4. First Contact Considerations
4.1 Standard A - Screen for Serious Pathology Indicators (Red Flags)
NHSScotland is focused on improving quality, addressing excessive variation in practice, and ensuring the highest standards of patient safety. It is therefore imperative to identify conditions or co-morbidities that may deter a patient's recovery and function or place the patient at risk of serious medical consequences. The clinician must remain alert to potential clinical indicators that require more extensive testing than that afforded by a basic clinical examination. The term 'red flags' refers to clinical features that may be associated with the presence of serious, but relatively uncommon conditions, requiring urgent evaluation. Such conditions include tumours, infection, fractures and neurological damage. Previous scoping in NHSScotland highlighted that clinicians required to improve their assessment and documentation of serious pathology indicators.
Screening for serious conditions occurs as part of a history and physical examination and should occur at the initial assessment and subsequent visits along the service user pathway.
Rather than recording an exhaustive list of serious pathology indicators ('red flags'), clinicians should consider a small numbers of disorders in which early diagnosis might make a large difference (i.e. cauda equina syndrome, major intra-abdominal pathology, focal infections, and fractures) and cancer. Other musculoskeletal conditions that may benefit from early specialist referral should also be considered at this point, for example spondyloarthropathies[56,57], inflammatory joint disease[56,57,58,59], specific foot conditions and poor bone health[61,62,63,64,65].
Common serious pathology/red flag indicators for low back pain are shown as examples in Table 1.
Table 1: Serious Pathology Indicators (Red Flags) Using Low Back Pain as an Example [52,56,66,67,68]
Possible Indicators of Serious Pathology
Possible Indicators of Spinal Inflammatory Disease
Four or more of the above indicates possible inflammatory back pain and should be referred to the rheumatology services.
Other useful indicators include a history of uveitis, colitis or psoriasis
4.2 Standard B - Consistent Advice from All Contact Points Utilising NHS Inform Resources
A large body of evidence consistently indicates that patients who gain knowledge and skills improve their ability to manage self-care, enhance decision making and improve their quality of life[69,70,71]. For some conditions, such as neck pain[72,73] and shoulder pain, there is evidence that supplementation of physiotherapy exercises with manual therapy may be of additional benefit, for other conditions such as osteoarthritis the main recommended treatment is advice about maintaining physical activities and provision of a structured exercise programme. Furthermore, the consensus of evidence suggests that supporting self-management can have benefits from people's attitudes and behaviours, quality of life, clinical symptoms and use of Healthcare resources[71,76]. NHS Inform (www.nhsinform.co.uk/msk) has a current work programme that is developing a range of web-based enhanced information, advice and self-management options for musculoskeletal conditions. This also includes the option to supply appropriate exercise regimes. National pain resources should also be promoted (www.chronicpainscotland.org). Musculoskeletal services should provide service users maximum opportunity to access and benefits from these extensive resources.
Service user Information and related resources to be available to all members of the musculoskeletal team on common musculoskeletal conditions.
4.3 Standard C - Medication/Analgesia as Appropriate
Acute and chronic pain are significant problems in musculoskeletal disorders. Pain is the most common symptom that causes patients to seek the help of health professionals. Many service users seek advice and treatment for acute episodes of self-limiting pain, but many others experience ongoing discomfort. It is estimated that approximately 50% of those with chronic pain have a musculoskeletal problem. The benefits and risks of medications, in acute and chronic pain, are complex and probably dependent on the type and duration of the condition, underlying
pain mechanisms involved and co-morbidities[81,82]. Nevertheless, appropriate analgesia has the potential to ease pain, and reduce disability[83,84]. Furthermore, appropriate pharmacological treatments are either the treatment of choice or a useful adjunct to non pharmacological therapies, for example in neuropathic pain conditions[85,86,87,88]. It is important that national advice on pain management should be followed to enhance effectiveness and reduce abnormal side-effects, including dependency. An appropriate systematic pain history will help determine the mechanisms producing pain and factors influencing the painful experience.
Table 2: Pain History P Q R S T Approach
4.4 Standard D - Appropriate Investigations
The Scottish Government National Access Policy aims to ensure consistency of approach in providing access to services. It advocates that wherever possible patients should be referred for appropriate diagnostic tests prior to the referral being made for the first outpatient appointment. It has previously been estimated that at least 30% of patients attend an orthopaedic outpatient clinic either to find the 'cause' of their pain or to discover that there is nothing 'seriously wrong' with them. If these expectations can be addressed to the satisfaction of service users, this will reduce these inappropriate demands on musculoskeletal services.
The purpose of pre-referral investigations is to inform whether or not referral is required and to make the most appropriate use of AHP and medical services.
4.5 Standard E - Equal Opportunities to Access Musculoskeletal Pathways via Self or Healthcare Professional Referral
In the UK health service, patients with a musculoskeletal problem usually consult in general practice initially. Providing timely access to AHP services has been a long-standing problem in the NHS, with waiting times of several weeks or months for access in many areas of the UK. Waits for assessment, advice and appropriate management can result in patients' problems becoming chronic which may have consequences for their health and wellbeing and for the economy. Conversely, prompt and timely treatment and/or advice may mean that individuals are able to remain at, or return to, work whilst receiving treatment or return faster with more prompt management by AHP services. In recent years, access has been improving and the efficacy for patient self-referral established[97,98,99,100,101], under the right circumstances. During this time, examples have also emerged of physiotherapists offering initial assessment and advice by telephone and internet technologies using algorithms with self-management and/or face-to-face treatment options, where necessary[92,104]. Early research findings around telephone assessment and advice services for patients with musculoskeletal conditions are promising, although these innovations require further evaluation[92,104]. The vision would be to widen these opportunities and modes of access for patients, if appropriate.
Email: Susan Malcolm