MKCCG GP PLT Thursday 22 March 2018 CCG
- Slides: 98
MKCCG GP PLT Thursday 22 March 2018
CCG Update Dr Nicola Smith MKCCG Chair
Finance Update
Integrated Urgent Care
Integrated Urgent Care 111 Direct appointment booking to • • • GP OOH In hours GP (pilot) GP Access slots Children’s primary care Dental End to Walk-in services except for true emergency care
Same day demand Current state Transition State Final State UTC walk in UTC appts Calls to GP Practices 111 Contacts GP practice appts Streamed to other services
Future CCG PLT events • • • May 24 – Mental health focus July 19 – Winter in July – preparation for Winter October 18 –Safeguarding January 24 - CCG March 21 - CCG
Milton Keynes Registration Service Presentation by Viv Boyce - Registrar
What is the role of the Registration Service? The Registration Service is responsible for the accurate and timely registration of all: • Births, Still-Births, Deaths, Notices of Marriage and Civil Partnership and the Registration of Marriage and Civil Partnership. • Corrections or issues with registrations. • Statutory and non statutory ceremonies. • Annually, we register approximately 4000 births and 1800 deaths.
Legalities • We comply with the legal obligations of Milton Keynes Council, Registration legislation and codes of Good Practice. • By law all registrations must be registered by statute in set time periods. • Deaths, unless there is Coroner involvement, must be registered within 5 days. • Births must be registered within 42 days. • If a registration is not completed, informants are requisitioned. • There are strict guidelines as to who is considered to be a qualified informant to register both births and deaths.
How can we work well together? • Developing positive relationships between the registration service and healthcare colleagues. • Communicate ideas. • Feedback any issues promptly. • Ensure our procedures are as straight forward as possible and everyone is informed of any changes. • Being aware of the legal statutes and time constraints we all have.
What are we doing to build professional relationships? • We have asked if we can attend meetings. • We have made contact with Practice Managers regarding birth registrations. • We have provided birth registration leaflets and posters. • We are sharing some of the issues we all face when completing MCCDs and death registrations.
Birth Registrations • Email communication with Practice Managers regarding birth registrations. We attached a copy of our birth registration leaflet and a poster. • We received a really positive response and supplied a number of surgeries with leaflets and posters. • We were notified that some surgeries had attached the details to their newsletters and websites. • We will provide more leaflets if they are requested.
Death Registrations Did you know……. • We have to offer a registration appointment within 2 days of an informant contacting us. • The registration must be completed within 5 days of the death, not from the date the MCCD is issued. • Registration Officers are unable to register a death using an MCCD (Medical Certificate of Cause of Death) unless they have verified the certifying doctor is registered with a licence to practice. • The Registration Officer has to check this information at every registration, even if they recognise a doctor’s name. • Registration Officers have 30 minute appointment slots to complete a death registration. • The MCCD must be completed correctly for the registration to take place.
What information is required to enable the Registration Officer to verify who the certifying doctor is? • The MCCD must be signed and dated by the certifying doctor. • The doctor’s full name, clearly written. • The doctor’s GMC number, clearly written. • Details of the surgery or hospital the doctor is working at.
Signature Lists Historically, the Registration Service has requested that surgeries provide up to date signature lists for their doctors. Information required: • List of GPs and Locums working at the surgery. • Full name of each doctor. • Signature of each doctor. • GMC numbers. Registration Officers have used these lists to check doctor’s signatures if the name and GMC number of the doctor has not been recorded on the MCCD.
Issues with signature lists • • They become out of date very quickly. Lists are not updated regularly. It is a time consuming task. Information is not always recorded accurately. • Doctors do not always record the details of the surgery they work at on the MCCD.
How can we overcome this issue? If a certifying GP follows this guidance, signature lists will not be required: • Sign and date the MCCD. • Print their full name clearly. • Record their GMC number. • Record their qualifications. • Record the details of the surgery or hospital they work at.
Overcoming the issue…continued • Doctors surgeries having stamps so that their MCCD books can be stamped with a prompt of ‘name and GMC number’. • Good communication links between surgeries and the registration service.
What happens when a MCCD is not completed correctly? • Telephone calls will be made to the surgeries in some instances, these will require urgent responses putting services under pressure. • Informants may return to surgeries asking for a new MCCD. • Potentially, there will be a referral to the Coroner’s Office. • Ultimately, the Registration Officer cannot complete the registration.
Common issues with MCCD’s • ‘Last seen alive by me’ crossed out and changed to ‘last seen alive by (different doctor’s name entered)’. • The deceased was not seen by the certifying doctor either after death or within the 14 days before death. • ‘Last seen alive by me’ date not completed. • Residence - The doctor submits their home address rather than that of the surgery or hospital they work at. • Full name and GMC number not clearly written on the form. • Place of death not recorded. • Cause of death not appropriate or abbreviations used – we need words in full. • A mode of death rather than a cause of death is recorded.
Spelling errors • Registration Officers have to record the cause of death exactly as it is recorded on the MCCD. • If there is a spelling error, this cannot be corrected by the Registration Officer. It is always pointed out to the informant and if they would like it to be corrected, they need to return to the surgery for a new MCCD. • Words that are regularly spelt incorrectly are: Frailty and Alzheimer’s.
MCCD Stock • Orders for MCCD stock should be posted to the Register Office, preferably using the beige order forms that are in the MCCD books. If they are not available, a letter on headed paper from a GP registered at the practice or hospital will be accepted. We require the doctors full name and GMC number. • All MCCD books and envelopes must be collected from the register office after they have been ordered. The secure nature of this stock means that it cannot be posted to surgeries. • We require ID and a letter (on headed paper) from a GP registered at the practice to be produced on collection. • It is helpful to receive a name and either telephone number or email of the person who has ordered the stock.
How to contact the Registration Service Email: registrars@milton-keynes. gov. uk Address: Milton Keynes Register Office Bracknell House Aylesbury Street Bletchley Milton Keynes MK 2 2 BE (we will be moving premises later in 2018 but will update all practice managers when this occurs). Telephone number: 01908 372101 (This is a contact centre so email may be a preferred option)
Questions and Ideas
ENGAGEMENT WITH DIAGNOSED BUT NOT IN CARE HEPATITIS C PATIENTS USING LABORATORY DATABASE (IREEN-C) THE JOURNEY IN THE EAST OF ENGLAND DRAFT REPORT On behalf of IREEN-C Steering Committee Dr Anne Day, Dr Annapurna Sen, Dr Bharathy Kumaravel, Dr Dushyant Mital, Dr Mansoor Raza, Dr Prakash Gupta, Dr Rohinton Mulla, Dr Sambit Sen, Dr Simantee Guha, Dr Sultan Salimee, Carole Holder, Ruth Lovelock and Jeremy Phillips
BACK GROUND: NATIONAL AND REGIONAL CONTEXT National burden: Hepatitis C infection is a major cause of chronic liver disease and liver cancer and is now a global health problem. The most recent national estimates suggest that around 214, 000 individuals are chronically infected with hepatitis C (HCV) in the UK; most of this infection (~90%) is genotype 1 and genotype 3. (https: //www. gov. uk/government/uploads/system/uploads/attachment_d ata/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_2807 2015_v 2. pdf) Regional burden(EOE): The estimated number of patients with hepatitis C was 13, 665 (all types) in 2014. Of these almost 50% (6149) were Type 1. www. phe. gov. uk/FES/East 30
LOCAL BURDEN: BEDFORDSHIRE, LUTON AND MILTON KEYNES(BLMK) Average detection rate of confirmed chronic hepatitis C per 100, 000 for BLMK is 25. 6/100, 000 Bedfordshire-23. 5/100, 000 Luton-32. 6/100, 000 Milton Keynes-22. 9/100, 000 (Please note this indicator reflects both the local burden of chronic hepatitis C and local testing activity for a given population, also, this data does not indicate actual proportion of cases) Crude hospital admission rate for hepatitis C related end-stage liver disease/hepatocellular carcinoma per 100, 000 population ( 3 year pool 2012 -15) is 2. 75 which is higher than the England average of 2. 4/100, 000. Bedford -3. 9/100, 000 Central Bedfordshire-1. 8/100, 000 Milton Keynes-1. 6/100, 000 Luton- 3. 7/100, 000 (Please note this indicator includes patients admitted to hospital with a diagnosis in in any Diagnosis field( primary and secondary) of: i) Hepatitis C, ICD 10 codes B 171 or B 182; AND ii) a diagnosis of end stage liver disease, ICD 10 codes I 850, K 704, K 720, K 721, K 729, K 767, R 18 OR Hepatocellular carcinoma, ICD 10 code C 220). Data source https: //fingertips. phe. org. uk/profile/healthprotection/data#page/0/gid/1000002/pat/104/ati/102/are/E 06000055 31
LOCAL BURDEN: BEDFORDSHIRE, LUTON AND MILTON KEYNES(BLMK) Premature mortality: Crude rate of mortality from hepatitis C related end-stage liver disease/hepatocellular carcinoma in persons less than 75 years of age per 100, 000 population (3 year pooled 2014 -16)for BLMK is 0. 75/100, 000 which is higher than England average of 0. 67 and Eo. E average of 0. 59/100, 000. Bedfordshire-0. 87/100, 000 Luton-0. 99/100, 000 Milton Keynes-0. 40/100, 000 this indicator includes number of deaths from hepatitis C related end-stage liver disease/hepatocellular carcinoma (classified by a cause of death mention of ICD codes B 171 or B 182 and a cause of death mention of at least one of the following C 220, I 850, K 704, K 720, K 721, K 729, K 767, R 18) registered in the respective calendar years, in people aged under 75. Data Source: https: //fingertips. phe. org. uk/profile/healthprotection/data#page/0/gid/1000002/pat/104/ati/102/are/E 06000055 32
CLINICAL BENEFIT OF MANAGING ACTIVE HCV INFECTION Early diagnosis and management of an infected person may prevent: Hospital admissions due to end stage liver diseases and hepatocellular carcinoma due to Hepatitis C Milton Keynes: probable 5 -6 admissions/year with end stage liver diseases Bedfordshire: probable 14 -15 admissions /year with end stage liver diseases Luton – probable 11 -12 admissions/year with end stage liver diseases. Early deaths ( Premature mortality): Milton Keynes -1 -2 deaths /year Bedfordshire -4 -5 deaths /year Luton -2 -3 deaths/year# Numbers have been calculated using data from https: //fingertips. phe. org. uk/profile/healthprotection/data#page/0/gid/1000002/pat/104/ati/102/are/E 06000055 33
COST BENEFIT OF MANAGING ACTIVE HCV INFECTION In simple terms, treating a mild case of (early diagnosed) HCV at an average cost £ 10 -20, 000 per case may reduce costs by preventing cirrhosis, End Stage Liver Disease or HCC later on, and reducing need for liver transplants. It has been estimated that cost saved per case of ESLD/ HCC averted in England is £ 100, 000 -150, 000. (Harris et al, J Hep 2014) Early treatment is cost effective and appear to be good value for money if a cost per QALY of £ 30, 000 is used as the threshold for reasonable value. (Stephanie Coward, Laura Leggett, Gilaad G Kaplan, and Fiona Clement Cost-effectiveness of screening for hepatitis C virus: a systematic review of economic evaluations BMJ Open. 2016; 6(9): e 011821) 34
WHAT IS THE PROBLEM? Current picture of testing and commissioning: In the UK, including East of England, patients with HCV are tested for HCV-Ab only when there is an indication of exposure to HCV, not presence of an active HCV virus. To confirm the presence of an active HCV virus, a RNA test should be performed. Evidence from most audits indicate that this does not happen in most part of the UK because of: inappropriate commissioning arrangements with the providers; lack of knowledge in primary care in dealing with people at risk of HCV or with HCV; and not well acquainted with local protocol of managing and treating a case. 35
TO ADDRESS THE ISSUE: A proposal was submitted to request a grant from Gilead UK/Ireland to carry out a study with the aim of protecting those with or at risk of HCV from the consequences/complications of the infection Grant received to deliver a multi-centre/ multi-agency research project/study in the East of England. Study planned to include Luton, Bedfordshire and Milton Keynes with the objectives of: identifying patients with incomplete serological hepatitis C tests and active infection but still not under specialist care by exploring laboratory databases, and re-engaging these patients by referring them to the local Hepatitis treatment centre (specialist care) via their General Practitioners (GPs). 36
ACTIVITY PLAN INCLUDED: o Recruitment: research nurses/PH analyst Clinical governance/Audit team Laboratory Data search: five years (2012 -2016)data extracted by BGH, L&D UH and MKUH. Data Analysis and GP contacts: carried out by PH analysts and Research coordinator/nurse Professional update on Hepatitis C and BBV: to primary care and secondary care professionals Public Engagement and Health Education: educating local population targeting at risk groups. Laboratory databases of three participating hospitals have been interrogated to identify all blood samples which tested positive for anti. Hepatitis C antibodies from January 2012 – December 2016. (Please note: Steering group agreed on an assumption that patients with genotype testing done may be under specialist care. Most of the patients with viral load measured may have had contact with specialist care) 37
Persons tested HCV Antibody positive (2012 -2016) 38
FURTHER INVESTGATIONS CARRIED OUT (2102 -2016) Table below demonstrates local practice protocol of participating hospitals. MK University Hospital Trust Ab+ve persons RNA tested Viral Load measured Genotyping completed 434 102 241 8 39
IDENTIFIED HCV ANTIBODY POSITIVE REQUIRING RE-ENGAGEMENT WITH SPECIALIST CARE Milton Keynes University Hospital NHS Foundation Trust Antibody Positive Count Viral Load measured Genotype identified Remaining Patients to be followed up* 434 241 8 185 * research assumption may not have had contact with specialist care MKUH: 185 patients are identified who may not have had any contacts with specialist care and they need to be followed up. 40
NEXT STAGE OF ACTION Contacting GPs Research Coordinator/nurse rings GPs to confirm registration and health status of HCV Ab positive patients: Milton Keynes-185 patients A letter with referral protocol sent to GPs requesting referral of those patients to the local hepatology service. Once patients in contact with specialist care- treatment and follow-up management will be monitored as per the local protocol. 41
LETTER TO BE RECEIVED BY GPS (PART 1) 42
LETTER TO BE RECEIVED BY GPS (PART 2) Milton Keynes University Hospital NHS Foundation Trust 43
Local care pathway of partner hospitals for specialist care 44
LOCAL CARE PATHWAY FOR MKUH SPECIALIST CARE HCV +ve patients referred to Hepatology by GP, Infectious Disease, GUM, General medicine Patient reviewed by hepatologist to check suitability for Treatment Fibroscan + Nurse led screening questionnaire and blood tests Case discussed at regional MDT and treatment commenced at next appointment 45
LOCAL CARE PATHWAY FOR MKUH SPECIALIST CARE Additional points: Current regional MDT is through Thames Valley (historic links with Oxford) Currently using Hepatology nurse from Oxford to perform screening and fibroscan clinics 1 -2/month Once patients have been treated (usually 3 months worth of drugs) they could be discharged, after negative viral load measured 3 months after the treatment. Long term follow up for patients with cirrhosis continues in secondary care. There is a plan of hiring a Hepatology nurse to run clinics locally and go into community. 46
CHALLENGES IN DELIVERING ACTIONS Capacity and release of workforce Recruitment- conflict of policies across partner organisation/lengthy procedure/ HR processes. Governance: permission to access information Varied data recording and data outputs and volume of data Multiagency partners with different work culture and understanding working to a common goal. 47
BBV screening in primary care pilot Lucy Hubber Specialty Registrar in Public Health
Blood Borne Virus screening pilot in primary care • • Rates of BBV are increasing nationally. Found in identifiable at-risk groups. Five GP practices agreed to a pilot to screen for HBV and HCV in addition to HIV. Commenced in February 2017, following training and implementation of reporting structure. Practice Total aged BME aged Annual new 6 month Expected pop’n all 15 -64* registration** estimated number to age number be tested Ashfield MC 12283 8146 2126 425 213 53 Central Milton Keynes 17337 12817 3345 669 335 84 MC Fishermead MC 6482 4646 1213 243 121 30 The Grove Surgery 6544 4525 1181 236 118 30 Wolverton HC 15080 10043 2621 524 262 66 * Based on 26. 1% of population, 2011 census **Estimated at 20%
Patient pathway • Agreed with GP practices and secondary care • Developed following learning from LTBI pilot • Clarifies roles, reimbursement and recording • Included in service specification/contract
Results • 19. 6% of those tested are positive for HBV • 24. 5% positive for exposure to HCV. • Of these 19. 2% (or 4. 7% of the total tested) were positive for active HCV infection, shown through a positive PCR test. This compares to estimated national prevalence of 0. 1 -0. 5% for HBV and 0. 5 -1. 0% for HCV (HSE, 2017). • The total cost of the primary care elements of the project came to £ 5, 165 (£ 103 per positive test). Ashfield MC Central Milton Keynes MC Fishermead MC The Grove Surgery Wolverton HC 0 Identification of HBV through core antibody or surface antigen test 0 113 0 9 0 122 HBV test HCV test Identification Confirmation of HCV using DNA through PCR test antibody test 0 0 24 0 97 0 26 0 5 0 10 0 24 9 0 106 0 0 26 0 0 5 0 0 10
Refreshment Break
IMSK and Pain Management – A Service Overview Raja Challuri and Emma Gayton 22 March 2018
IMSK and Pain Management Introduction • Commissioned by Milton Keynes CCG and delivering since April 2017. • Service started as a pilot in September 2014. • Following a successful pilot during which included good clinical outcomes, financial savings and decreased secondary care activity MK CCG decided to commission a long term Community MSK service. • The service comprises of a Multidisciplinary Team.
IMSK and Pain Management – Our Role • Help with managing most patients with MSK conditions in the line with current guidelines. • Signposting to the appropriate service • Provide advise and guidance • Request diagnostics as appropriate • Minor procedures in the community – joint injections, Ultrasound Guided Injections. • Pain management – Interventionist and Bio-psychosocial. • Onward referral to secondary partners as appropriate.
IMSK and Pain Management – Referral Criteria • Age 16 years and over. • Patient registered wit Milton Keynes GP Practice. • All MSK conditions – orthopaedic and pain management. • Assessment for Prior Approval. • Patient has been ruled out for presence of Red Flags.
IMSK and Pain Management – Locations • Westfield Road, Bletchley, MK 2 2 RA. • Westcroft Health Centre. • Purbeck Health Centre. • Broughton Gate Health Centre.
IMSK and Pain management – Our Team Operational Management • Clinical Leads – Sachin Parab and Raja Challuri • Medical Director – Dr. Chandu Prasannan • Practice Manager – Mrs. . Emma Gayton
IMSK and Pain Management – Our Team Orthopaedic Consultants • Mr. Don Wallace – Shoulder, Elbow and Knee. • Mr. Mohammed Khalik – Foot and Ankle. • Mr. Cyril Marek – Knee and Hip. Pain Consultant • Dr. Yaseer Mehrez – Interventional Pain and Neuromodulation
IMSK and Pain Management – Our Team MSK PHYSICIANS (GPw. SI in MSK) • Dr. Chandu Prasannan (Caudal Epidural Injections, Pain Management) • Dr. Martin Cave (Caudal Epidural Injections, SIJ Injections, Lumbar Facet Injections) • Dr. Vinay Ketkar (Caudal Epidural Injections, Pain Management • Dr. Davinder Gunjal (Caudal Epidural Injections, Pain Management, Rheumatology)
Our Team Extended Scope Physiotherapists • Mr. Sachin Parab – Joint Injections, MMACP. • Mr. Raja Challuri – Joint Injections, USG Injections. • Mr. Mohit Kothadia – Joint Injections, MMACP. • Mr. Nitin Gumber – Joint Injections. • Mr. Prashant Sahu – Joint Injections. • Mrs. . Priya Shah – Pain Management. • Mr. Praveen Thamattore – USG Injections, Specialist Procedures. • Mr. Boobal Chandran – USG Injections, Specialist Procedures.
Our Team Clinical Psychologists • Dr. Susan Bartholomew – Pain Management Programme, CBT • Dr. Sue Peacock – CBT and 1: 1 Psychology.
IMSK and Pain Management – Overall Pathway
IMSK And Pain Management – Pathway Overview. Assessments • Referral Triage – through RMS • Telephone Assessment. • Face to Face assessment. • Referral for Diagnostics – including X-ray, MRI scan, US scan, Nerve Conduction Studies • Prior Approval for procedures under the Po. LCV policies.
IMSK And Pain Management – Pathway Overview. Interventions Offered • • • Manual Therapy. Manipulation. Exercise Prescription. Acupuncture and TENS pain management. Joint Injections. Ultrasound Guided Joint Injections. Caudal Epidural Injections. SIJ Injections. Pain Management Programme. 1: 1 CBT for pain management.
IMSK And Pain Management – Pathway Overview. Specialist Procedures • Trigger Point Injections. • Ultrasound Guided Lumbar facet injections (being developed with the Pain Consultant) • Ultrasound guided procedures like Barbotage for shoulder condition, High Volume Injections, Hydro distension. • Shockwave Therapy (In the near future – speaking to the CCG about the same).
IMSK and Pain management – Key Facts (Feb 2018) • Average waiting times. • Routine appointments – 15 working days. (after referral received from RMS) • Urgent appointments – 3 -5 working days (after referral received from RMS) • DNA rates – 4% • Conversion to surgery – 92% • Patient satisfaction – 98%
IMSK and Pain Management – Updates and CPD • Organise regular CPD Evenings • Managing Persistent Back Pain in Primary Care – Dr. Yaseer Mehrez and Mr. Mohit Kothadia (ESP) • Management of Common Shoulder Conditions – Mr. Don Wallace and Mr. Sachin Parab (ESP) • Quarterly newsletters providing update about the service.
IMSK and Pain management – Useful Contacts Administrative queries Mrs. Emma Gayton (Practice Manager) Email: emma. gayton@nhs. net Number: 019082 270175. Clinical queries • Sachin Parab (Clinical Lead) Email: contracts. ravenscroft@nhs. net Number: 01908270175. • Raja Challuri (Clinical Director) Email: contracts. ravenscroft@nhs. net Number: 01908270175.
MSK and Pain Management Case Studies Sachin Parab – Clinical Lead 22 March 2018
Case Study 1 • 55 year old gentleman presented with right medial knee pain. • Gradual onset after a walking holiday about 4 weeks before the assessment. • Swelling at the time but had settled. No bruising. • Aggravated with kneeling, squatting and prolonged periods of standing. • No locking or giving way. • PMH – Hypertension, Type 2 DM.
Objective Examination • • No Swelling, wasting and skin changes. Biomechanics and gait – Limping. Functional assessment – squats, kneeling, lunges. Ranges of motion Manual muscle testing Motor control Proprioceptive testing.
Special Tests - Meniscus (Malanga et al 2005) • Mc. Murray’s • Thessaly’s • Joint Line Tenderness
Special Tests – Knee Ligaments ACL • Lachmann’s • Anterior Drawer’s PCL • Posterior drawer’s • Posterior sag sign MCL/LCL • Varus/Valgus Stress test
Clinical Impression • Degenerative medial meniscus tear +/ - OA • Investigation • X-ray in weight bearing to assess OA • MRI scan if locking or not responding to conservative management.
Management • Conservative management – IMSK and Primary Care. • Wait and Watch • Pharmacological cover • Functional strengthening exercises • Proprioceptive and plyometric • Joint injection if established OA and inflammatory component present.
Management • Surgical management Mechanical symptoms present – locking/giving way Failed conservative management Pain affecting everyday functions MRI scan evidence of complex/unstable tear Arthroscopic debridement better at 3 -6 months, but no different at 1 year as compared to physiotherapy and worse than physiotherapy at the end of 2 years. • 22% acceleration of OA at 8 -14 years. • Evidence in line with Prior Approval Policy for Knee Arthroscopy • • •
Case Study 2 • 50 year old lady presenting with central low back and right leg pain – 4 weeks onset. • Numbness and tingling in right lateral leg and foot • Sudden onset after prolonged period of weeding in the garden. • Pain increased with prolonged periods of standing and walking • Sleep disturbed • PMH – Hypertension and hypercholestremia • No CES symptoms • No P/H Ca or F/H Ca
OBSERVATION • POSTURE • GAIT Tip toe walking – S 1 weakness Heel walking – L 5 weakness
Examination • Spinal mobility • Pain pattern • Work nature • ADL
Examination Neural Sensitivity Tests • SLR • SLUMP • Prone knee bending Neurological testing • Jerks • Dermatomes • Myotomes • Babinski • Clonus
Clinical Impression • L 5/S 1 discogenic pathology • Possible S 1 nerve root irritation/compression • Radiculopathy
Management • Before 6 weeks • STar. T Back Score. • Wait and Watch • Pharmacological cover • Advise and exercises • After 6 weeks if no better consider referral to IMSK service
Management • In IMSK service • Referral for diagnostics if appropriate • Manual therapy • Acupuncture • Spinal injections (caudal epidural) • Onward referral
Case Study 3 • 55 year old factory worker presented with right anterior shoulder and lateral arm pain. • Gradual onset over a year but worsened in the last 2 months. • Aggravated with elevation, lying on right side and hand behind back. • On examination – painful arc, positive Hawkins's Kennedy, Empty Can test and Neer’s sign.
Clinical Impression • Sub acromial Pain Syndrome • Sub acromial bursitis • Calcific tendonitis • Rotator cuff strain/tear (partial thickness)
Investigations • Ultrasound – sensitive and specific • MRI scan – only if considering surgery to look fatty deposition in the cuff to predict outcome.
Management Options • Physiotherapy – Holmgren exercise programme • Corticosteroid injections x 2 • CSI and Exercises 92% improvement (Lewis et al 2014) • ESWT • Arthroscopic subacromial decompression
Case Study 4 • 62 year old lady sudden onset of right arm weakness following digging in the garden over the weekend. • Initially pain but then stopped. Unable to lift the arm in elevation and abduction. • On examination restricted AROM but full PROM • Positive External Rotation Lag Sign • Weak external rotators
Clinical Impression, Investigation and Management • Clinical Impression • Full thickness/massive rotator cuff tear (? degenerative) • Investigation • USS – specific and sensitive • MRI scan – for fatty deposition • Management • Non surgical – Anterior deltoid eccentric strengthening exercises (degenerative tears) • Injections • Refer for surgical opinion if conservative management fails.
Case Study 5 • 45 year old female presenting with multiple joint pains mainly back and knees • Ongoing for 15 years. • Diagnosis of Chronic Pain Syndrome (“Fibromyalgia”) • Has had physiotherapy on and off – not compliant with self management. • Pain killers as per the analgesic ladder. • Been to the pain clinic where tried acupuncture – short term relief • Failed to attend the pain management programme. • STar. T Back Score – Medium - High Risk
Management Primary Care • Review Pain medication in line with analgesic ladder. • Review if previous management plan has been adhered to. IMSK Service • Review previous management. • If symptoms different and neurological signs consider further diagnostics. • Acupuncture and TENS. • Intervention Pain Management – Trigger point injection, Facet joint injection. • Pain Management Programme
Pain Management Programme • Evidence Based Programme adapted from recommendations of the British Pain Society • 7 week programme for 3 hours every week • Conducted by Pain Psychologist and Physiotherapist with Special Interest in Pain Management. • Covers bio psychosocial aspects of pain including pacing, stress and emotions, sleep hygiene, communication, medication management.
Case Study -5 • 50 year olf computer worker presents with insdious onset of pins and needles and numbness in the lateral 3 and ½ fingers in the right hand. • Symtpoms most pronounced at night • Eased with shaking. • O/E Mild thenar wasting • Phalene’s and Tinel’s positive.
Clinical Impression and Management • Carpal Tunnel Syndrome. • Management – Conservative • • Splinting Physiotherapy Activity modification Injection x 2
Management • Management – Surgical • NCS investigation • Carpal tunnel release
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