difficulty lying flat.

Emergency conditions

The following serious pathologies must be dealt with on the day as an emergency. Pathways for emergency referral have changed in many areas: please keep updated about changes in the local system.

  • Cauda equina syndrome (CES): see Neurosurgery / Spine CRG
  • Metastatic spinal cord compression (MSCC): see Neurosurgery / Spine CRG
  • Spinal Infection: see Neurosurgery / Spine CRG
  • Septic arthritis: If the person presents unwell, with or without a temperature, with a sudden onset of a hot swollen painful joint and multidirectional restriction in movement, septic arthritis should be expected until proven otherwise. This is particularly important in children, who may present with a painful limp or loss of function in the upper limb, and not as a hot, swollen, painful join

Urgent Conditions

The following require an onward urgent referral:

Please refer to Neurosurgery / Spine CRG for the following:

  • Primary or secondary cancers: (Primary cancers such as breast, prostate and lung can metastasise to the spine).
  • Insufficiency fracture
  • Major spinal-related neurological deficit
  • Cervical spondylotic myelopathy (CSM)
  • Acute inflammatory arthritis and suspected rheumatological conditions:
    • Refer any person to rheumatology with:
      • persistent synovitis (i.e. hot swollen joints), particularly if the small joints of the hands (metacarpophalangeal or proximal interphalangeal) and/or feet are affected, and person reports early morning joint stiffness lasting more than 30 minutes, even if the acute phase response (C-reactive protein – CRP or erythrocyte sedimentation ratio – ESR) is normal and cyclic citrullinated peptide antibody (anti-CCP) or rheumatoid factor (RF) are negative. The person may have rheumatoid arthritis or psoriatic arthritis
      • a suspected new-onset autoimmune connective tissue disease (e.g. lupus, scleroderma) or vasculitis. Symptoms include extra-articular manifestations such as a rash, Raynaud's (colour change, with hands and/or feet turning white– blue and/or red in the cold), mouth ulcers and/or sicca symptoms (dry eyes/mouth) in association with their new inflammatory arthritis
      • myalgia which is not secondary to a viral infection or fibromyalgia but worsens proximally, ie affects the shoulder and pelvic girdles in a symmetrical pattern, is worse in the morning and associated with more than 30 minutes of stiffness, and accompanied by a raised acute phase response (ESR or CRP). They could have:
        • polymyalgia rheumatica (PMR): person usually aged over 50; refer urgently to GP, or
        • myositis: any age, usually accompanied by some weakness and raised creatine kinase (CK); refer urgently to rheumatology service
        • new-onset headache predominantly in temples with or without associated symptoms such as jaw claudication, proximal girdle pain, visual symptoms and accompanied by a raised acute phase response (ESR or CRP) in people usually aged over 50. They may have giant cell arteritis
        • suspected inflammatory spinal pain: person may report prolonged early morning stiffness, pain radiating to buttocks and/or night pain. They may or may not have associated psoriasis, inflammatory eye disease (uveitis, iritis) and/or inflammatory bowel disease. For further information see the link: NICE guidance on recognition and referral of Spondyloarthritis

Urgent advice

Please see advice and guidance contact details for any urgent MSK queries:

A Trauma & Orthopaedics consultant will be available at Nuffield Health Plymouth for phone call advice and guidance 7 days a week between the hours of 08:00 – 22:00.

Telephone: 01752 517508

Fracture advice: please email fracture queries to: plh-tr.fracture-clinic@nhs.net

Advice & Guidance

Please see advice and guidance contact details for any urgent MSK queries:

A Trauma & Orthopaedics consultant will be available at Nuffield Health Plymouth for phone call advice and guidance 7 days a week between the hours of 08:00 – 22:00.

Telephone: 01752 517508

Fracture advice: please email fracture queries to: plh-tr.fracture-clinic@nhs.net

Referral

Lumbar Spine Pathway-Physiotherapy led service is now running as normal, please refer in the usual way.

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Publication date: May 2020

Last updated: 17-07-2020

 

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