Neck Pain

Information for GPs who refer into PAH Spinal and knee MRIs should only be requested as a pre-cursor to surgery.

If you think a patient requires an MRI as there may be a need for surgery, please refer the patients in the first instance to the Herts MSK Triage Service (Phone 01707 781621). Patients will then be triaged by an Extended Scope Practitioner (ESP) who will be able to request an MRI if required.

If you encounter any issues accessing the Extended Scope physio service or direct access to MRI for the red flag conditions specified in Appendix 1 of the guidance document linked to above, please call the Contract Hotline on 07786 625043 or emailcontracthotline.enccg@nhs.net

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Clinical Presentation

HistoryClick for

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Consider measuring neck disability index (NDI)

http://www.physio-pedia.com/Neck_Disability_Index

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ExaminationClick for

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Consider causes of neck pain

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RED FLAG!

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Refer urgently toappropriate specialist

Vertebro - basilar symptoms

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Refer to neurology

Whiplash injuryClick for

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RED FLAG!Click for

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Initial managementClick for

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Consider physiotherapy if persists after

2-4 weeks

Management of persistent symptoms (6 months)

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Refer to pain serviceIf patient is likely to be at risk for

developing chronic symptomsNB: unless the patient is high risk it is

recommended patients at this stage are

usually referred to ESP

Referral to painservice

Refer to ESP (MSK triage service)Further assessment, investigations and MDT discussion with secondary care as appropriate - please see information at

the top of this pathway

ESP/MSK referralImaging – ESP will order imaging as appropriate

MDT discussionMDT discussion with ESP, spinal

surgery, pain consultant, psychology as appropriate

Non-specific neck painClick for

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Initial management and investigations

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Management of neck pain for 4 to 12 weeks

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Refer to physiotherapyhttp://www.enhertsccg.nhs.uk/

No resolution after 12weeks

Alternative treatment options

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Referral to pain orother service as required

Acute torticollisClick for

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ManagementClick for

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Cervical radiculopathyClick for

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See pathway Cervical Radiculopathy

http://www.enhertsccg.nhs.uk/

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Potential for home exercises

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Click for referral info for HCT MSK triage

service

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Scope:• assessment of neck pain in adults (age 18 years and older)• common causes of neck pain, including:

• acute torticollis• whiplash injury• non-specific causes

• management of cervical radiculopathy• investigations in secondary care• pharmacological and non-pharmacological treatments

Out of scope:• assessment of neck pain in children (age less than 18 years)

Definition:• acute torticollis is commonly known as 'wry neck' or 'twisted neck' [8]:

• usually sudden onset producing a unilateral pain with deviation of the neck to that side• no history of trauma or strain

• acute whiplash injury usually follows sudden or excessive hyperextension, hyperflexion, or rotation of the neck [9]• non-specific neck pain has no readily and accurately identifiable pain source and it is typically provoked by neck movements [23]• cervical radiculopathy is usually caused by compression to a nerve root in the cervical spine [7]

Prevalence:• lifetime prevalence of neck pain has been reported to be up to about 70% [2]• the 12 month prevalence of simple neck pain in adults is between 30 and 50% [20]• neck pain can become chronic and affects up to 10% of males and 17% of females [12]

Risk factors include:• advancing age causing degenerative disc disease [25]• bad posture [8]• poor positioning at a computer screen [8]• inappropriate seating [8]• sleeping without adequate neck support [8]• carrying heavy, unbalanced loads, e.g. briefcase or shopping bags [8]• workplace associated risk, e.g. duration of sitting and neck posture [6]• behaviour or incident with the potential to cause a whiplash injury, such as [9]:

• diving• motor vehicle accident

Prognostic factors of delayed functional recovery include [6]:• high initial pain intensity• greater number of symptoms• greater initial disability

References:[2] Falco FJ, Manchikanti L, Datta S et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain physician 2012; 15: E839-E868.[6] Clinical Knowledge Summaries (CKS). Neck pain - non-specific. London: CKS; 2009. Available from: http://cks.nice.org.uk/neckpain-non-specific[7] Clinical Knowledge Summaries (CKS). Neck pain - cervical radiculopathy. London: CKS; 2009.[8] Clinical Knowledge Summaries (CKS). Neck pain - acute torticollis. London: CKS; 2009.[9] Clinical Knowledge Summaries (CKS). Neck pain - whiplash injury. London: CKS; 2009.[12] Patel KC, Gross A, Graham N et al. Massage for mechanical neck disorders. Cochrane Database Syst Rev 2012; 9: CD004871.[20] Langevin P, Peloso-Paul MJ, Lowcock J et al. Botulinum toxin for subacute/chronic neck pain. SO: Cochrane Database Syst Rev 2011; CD008626.[23] Langevin P, Lowcock J, Weber J et al. Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis. J Rheumatol 2011; 38: 203-14.[25] Jacobs WC, Anderson PG, Limbeek J et al. Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease. Cochrane Database Syst Rev 2004; CD004958.

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History

Consider Red Flags

Pain:• characteristics of pain• effects of pain – including occupation and recreational activities• risk factors for developing neck pain, including workplace associated risk [6]• osteoporosis risk factors [10]• inquire about neurological symptoms, bladder, and bowel symptoms [6]

If the patient was involved in a motor vehicle accident:• was the collision a simple rear-end?• can the patient sit now?• could the patient walk after the injury?• has there been delayed onset of neck pain?

Psychosocial factors which increase risk of chronicity and disability:• unrealistic expectations of treatment• disabling sickness behaviour• problems with compensation, work, family, mood, and emotions• stress, anxiety, depression or poor concentration

NB: the negative predictive value of red flag symptoms is high and if none are present it is unlikely that a serious spinal abnormality has been missedNB: interpret positive findings with caution as the positive predictive value for diagnosing disease is poor

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Consider measuring neck disability index (NDI)

Ask the patient to self-evaluate their level of pain using the neck disability index (NDI): http://www.physio-pedia.com/Neck_Disability_Index:• acute and chronic conditions• neck pain associated with musculoskeletal dysfunction, whiplash-associated disorders (WADs), and cervical radiculopathy• score is out of 50 (as recommended by the developer) - caution should be used when reading clinical reports to ascertain which metric was used (may

be given as percentage)

• Vernon and Mior [1] suggest that a score between:• 0-4 represents no disability• 5-14 represents mild disability• 15-24 represents moderate disability• 25-34 represents severe disability• > 35 represents complete disability

• Sterling et al [2] suggest that a score between:• 0-8 represents recovery• 10-28 represents mild disability• > 30 represents moderate to severe disability

• short-term therapy goals should require a minimum of 5-10 points change for WADs• longer-term treatment goals should be set for a minimum 7 point reduction in score• when the baseline score is outside of the 10-40 range, supplementation of the NDI with a Patient-Specific Functional Scale (PSFS) should be considered

References:

[1] Vernon H, Mior S. The neck disability index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics, 1991, 14:409-15

[2] Sterling M (2014) Physiotherapy management of whiplash-associated disorders (WAD).Journal of Physiotherapy60: 5–12

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Examination

• should include neck examination and neurological examination [27]:• palpate for areas of spasm or tenderness and identification of trigger points [11]

Neurological examination:• evaluate muscle strength, sensation, and tendon reflexes [11]• assess for [10]:

• upper motor neuron signs, e.g. Babinski's sign – up-going plantar reflex, hyperreflexia, clonus, spasticity• lower motor neuron signs such as atrophy and hyporeflexia• sensory changes – vibration, soft/sharp touch, proprioception (e.g. joint position)

References:[10] Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Acute Pain. Bloomington, MN: ICSI; 2008.[11] Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Chronic Pain (Guideline). 5th ed. 2011.[27] Practice-informed recommendations, including contributors representing the Royal College of General Practitioners; 2013.

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Consider causes of neck pain

First consider RED FLAG causes

Then consider the following common causes of neck pain [6]:• acute torticollis – if neck pain is due to spasm with no obvious underlying cause• whiplash injury – if neck pain occurred following a recent sudden or excessive episode of hyperextension, flexion, or rotation• non-specific neck pain:

• if neck pain varies with different physical activities and with time; or• is related to awkward movement, poor posture, or overuse

• consider cervical radiculopathy if there is evidence of:• unilateral neck, shoulder, or arm pain that is approximately related to a dermatome• altered sensation or numbness, or weakness in related muscles• NB: the presence of pain or paraesthesia radiating into the arm is not specific for nerve root pain and may be present in those with non-specific neck pain

• consider other causes, including fibromyalgia or inflammatory arthropathies such as rheumatoid arthritis

References:[6] Clinical Knowledge Summaries (CKS). Neck pain - non-specific. Version 1.0. Newcastle upon Tyne: CKS; 2009.

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RED FLAG

If any of the following conditions are suspected, refer urgently for investigations and further assessment:• new symptoms before age 20 years or after age 55 years• weakness involving more than one myotome or loss of sensation involving more than one dermatome• intractable or increasing pain

Myelopathy (compression of the spinal cord)• insidious progression• neurological symptoms – gait disturbance, clumsy or weak hands, loss of sexual, bladder, or bowel function• sensory changes

Malignancy, inflammation or infection• fever• pain that is increasing, unremitting, or disturbs sleep• history of inflammatory arthropathy e.g. RA, ankylosing spondylitis• severe trauma or skeletal injury• unexplained weight loss, malaise, fever• history of cancer, inflammatory arthritis, tuberculosis, immunosuppression, drug abuse, AIDS, or other infection• lymphadenopathy• exquisite tenderness over a vertebral body

Trauma or skeletal injury• history of trauma or fall from a height• history of neck surgery• risk factors for osteoporosis, such as premature menopause and use of systemic steroids – minor trauma may cause compression fractures in those

with osteoporosis

Vascular conditions• drop attacks• dizziness and blackouts on movement, especially extension of the neck when gazing upwards

Seek immediate specialist advice if the person has severe or progressive motor weakness, or severe or progressive sensory loss.

The imaging modality of choice is MRI and should be considered when there is an objective neurological deficit on examination or red flags are present.

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Vertebro - basilar symptoms

The presence of dizziness is the most common presenting symptom of Vertebrobasilar Insufficency (VBI). If dizziness is present, other symptoms associated with VBI should be sought, including:

• Visual disturbances such as diplopia (double vision), blurred vision and transient hemianopia• Dysarthria (difficulty with speech)• Dysphagia (difficulty with swallowing)• Drop attacks (sudden loss of power with no loss of consciousness)• Nausea and vomiting• Lightheadedness and fainting• Disorientation or anxiety• Hearing disturbances such as tinnitus• Facial or oral paraesthesia or anaesthesia• Pallor, tremors and sweating• Other neurological symptoms

If any suspicion of Vertebrobasilar insufficiency refer to neurology.

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Whiplash injury

Whiplash is caused by an acceleration-deceleration mechanism which commonly occurs in:• rear-end or side-impact motor vehicle collisions• other activities and mishaps, e.g. diving

Confirm a history of sudden or excessive neck extension, flexion, or rotation [6].

Symptoms – may be delayed for hours or days after the injury [9]:• the two most common are disabling neck pain, with or without referral to the shoulder or arm, and headache• other features include:

• fatigue• dizziness• paresthesia• nausea• jaw pain• posterior cervical sympathetic syndrome – headaches or facial formication (sensation of ants crawling over face)

Alarming presenting symptoms include:• visual disturbance• impairment of the proprioceptive control of head and neck position• impaired cognitive function

'Late whiplash syndrome' is characterized by a variety of symptoms that persist for more than 6 months after an acute whiplash injury [9].

Prognostic factors of delayed functional recovery include high initial pain intensity, a greater number of symptoms, and greater initial disability [6].

References:[6] Clinical Knowledge Summaries (CKS). Neck pain - non-specific. Version 1.0. Newcastle upon Tyne: CKS; 2009.[9] Clinical Knowledge Summaries (CKS). Neck pain - whiplash injury. London: CKS; 2009.

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RED FLAG (Whiplash)

If a fracture or subluxation of the cervical vertebrae is suspected, refer immediately to Accident and Emergency – midline cervical tenderness suggests a fracture or dislocation, or other serious injuries.

Urgent X-ray of the cervical spine is recommended by the Royal College of Radiologists if any of the following are present:• not safe to examine• inability to laterally rotate the neck left and right to 45 degrees• Glasgow Coma Score less than 15• paraesthesia in extremities• focal neurological deficit• age ≥ 65 years • dangerous mechanism of injury, e.g. fall from height greater than one meter

References:[9] Clinical Knowledge Summaries (CKS). Neck pain - whiplash injury. London: CKS; 2009.

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Initial management

Self-care advice:• provide reassurance that whiplash-associated disorder is usually benign and self-limiting• encourage early return to usual activities and early mobilization – these may be painful initially but they are not harmful or indicative of ongoing damage• discourage rest, immobilization, and use of soft collars

Offer analgesia:• paracetamol and/or ibuprofen taken regularly, or as required• codeine may be added to regular paracetamol or ibuprofen – prescribe separately for flexible dosing and titration of analgesic effect (combination

products, e.g. co-codamol, are not recommended)• escalate analgesia depending on severity and other symptoms

Consider psychosocial factors such as depression and anxiety, and manage as appropriate.

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Management of persistent symptoms (6 months)

If whiplash injury symptoms persists for more than 6 months consider the following:• resist the pressure to over-treat and over-investigate• encourage and facilitate a return to normal activities• diagnose and treat anxiety and depression where they coexist• do not sanction behaviours that promote disability• use the lowest doses of the simplest medications• do not enhance the person's expectations of a poor outcome and chronic disability• reduce, where possible, the influence of 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• a trial of low-dose tricyclic antidepressants for 1 month may be helpful in those with persisting pain for 4-6 weeks who are unresponsive to full-dose

analgesics

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Non-specific neck pain [23]

• also called simple or mechanical neck pain• may be subacute (30 to 90 days) or chronic (> 90 days)• may cause:

• referred pain in the upper extremity – cervicobrachial pain• head – cervicogenic headache

• may be caused by:• degenerative changes such as spondylosis• myofascial pain syndrome

Clinical Features [6]:• aggravated by particular movements, posture, and/or activities, and relieved by others• commonly, exercise makes the pain worse and rest relieves it, but the opposite may also be true• typically radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae• commonly associated with muscle stiffness and spasm• may also be associated with:

• odd sensations, e.g. temperature change, subjective weakness• paraesthesia• hyperaesthesia• cervical stiffness• headache or dizziness• pain in the spine• not usually associated with objective loss of sensation or muscle strength/power

• very rarely, it may be associated with:• dysphagia (due to large anterior osteophytes)• syncope• triggering of migraine• pseudo-angina

Typical signs include [6]:• positional asymmetry – degree of asymmetry varies, e.g. a small positional change from normal resting position of the neck, to torticollis where the

neck is pulled to one side• unequal restriction or limited range of movement (common with ageing)• tenderness in hypertonic muscles or intervertebral joints – usually poorly localized• soft-tissue signs – localised areas of increased muscle tone that can be palpated as nodules or tender bands

Reference:[6] Clinical Knowledge Summaries (CKS). Neck pain - non-specific. Version 1.0. Newcastle upon Tyne: CKS; 2009.[23] Langevin P, Lowcock J, Weber J et al. Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis. J Rheumatol 2011; 38: 203-14.

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Initial management and investigations

• Cervical X-rays are not routinely required to diagnose or assess acute non-specific neck pain.• NB if objective neurological deficit/red flag refer urgently for MRI; no other investigations needed

Initial management (if no red flags):• reassure the patient that neck pain is common and often resolves within a few weeks• encourage the patient to stay active and return to a normal lifestyle, including work, as soon as possible:

• advise them not to drive if their neck range of motion is restricted• discourage the use of cervical collars because this restricts mobility and may prolong symptoms

• advise the patient that 1 firm pillow may provide additional comfort during the night, whereas 2 pillows can force the head into an unnatural position• offer analgesia:

• paracetamol and/or ibuprofen taken regularly, or as required• codeine may be added to regular paracetamol or ibuprofen – prescribe separately for flexible dosing and titration of analgesic effect (combination

products, e.g. co-codamol, are not recommended)• Escalate depending on severity and other symptoms

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Management of neck pain for 4 to 12 weeks

Consider the following in addition to initial management for those with neck pain for 4 to 12 weeks.

Consider referral to a physiotherapist • exercises:

• effectiveness remains unclear• low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain

immediately post-treatment and intermediate term, and for cervicogenic headaches in the long-term• manipulation and mobilization:

• may provide immediate or short-term improvement• no long-term data available

• massage:• Cochrane review: immediate or short term relief of pain and tenderness, however no recommendations for practice have been made

Address any psychosocial factors and refer as appropriate:• beliefs about avoiding activity• associated anxiety and depression• medico-legal issues• family dynamics

Consider referral to Occupational Health for people with neck pain related to work

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Alternative treatment options

Pain which is suspected or identified to be originating from the facet joint• facet joint injection [11]:

• facet joints can be reliably anaesthetised using fluoroscopically guided injections• depot corticosteroid may be administered concomitantly, which may provide short-term benefit for a subset of patients• clinical trials have failed to demonstrate any sustained therapeutic benefits following facet joint corticosteroid injections

• percutaneous radiofrequency neurotomy [11] – the evidence for treatment effect is fair [2]• cervical medial branch block – the evidence for treatment effect is fair [2]• botulinum toxin [20,23]:

• has been used for subacute and chronic neck pain• current evidence fails to confirm either clinical importance or the statistical significance of Botulinum toxin for neck pain

• low-level laser therapy – there is inconclusive evidence and the benefit has not been clinically established [24]

References:[2] Falco FJ, Manchikanti L, Datta S et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain physician 2012; 15: E839-E868.[11] Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Chronic Pain (Guideline). 5th ed. 2011.[20] Langevin P, Peloso-Paul MJ, Lowcock J et al. Botulinum toxin for subacute/chronic neck pain. SO: Cochrane Database Syst Rev 2011; CD008626.[23] Langevin P, Lowcock J, Weber J et al. Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis. J Rheumatol 2011; 38: 203-14.[24] Kadhim-Saleh A, Maganti H, Ghert M et al. Is low-level laser therapy in relieving neck pain effective? Systematic review and meta-analysis. Rheumatol Int 2013.

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Acute torticollis [8]• common condition also known as 'wry neck' or 'a twisted neck' – occasionally pain may be in the middle of the neck or referred to the head or

shoulder region• thought to be due to minor local musculoskeletal irritation causing pain and spasm in neck muscles• cause of torticollis is often not known, but it may be due to:

• bad posture• poor positioning at a computer screen• inappropriate seating• sleeping without adequate neck support• carrying heavy, unbalanced loads, e.g. briefcase or shopping bags

Assess for typical features, such as [8]:• sudden onset (often on waking) of severe unilateral pain with deviation of the neck to that side• neck feels stuck in one position and any attempted movement to free it results in sharp spasms of pain• no history of trauma or strain• history of:

• localized exposure to prolonged cold• unusual positioning of the neck• unusual posture, e.g. holding the neck in an unusual position whilst working, sleeping, or reading

• on examination there is usually unilateral diffuse tenderness with palpable spasm and restricted or painful movement

Reference:[8] Clinical Knowledge Summaries (CKS). Neck pain - acute torticollis. Version 1.0. Newcastle upon Tyne: CKS; 2009.

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Management

Explain to the patient that [8]:• acute torticollis usually resolves within 24-48 hours• occasionally symptoms take up to a week to resolve• recurrence is common

Advise the patient of general measures which they can do to relieve symptoms [8]:• gentle exercise (within comfort zone)• intermittent heat or a cold pack to help reduce pain and spasm• sleeping on a low firm pillow• maintaining a good posture

• routine use of a soft cervical collar is not recommended:• if there is severe pain on moving the neck then wearing a soft collar for a few days may help• consider driving ability – may be difficult to rotate the head to view traffic

Offer analgesia [8]:• paracetamol and/or ibuprofen taken regularly, or as required• codeine may be added to regular paracetamol or ibuprofen – prescribe separately for flexible dosing and titration of analgesic effect

(combination products, e.g. co-codamol, are not recommended)• escalate depending on severity and symptoms

Reference:[8] Clinical Knowledge Summaries (CKS). Neck pain - acute torticollis. Version 1.0. Newcastle upon Tyne: CKS; 2009.

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Cervical radiculopathy

• commonly caused by degenerative disc disease• radiculopathy occurs as a result of nerve root compression, whereas myelopathy occurs due to compression of the spinal cord• NB: myelopathy is a red flag and if suspected should be referred urgently for investigations and further assessment [6] • can cause:

• loss of disc space height• loss of foraminal area• herniated intervertebral disc• protruding osteophytes

• can result in significant pain, instability, radiculopathy, myelopathy, or a combination of symptoms

References:[6] Clinical Knowledge Summaries (CKS). Neck pain - non-specific. London: CKS; 2009.[25] Jacobs WC, Anderson PG, Limbeek J et al. Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease. Cochrane Database Syst Rev 2004; CD004958.

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Information for patients and carers

Potential for home exercises

British Pain Society leaflet, Managing your pain effectively using over-the-counter medicines: http://www.selfcareforum.org/fact-sheets/

Brain and Spine Foundation: http://www.brainandspine.org.uk/information-brain-spine-conditions

BUPA – Osteopathy: http://www.bupa.co.uk/health-information/directory/o/osteopathy

Patient Info - Nonspecific Neck pain: http://patient.info/health/nonspecific-neck-pain

Patient Info – Torticollis: http://patient.info/health/torticollis-leaflet

Patient Info - Whiplash Neck Sprain: http://patient.info/health/whiplash-neck-sprain

Patient Info - Cervical Spondylosis: http://patient.info/health/cervical-spondylosis-leaflet

ARC neck pain exercises: http://www.arthritisresearchuk.org/arthritis-information/conditions/neck-pain/neck-pain-exercises.aspx

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Referral information for HCT MSK Triage Service

The administration team are based at the New QE2 hospital.

Appointments and General Enquires: 01707 247411 or 01707 247412

Fax: 01707 247428

E- referral enquiries via the MSK e-referral administration on: 01707 247416

Fax: 01707 247428

Referral to the service is via the NHS e- referral system (previously Choose and Book). Electronic screening of referrals takes place on a daily basis by clinicians. The referrals are either referred directly to secondary care where they manage the Choose and Book process, or seen for clinical assessment by the team to decide the appropriate pathway of care.

Clinics for assessment are held at The New QE2, Hertford County Hospital, Cheshunt Community Hospital and Lister Hospital.

The MSK Triage Service and the MSK Physiotherapy Service are both part of the whole integrated HCT MSK Service, and as such can refer directly to each other as appropriate.

The MSK Physiotherapy Service is a team of therapists specialised in the treatment and management of Musculoskeletal Conditions and based over 6 sites in East and North Herts. (Referral for this team is currently paper referral but we are working towards referral by email when we have transferred to full electronic records).

The MSK Triage Service is a team of Extended Scope Practitioners (Physiotherapists by background) but with training and advanced skills for specialist assessment, referring for diagnostics and providing injection therapy. This team meets regularly for 3 MDT meetings with the appropriate Consultant Surgeons for the upper limb, lower limb and spine. Complex cases are discussed at these meetings to provide integrated care as necessary.

Referral information for HCT MSK Triage Service

The administration team are based at the New QE2 hospital.

Appointments and General Enquires: 01707 247411 or 01707 247412

Fax: 01707 247428

E- referral enquiries via the MSK e-referral administration on: 01707 247416

Fax: 01707 247428

Referral to the service is via the NHS e- referral system (previously Choose and Book). Electronic screening of referrals takes place on a daily basis by clinicians. The referrals are either referred directly to secondary care where they manage the Choose and Book process, or seen for clinical assessment by the team to decide the appropriate pathway of care.

Clinics for assessment are held at The New QE2, Hertford County Hospital, Cheshunt Community Hospital and Lister Hospital.

The MSK Triage Service and the MSK Physiotherapy Service are both part of the whole integrated HCT MSK Service, and as such can refer directly to each other as appropriate.

The MSK Physiotherapy Service is a team of therapists specialised in the treatment and management of Musculoskeletal Conditions and based over 6 sites in East and North Herts. (Referral for this team is currently paper referral but we are working towards referral by email when we have transferred to full electronic records).

The MSK Triage Service is a team of Extended Scope Practitioners (Physiotherapists by background) but with training and advanced skills for specialist assessment, referring for diagnostics and providing injection therapy. This team meets regularly for 3 MDT meetings with the appropriate Consultant Surgeons for the upper limb, lower limb and spine. Complex cases are discussed at these meetings to provide integrated care as necessary.