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MSK self management workbook

Carpal Tunnel Syndrome and Cubital Tunnel Syndrome

July 2020

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Disclaimer

This workbook provides general advice which may not be specific to you. It is

important that if you are in pain you see a health care professional for an

assessment to rule out serious, albeit rare, pathology. Please talk to a health

care provider if you have not seen one before. You can use this workbook on

your own, however, we recommend that you do so alongside a health

professional.

Health and safety

This workbook is designed to help you manage your condition. It is

recommended that the workbook is used alongside advice from a health

professional. Together you can work to help with your recovery.

You may progress more rapidly or slowly through this workbook depending on

your symptoms and other factors related to your condition.

It is important that if you are experiencing pain during the activities in this

workbook then you should discuss your symptoms with a health professional.

Purpose of workbook

This workbook provides a general overview of the management of your

condition. The workbook is split into different sections with the main focus

being education, self-management advice and exercise. We recommend

reading all the sections over time, however, you may find that not all of this

information is relevant to you.

The exercise section gives you a choice of exercises, varying in difficulty.

Begin with the level you feel is appropriate, based on your pain and

confidence. You then have the option over time to make these exercises more

challenging or reduce to a more basic level as required.

The self-management section provides education on other management

options that can be used in conjunction with exercise to improve your

condition.

Finally, the workbook also includes a range of additional resources available

that may be of benefit, such as leaflets, videos and contact details for other

services.

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Contents Page

Page 5 What is an entrapment neuropathy?

Page 6 How to use this workbook?

Pages 7-16 Carpal Tunnel Syndrome (CTS)

- wearing a splint (Page 20)

- exercise (Page 21)

- other treatments and general information about CTS (Page 22)

Pages 17-22 Cubital Tunnel Syndrome

- night time splint (Page 20)

- exercise (page 21)

- other treatments and general information (Page 22)

Pages 23-25 General information on having an operation on your wrist

or hand

Pages 26-29 Self-Management Information

Page 30 How to wear and look after any splints you have

been given

Page 31-32 Useful Links

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Notes

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What is an entrapment neuropathy?

In the upper limb there are various nerves which travel down your arm providing

feeling and sensation to your arm and hand. Nerves are important for transmitting

electrical signals to and from the brain to our muscles and skin. This allows us to feel

sensation through our skin and create movement with the help of muscles supplied

by the nerve.

During their journey down the arm, nerves pass between muscles and other soft

tissues. They travel over and pass through joints occasionally becoming compressed

or irritated at these points. An entrapment neuropathy is where pressure on a

segment or a part of a nerve causes it to become irritated, compressed or

sometimes even damaged. The most common entrapment neuropathy in the upper

limb is Carpal Tunnel Syndrome (CTS).

Carpal Tunnel Syndrome (CTS) is when the median nerve becomes irritated or

compressed at the wrist. The second most common entrapment neuropathy is

Cubital Tunnel Syndrome. Cubital Tunnel Syndrome is when the ulnar nerve

becomes irritated or compressed at the elbow.

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How to use this workbook?

You have been asked to look through this workbook because you have symptoms

which could be due to either Carpal Tunnel or Cubital Tunnel Syndrome. If you suffer

from neck pain or your symptoms tend to travel along the entire length of your arm, it

is important to seek assessment and advice from a relevant health care professional

before commencing this workbook. If you proceed through this workbook and you

feel that the symptoms you are experiencing do not appear to be similar to those

described for either Carpal or Cubital Tunnel Syndrome we would advise you seek

assessment and advice from a health care professional.

If you do choose to proceed, this is how to use the workbook.

If your health care professional thinks you have Carpal Tunnel Syndrome (CTS)

please read the section on CTS. If your health care professional thinks you have

Cubital Tunnel Syndrome please read the section on that.

The sections that follow are useful for both conditions. They will give you information

to help support you with exercise as well as information on posture and positioning.

There is also a section to help you look after any splints you may have been given,

advised to buy or have already purchased.

The ultimate aim is to give you as much advice and help as possible to enable you

to improve and manage your symptoms.

Please look at the table of contents and use this to work through the book.

We hope you find it helpful.

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Carpal Tunnel Syndrome

What is carpal tunnel syndrome (CTS)?

The carpal tunnel is a tunnel in your wrist through which nine tendons (these control

the movement of your fingers and thumb) and a large nerve (median nerve) pass.

Over the front of the wrist there is a ligament and this forms the roof of the tunnel.

The floor of tunnel is formed by the carpal bones. When the median nerve becomes

irritated or squashed within this tunnel this is called Carpal Tunnel Syndrome (CTS).

CTS is a common hand condition and is referred to as a “compressive neuropathy”.

Diagram 1: Picture of the Site of Compression for Carpal Tunnel

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What are the symptoms of CTS?

The main symptom of CTS is altered feeling in the hand, often felt or described as

pins and needles and/or numbness. Pain can also be felt but this is usually less

common. The median nerve gives feeling to the thumb, index, middle and the thumb

side of the ring finger. This is why people who have CTS normally feel their

symptoms more so in these digits.

Diagram 2: Picture of Where Altered Sensation for Carpal Tunnel Occurs

The symptoms experienced with CTS can often be felt more so;

At night (sleep can be disturbed)

First thing in the morning

Carrying out activities which involve gripping (for example, holding the phone,

driving and reading).

In more severe cases the altered feeling may become more continuous. There may

also be weakness and wasting (loss of muscle bulk) at the base of the thumb. In

advanced or severe cases, some patients with CTS may describe a feeling of

clumsiness and/or find they are dropping objects easily. The majority of people with

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CTS have much milder symptoms that come and go but these rarely affect the ability

to carry out activities involved with daily living.

How common is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome (CTS) is a common condition of the upper limb.

About 7%-11% of the population will experience CTS symptoms at some point

in their lifetime.

CTS is three times more common in women than men.

CTS can occur at any age and occurs in both men and women but most

commonly affect women in middle age.

What causes it?

In most people, the cause of Carpal Tunnel Syndrome is not known.

Anything that reduces the space within, or increases the pressure within the

Carpal Tunnel, can potentially lead to symptoms of Carpal Tunnel Syndrome.

Factors that have strong evidence supporting an increased risk of Carpal Tunnel

Syndrome include, obesity or being significantly overweight.

Other factors that have been associated with an increased risk of Carpal Tunnel

Syndrome include:

o Overuse of the hand and wrist such as in gardening or renovating a house,

activities requiring forceful grip/exertion (evidence on an association between

computer work and Carpal Tunnel Syndrome is variable)

o Osteoarthritis and rheumatoid arthritis

o Wear and tear in your tendons or inflammation of your tendons

o Hypothyroidism

o Diabetes

o Wrist trauma

o Pregnancy

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Tests for Carpal Tunnel Syndrome Usually the diagnosis of CTS is made of the basis of your story about your

symptoms. Symptoms of CTS tend to follow certain patterns and most patients

report similar things. Examining the hand is helpful too. Most patients with CTS will

find the splint and exercises in the following section helpful. This information can

help to confirm, or exclude, the diagnosis and explains why patients are often

encouraged to try this first.

Some patients require electrical tests called nerve conduction studies. This is often

because the diagnosis is in doubt or because you have diabetes. These tests can

provide some evidence to confirm the CTS diagnosis and the level of severity.

Blood tests

Some conditions can cause symptoms similar to CTS, or make the symptoms of

CTS worse. This is known as peripheral neuropathy. Therefore, your health care

professional may request that you have simple blood testing to check for diabetes

and to check that your thyroid, folate and Vitamin B12 levels are within are normal

limits.

Carpal Tunnel Syndrome Myths vs Facts

Myth Everyone with Carpal Tunnel Syndrome needs an operation

Fact The symptoms of Carpal Tunnel Syndrome can settle on their own. Many

cases settle with simple treatment or advice. If your symptoms do not settle

with simple treatment or advice other treatments are available but not

everyone will require these treatments.

What can be done to help reduce symptoms?

There are a few things that can help you reduce or prevent the symptoms of CTS.

Modifying activity, being aware of your posture, exercise and splinting can be helpful

in most cases. Let’s look at these in more detail now.

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Splints

Diagram 3: Picture of a Futuro Wrist Splint

A wrist splint can be worn so that the wrist is kept in a straight position at

night for mild CTS symptoms. It can take some time before significant relief is

experienced. The splint should be worn for up to three months at night

whilst sleeping, by which time you will be able to decide whether it has helped

in a satisfactory manner or not. If the splint was helpful and allowed your

symptoms to settle, it is useful to store it in a clean, dry place. Should your

symptoms ever return, you may wish to use it again a short time.

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Exercise

These exercises can help relieve CTS symptoms by gently gliding the median nerve

and tendons through the carpal tunnel.

‘Tendon Glides’

The following exercises have been suggested as being helpful in improving the

movement of the tissues in and around your wrist. Learn the sequence of moving

through positions one to five. Once you have learned the sequence, this should be

repeated 10 times. Aim to do these exercises little and often throughout the day for

example, three or four times a day.

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‘Median nerve glide; arm’

1. Hold your arm out to the side with your elbow bent, your palm facing up and

the wrist extended back.

2. Straighten the elbow and hand three quarters of the way

3. Go between the two positions

4. Repeat five times, five times per day

‘Median nerve glide; wrist’

Bend your wrist down (flexion) and back (extension). Keep your fingers relaxed.

Keep your elbow still whilst you do the exercise - Repeat the exercise 5 times - Do this 5 times a day

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Please Note:

It is normal to feel mild discomfort that lasts for a short time after your exercise. However, if you feel an increase in your pain or symptoms you should stop that exercise until you talk to your health care professional.

Your exercises are an important part of recovery and will only help if you do them as instructed.

This information is intended as a general guide only, if you have any further questions please ask your therapist.

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Other Treatments – General Advice

In many patients, symptoms from Carpal Tunnel Syndrome can come and go for some time before either settling down or becoming a problem. If there is an underlying cause such as diabetes, thyroid disease, pregnancy, or even menopause in women, then treating this condition may help resolve symptoms.

Carpal Tunnel Syndrome due to pregnancy will often get better after the baby is born.

Steroid injection

A single/one off steroid and local anaesthetic injection can be effective in select cases; for example, during/after pregnancy, where surgery cannot be undertaken safely, or when the patient opts not to have surgery.

Steroid injections work by reducing any inflammation within the Carpal Tunnel but not everyone with CTS is suitable for a steroid injection. Splints are easier to use, known to be beneficial and have less side effects than steroid injections. This is why you are often encouraged to try this before other, more invasive treatment options.

Surgery

In some patients with CTS where the symptoms are severe or deteriorating, surgery

may be considered. Usually this would be after the splint, advice and exercises have

been tried and have failed to help. Surgery remains the most effective, proven long-

term solution to Carpal Tunnel Syndrome. The operation involves cutting the

ligament over the front of the wrist to ease the pressure on the nerve. The surgery is

routinely done under local anaesthesia as a day case procedure.

Diagram 4: Picture of Carpal Tunnel Decompression

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Surgery usually cures the problem. Night pain and tingling usually disappear within a few days. In severe cases, constant numbness and muscle weakness may be slow to get better or may not fully resolve. Occasionally pain can be felt over, in and around the wrist after surgery. It generally takes about three months to get back full strength and a comfortable scar. The hand can be used for light activities from the day of surgery.

Although surgery is a relatively safe and effective option with there is a price to pay. Some patients find their grip is decreased, feel uncomfortable putting pressure over the scar and feel their scar can be initially be quite sensitive. These symptoms normally settle after a few weeks but can take longer in some patients.

Overall, the results of open Carpal Tunnel decompression are excellent with around 96% of patients reporting good outcomes at one year. There are risks involved with all surgery, however, and you can read more about these risks by following the link below.

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Cubital Tunnel Syndrome

What is Cubital Tunnel Syndrome?

Cubital Tunnel Syndrome is compression or irritation of the ulnar nerve within a

tunnel on the inside of the elbow behind a bone called the medial epicondyle (where

your ‘funny bone’ is).

Diagram 5: Picture of Where the Ulnar Nerve Can be Compressed

The ulnar nerve is one of three important nerves for hand function. It enables

feeling/sensation to the skin of the little finger and half of the adjacent ring finger,

power to some of the muscles that bend the little and ring fingers and to some of the

small muscles in the hand and thumb.

Diagram 6: Area of Where Altered Sensation Can Occur in Cubital Tunnel

Syndrome

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What are the symptoms of Cubital Tunnel Syndrome?

Pain, numbness and/or tingling of the little and ring fingers are usually the earliest

symptom. It is frequently intermittent, but may later become constant in nature. Often

the symptoms can be provoked by repetitive elbow bending and straightening, by

leaning on the elbow or holding the elbow in a bent position (for example, on the

telephone). Sleeping with the elbow habitually bent can also aggravate the

symptoms. Some patients may also notice some weakness of pinch grip with their

thumb.

In the later stages, the numbness is constant and the hand becomes weak. There may

be visible loss of muscle bulk in severe cases, particularly noticeable on the back of

the hand between the thumb and first finger, with loss of strength and dexterity.

What causes it?

Cubital Tunnel Syndrome is the second most common entrapment neuropathy in the

human body. Most cases arise without an obvious cause, but the tunnel can be

narrowed by arthritis of the elbow joint or by an old elbow injury. Many patients

develop symptoms as a result of overuse of the elbow, leaning on the elbow or from

direct pressure over the ulnar nerve when using a computer at a desk.

As with all nerve disorders, patients with diabetes are at increased risk of ulnar nerve

symptoms. Other factors associated with an increased risk of Cubital Tunnel

Syndrome include wear and tear/inflammation of your tendons, hypothyroidism and

obesity.

What is the natural history?

The symptoms of Cubital Tunnel Syndrome generally come and go and rarely affects

the ability to carry out activities involved with daily living. The condition will often

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settle completely with simple measures such as avoiding direct pressure on the nerve

and avoiding prolonged full flexion of the elbow.

Diagnosis of Cubital Tunnel Syndrome

Diagnosis can often be made from the clinical history (the account of events and

symptoms from the patient) and a clinical examination of the elbow and hand. The

examination will assess for muscle weakness, irritability of the nerve to tapping and/or

bending of the elbow, and changes in sensation. Other medical conditions may need

to be evaluated such as thyroid disease or diabetes. A test called electromyography

(EMG) and/or nerve conduction study (NCS) may be done to confirm the diagnosis of

Cubital Tunnel Syndrome and determine its severity.

Myths versus Facts

Myth If I have Cubital Tunnel Syndrome I will need an operation

Fact The symptoms usually settle on their own or with simple advice and exercise.

It is relatively rare that surgery is required.

What is the treatment?

Avoiding or modifying any activity which aggravates your symptoms is the main

treatment in the early stages and may significantly reduce the pressure on the nerve.

This should include a workstation assessment. For example, wear a headset for using

the telephone, place computer keyboards at the edge of the desk and use a chair that

does not have an arm rest. The next section of this workbook will give you much more

information regarding this.

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Prolonged flexion (bending) of the elbow should be avoided and any activity that puts

direct pressure on the nerve should be modified. Avoid leaning on the inside of the

elbows and wearing an elbow pad over the ulnar nerve and “funny bone” may help.

Splint

Excessive bending of the elbow at night can be minimised by wrapping a folded towel

around the elbow or by wearing a splint.

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Exercises for Cubital Tunnel Syndrome

‘Tendon Glides’

The following exercises have been suggested as being helpful in improving the

movement of the tissues in and around your elbow. Learn the sequence of moving

through positions one to four. Once you have learned the sequence, this should be

repeated 10 times. Aim to do these exercises little and often throughout the day, for

example, three or four times a day.

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Other Treatments – General Advice

Surgery for Cubital Tunnel Syndrome

As we have mentioned previously, surgery to decompress the nerve (relieve

pressure) may be required in severe cases, or in those that do not respond to the

non-surgical treatments above. Surgery frequently improves the numbness, but its

main objective is to prevent the progressive muscle weakness and wasting that

tends to occur in severe untreated cases. Surgery is rarely required and usually you

would have to go for special tests on your nerves, called nerve conduction studies,

before this is considered.

What is the outcome?

The outcome of surgery depends upon the severity of the compression being treated.

Numbness frequently improves, though the improvement may be slow. Surgery

generally prevents worsening of the muscle weakness, but improvements in muscle

strength are often slow and incomplete.

Surgery does not help if the cause of your symptoms are related to posture and

positioning. Therefore, if you have been given this advice it very important that

you work on improving this to the best of your ability.

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General information on having an operation on your wrist or hand

As previously stated, not all people with hand and wrist problems will require an

operation. In some cases surgery may be discussed and considered and the majority

of routine operations are successful, however, it is not the best option for everyone.

The following information provides a rough guide to some of the issues that can occur

following surgery. It is important that these are taken into consideration before surgery

to the wrist and hand is performed

Wounds

After hand/wrist surgery, all wounds must be kept clean, dry and covered for seven to

12 days. This allows normal wound healing to start and reduces the risk of infection.

Once the stitches are removed the wound can be cleaned and left open to the air. You

are advised not to soak the wound for two weeks after surgery. During the healing

process the wound is tender and often itchy which is completely normal. The wound

normally takes a few weeks to heal but it often takes around six to 12 months for scar

tissue to settle.

When you have an operation, nerves on the skin surface are always divided in the

wound. This can make the skin surface feel numb around the wound which can be

permanent. It is very unusual for this to give any major problems, but you should be

careful when handling hot or cold objects.

Scar formation

Scar tissue will form as an important part of the healing process. This is the body’s

normal reaction to injury or surgery. Scar tissue can sometimes become thick and

lumpy and stick to underlying structures and restrict movement. It may also be

sensitive to touch. This is normal following surgery and in most cases will settle within

two to three months of the operation. Rarely, long-term tenderness is an issue

although hypertrophic scar formation can occur. This is a condition in which the scar

increases in width and feels lumpy. It can give rise to a cosmetic issue but is not

serious. It is very important to start scar management once the wound area has fully

healed.

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You can also help your scar to heal by eating a balanced diet, especially food rich in

vitamins such as milk, yoghurt and green leafy vegetables. Also try and drink lots of

water each day unless you have been told not to. Smoking is not advised as it slows

down the healing process. Scar tissue can also burn easily so you should stay out of

direct sunlight or use total sun block where this cannot be avoided. Massaging your

scar regularly each day using a non-perfumed moisturiser will helping to soften and

reduce scar tissue and improve sensitivity.

Hand swelling/stiffness

Following surgery swelling is common in the area operated on. Keeping your hand

elevated following surgery can help to reduce swelling. It is important to move the

hand early and often following hand surgery to avoid stiffness developing in the fingers

and wrist. Exercise is also important as it can prevent the scar tissue from tightening

and adhering to underlying structures.

Infection

Developing a wound infection occurs in around one in 100 patients following an

operation. It is vital that you are aware of the signs of infection following your surgery

which includes increased pain and swelling, heat, increased odour, and redness

which spreads and tracks up the hand. More severe cases may require antibiotic

treatment and occasionally a further operation to clean out the wound but this is very

unusual.

Nerve and blood vessels injury

There is a risk of nerve or blood vessel injury when operating on the arm and hand.

There are very small nerves in the skin that can be damaged resulting in some altered

sensation at the site of the surgical incision. This altered sensation tends to improve

over time. Damage to large nerves is rare but may occur if the nerve is stretched or

bruised. This can result in altered sensation and occasionally weakness that is usually

temporary. Blood vessels can be damaged during surgery however most bleeding

stops during surgery or resolves shortly after.

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Complex Regional Pain Syndrome (CRPS)

CRPS is a rare but very serious complication following surgery to the hand or arm,

affecting one in every 2000 patients. It causes pain, increased sensitivity, swelling and

stiffness in the hand which can often take up to two years to improve.

Working after an operation

Time off work may be required following surgery, depending on the nature of your job.

There are no hard rules about this. As a guide, patients with heavy manual jobs may

need four to six weeks off work. Patients with office based jobs often return to work

within a few days.

Driving

You should not drive after hand surgery until you are fit to do so. It takes time to

recover from the effects of the anaesthetic and some painkilling medication prescribed

after surgery may affect your fitness to drive. It is advised that you do not drive whilst

you have stitches in place. It is your responsibility to ensure that you are in full control

of the vehicle. There is detailed information on the DVLA website about fitness to drive

and you should refer to that before driving. If you are in any doubt, consult your

surgeon or family doctor (GP) as well as your insurance company. Different motor

insurers have different policies about medical fitness to drive and you should check

that you are fully insured before driving.

All adapted from Fife virtual hand clinic information

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Self-management

What else can you do?

Try not to worry

It is only natural to feel worried. However, feelings such as worry, anxiety, fear, or

negative expectations about treatment may prevent or delay recovery.

Painkillers

A range of different medications are available to help reduce your pain to allow you

to move more comfortably. Pain control can help your rehabilitation progress and

does not just “mask” your pain.

If you are unsure of what medication you can take, speak with your local pharmacist,

practice nurse or GP for guidance. Do not exceed the daily allowance of these

medicines even if your pain is high and always consult a health professional prior to

taking any new medication. It is important that if you are prescribed medication that

you take them regularly and at the recommended dose (see medication packet for

details). All medicines can cause side-effects, particularly if they are not used as

prescribed. Side-effects range from common to uncommon and vary from person to

person. Information on possible side-effects are available on the leaflet inside the

packaging of your medication. It is important to speak to your local pharmacist,

practice nurse or GP who may be able to change the dose or the medication itself to

something that is more suitable.

General Health

Your mental, emotional and physical health and wellbeing is vital in your recovery.

Many factors can impact on your arm and hand pain; giving up smoking, losing

weight, increasing your fitness, sleeping well and reducing stress can all aid in your

recovery.

See the links in the website section for more information and support.

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It’s not what you do, it’s the way that do it!

Positioning and posturing are thought to aggravate the symptoms of Carpal Tunnel and Cubital Tunnel Syndrome. Therefore, it is important to look at these points. Small changes can make a big difference.

Making small changes

The three very important P’s!

Small changes can make a big difference.

POSITIONIG

• Take regular breaks.Change your hand position regularly so you are not holding something or doing something in the same position for a long time.

• Try to reduce repetitive movements. Avoid positioning your wrist in extremes of movement.

• Loosen your grip and change position when reading a book, talking on the phone or drying your hair.

PROBLEM SOLVING

• Analyse problems and identify possible causes. Identify a range of possible solutions and try these solutions to see what works best for you.

• Try using stronger larger joints for some activities, for example, hips to push open doors.

• Take more frequent breaks if possible.

• Alternate heavier tasks with lighter tasks.

• Look at your workstation. Refer to section ...

Posture

• Change your posture regularly with mini breaks where you get up and stretch.

• Try the postural exercises detailed on the next page.

• Try not to lean directly through your elbows whilsts sitting.

• Look at your posture at your work station. See following page.

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Looking at your posture

As the nerves start in your neck and travel along the length of your arm, it is

important to be aware of your posture, particularly your neck and shoulders. Our

bodies like regular movement. Try the exercise below little and often as way of

interrupting your posture and keeping things moving.

‘Shoulder Roll’

Do the exercise slowly, 10 times per session and five times per day

Sitting

Always sit with your bottom and spine back in a firm chair, with shoulders relaxed.

Your elbows should rest by your side, with wrists straight and feet firmly on the floor.

When working at the computer, keep your screen at eye level so you are not bending

over your work. Ensure you are using a height-adjustable chair with a supportive

back rest. Keep your hands and wrists relaxed and supported. Taking regular

breaks during prolonged periods of work can reduce strain and discomfort. See the

picture on the following page for a guide to working at a desk.

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Guide for working at a desk

Diagram 7: Work Posture Suggestions

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How to wear and look after any splints you have been given

Wearing Instructions

Straps should be applied firmly, but not too tight.

Wear liners under splint for hygiene/comfort.

Your splint is to be worn overnight in bed.

Your therapist/health care professional will alter this wearing regime when

appropriate.

Precautions

Contact your therapist for a splint adjustment if you experience the following:

Rubbing

Increased pain

Skin irritation

Red marks lasting longer than 20 minutes

Increased swelling

An increase of, or new, ‘pins and needles’

Colour changes to your skin

Care of Splint

Hand wash in cold soapy tap water: Remove metal/plastic bar prior to

washing. Rinse thoroughly and dry in shade.

Splint liners may be washed more regularly in cold, soapy tap water.

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Section six

The websites below are useful for further information on shoulders.

NHS Ayrshire & Arran MSK

https://www.nhsaaa.net/musculoskeletal-service-msk/

NHS Ayrshire & Arran Pain management

https://www.nhsaaa.net/pain-management-service/

British Elbow and Shoulder Society

https://bess.ac.uk

MSK Reform

mskr.info (Type directly into browser with no www. If requested Code is

MSKR19

The British Society of Surgery of the Hand

https://www.bssh.ac.uk

Versus Arthritis

www.versusarthritis.org

The Sleep Council

www.sleepcouncil.org.uk

Quit your Way (Smoking advice and support) Tel: 0800 783 9132

https://www.nhsaaa.net/better-health/topics/smoking/

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NHS Ayrshire & Arran Mental Health and Well being

https://www.nhsaaa.net/better-health/topics/mental-health-and-wellbeing/