The underlying cause of the pain should be treated whenever possible

• Step 1 — paracetamol
• Step 2 — paracetamol should be substituted with ibuprofen (if suitable) or weak opioid (codeine)
• Step 3 — paracetamol should be added to ibuprofen or the weak opioid
• Step 4 — paracetamol should be continued and ibuprofen replaced with an alternative NSAID (naproxen)
• Step 5 — a weak opioid (codeine) should be started in addition to paracetamol and/or a NSAID (naproxen)

How to deal with medication requests for pain relief:

Find out:

1. How long patient has had the medication (paracetamol/codeine/ibuprofen/naproxen) 
2. Whether condition is getting better/staying the same/getting worse
3. Are there any red flags

If resolving but just not better yet

<6 weeks after acute pain initiation

continue to prescribe and send AccuRx message: 

New MSK Pain < 6 week AccuRx message: 

I have issued your prescription for your pain medication. Evidence shows that most new injuries, aches, & pains will improve within 6 weeks with the simple steps in this link: https://www.sussexmskpartnershipcentral.co.uk/new-injuries/

New back pain <6 weeks AccuRx message: 

I have issued your prescription for your pain medication. To know when you should seek urgent help for your back pain watch this video https://www.youtube.com/watch?v=FdlxfcJmn-4 otherwise here's some good advice on how to help your back pain https://www.sussexmskpartnershipcentral.co.uk/lower-back-how-can-i-help-myself/

>6 weeks after acute pain initiation

MSK Pain >6 week AccuRx message: 

I have issued a prescription for your pain medication. As your pain has been with you for over 6 weeks you can now self-refer for physiotherapy via this website: https://sussexmskpartnershipcentral.co.uk/self-referral/

Back Pain >6 weeks:

send AccuRx message above and consider filling out Keele STart Back Screening tool for chronicity - identifies patients with low back pain (LBP) at risk of a worse prognosis of persistent disabling back pain, and thereby facilitates triage to appropriate treatment level. If high risk then needs referal to FCP or clinician

Chronic user of pain medication >12 weeks

continue to prescribe and check if they have been advised to self refer to chronic pain clinic, if not then send AccuRx message: 

Chronic pain (>12 weeks) clinic self-referal:

I have issued a prescription for your pain medication. Persistent pain (also sometimes called chronic pain) refers to pain that last beyond 3-6 months. The Community Persistent Pain Service offers the chance to explore strategies to live a more meaningful with pain rather than a cure. You can self refer to this service via https://sussexmskpartnershipcentral.co.uk/pain-self-referral/

If they have already been sent this referal link, ask if they have refered

 

If acute presentation and not improving

issue medication and book in for appointment with FCP to discuss onwards referral

If acute and worsening

send task to triage team to book in urgent appointment within the week with an FCP or clinician

If suggestive for Red flags evolution

discuss with Clinical Lead then and there or direct the patient to A&E

Acute MSK Indications

Indication	Time to heal	Advice	Therapy
Rotator Cuff tendonitis or small tear	2-4 weeks (upto several months)	Rest, ice and physical therapy are ways to help heal faster. For physical therapy please see this link https://www.sussexmskpartnershipcentral.co.uk/rotator-cuff-pain/	NSAID
Plantar Fascitis	Most people will make a complete recovery within a year	Rest the foot (by avoiding standing or walking for long periods) where possible Wear shoes with good arch support and cushioned heels (such as laced sports shoes) Avoid walking barefoot Consider purchasing insoles and heel pads to insert in their shoes, with the aim of correcting foot pronation. Advise that 'magnetic' devices should be avoided Lose weight if overweight or obese	paracetamol & NSAIDs Icepack, self-physiotherapy If still symptomatic after a few months of above refer to podiatrist / physiotherapist  If still symptomatic refer to orthopedic or podiatric surgeon Can consider steroid injection
Back pain: Torn Disc / Herniated disc / Prolapsed disc	Up to a year	Exercise - pilates no vigorous	Pain medication - neuropathic antiniflammatory antspasmodic  Amitriptiline 10mg to 70mg

 

 

 

Sprain 

Commonly, a grade 1 sprain can take one to three weeks for recovery, a grade 2 can take three to six weeks, and a grade 3 recovery can last several months.