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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

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CPD courses and Barefoot talks (10/05/21) reflected with the Kolb-Cycle (1984)

Situation 1:

I started to attend Barefoot talks, which are external lectures at the school premises, in my second year of studying. Some courses were for 2 hours, others took a whole day, including practice sessions. During my forth year of studying, I started to attend CPD courses. One was a 9 hour course on Axial Spondyloarthropathies (AxSpa), which increased my awareness of inflammatory back pain in young adults. With this course I received a referral letter template, which will make it much easier for me to refer someone for a suspected AxSpa (see attachment)

Another CPD was on Cauda Equina and the third one was on Fascial Anatomy. The Fascia course was organised by the University of Pamplona and was spread out over 5 days with many online lectures and recorded dissections. This course had the biggest impact on my osteopathic practice and understanding of performing techniques. It improved my understanding of the connection of tissues and I find it easier now to palpate tissue movements on different layers. It enabled me to palpate the different fascia layers in combination of my anatomical knowledge that I gained by studying the anatomy with Flash-Cards during the first two years of practice. The fascia course also helped me to understand the molecular level of fascia dysfunctions which is called densification.

The most interesting articles about the subject are Pavan et al. (2014) and Hughes et al. (2019).

Self-reflexion 1:

This course enabled me to have a better understanding of the fascia and therefore the multiple connections of tissues and areas in the body. I am now able to palpate on different fascial layers and by knowing the connections from seeing the fascial connections in the dissection movies, I have a much better understanding of the effect my treatment can have.

For example: I finally understood why the phrenic nerve can have such a major impact on the C-spine. I always thought that the nerve itself would pull on the vertebrae and was wondering if it might not get damaged by the constant strain on the periosteum of the lateral foramen. Now I know the it is embedded in the pre-vertebral fascia and that therefore the fascia is putting the vertebrae under tension.

Action plan 1:

I will start to explain patients about the fascial connections in the body. I will explain this in easy words that the patient can understand what I am talking about.

Situation 2:

I was explaining the fascia connections to my patients and was able to make them aware of the connections in the body rather then repeating that everything is connected. Most patients understood my explanations when I talk bout a 'bag around the muscles and that they are all connected and the same good around the organs and the chest etc'.

Self reflexion 2:

I feel like the explanations of the fascial anatomy improved the informed consent of my patients regarding my treatment. In addition my patients had the chance to understand more about their body and therefore, in most cases, what was going on with them.

Osteopathic Treatment on myself during the course of M.Ost at the ESO reflected with the Kolb-Cycle (1984)

Situation 1:

Since the beginning of my studies, I went to the ESO-Clinic every 1-2 weeks. In my first treatment I was overwhelmed of all the new impressions I got, the length and details I needed to go through for the case history and I had four observers in the room. I was the first patient of the student practitioner and wanted her to calm down and make my case easy for her, because she was very nervous. I felt comfortable with the way she talked and acted around me, even though she was nervous and I was new in England and hoped to understand every question correctly. The treatment was a GOT routine and a HVT and i was a bit disappointed, because I new that an osteopath can treat me with other techniques in a more effective way.

Before I attended my next treatment I told myself, that if this treatment is not more advanced, I will not come again but look for a professional osteopath. To my surprise I was assigned to another student practitioner, who studied three years in France and learned cranial techniques already. In general, my body reacts better to soft treatments, thats what I know from other osteopathic treatments I had previous to these studies. When the student-practitioner asked me if it is ok, if he takes my case and that he believes, that I might rather need soft techniques then HVS, I was very impressed and felt understood.

Over the months we developed a good student to student-practitioner relationship and I am regularly seeing him now.

Self-reflexion 1:

This experience gave me a good insight of a patients feeling when first coming to a clinic, with the importance of patients-handling, in a way, that the patient wants to feel understood and in how relationships in a professional environment develop.

Situation 2:

After the summer break (I am a second year now), I have now realised that I become more confident in the surrounding. I find it sometimes uncomfortable to see my student-practitioner on a school party and not only in the professional life in clinic.

I feel now that it is time to find a professional osteopath that is happy to treat me and my practitioner said that he finds that he cannot do much more for me as his skills are not advanced enough anymore.

Self-reflexion 2:

I was happy to have an honest opinion from my student practitioner to be referred to a qualified osteopath. Because I was reacting very well to cranial treatment approaches, he advised me to see his tutor at the time which was very knowledgable regarding IVM. I was sometimes worried that something major was wrong with me because I was not getting much better anymore.

Reflexion on this from a fourth year perspective:

I think now, that I probably went so often for such a long time to the clinic, because I felt like someone who understood me was listening to me. Back then I was having my partner in my home country and had only contact to him over the phone. Even though I had a fantastic housemate by my side and I generally did not find it difficult to meet new people, it was nice to have felt looked after. It was a luxury and often I was booking an appointment for the next week, because I was scared that my headache would come back. And from then on I was sometimes not in pain at all when I came to see the osteopathic student-practitioner and had to invent some pains to have him treating something. This reflexion now on the experience makes me understand how easy it is for lonely patients to become addicted to treatment.

The situation reflected from the student-practitioner point of view (imagined by myself when I am a forth year) (20/04/21):

I just moved from France and started the studies at the ESO. It was a very different treatment style that they learned here and I feel like I learned some great techniques that would be beneficial for some patients, for example IVM.

One day I was observing my colleague on her first treatment. It was on a first year student and the student came with a variety of aches and pains into the clinic.

The patients communicated that she preferred gentle treatment and was scared of HVT-manipulations.

I thought to myself that I would be able to finally continue my IVM skills on that kind of patient.

The next week when the student came in again I managed to cover for my colleague as she was not in clinic. I explained the patient that the techniques I have learned were much more gentle and that I would be happy to take her over. In a way I took this patient from the other student but only because she agreed and was happy for me to use IVM techniques on her.

I started to be her practitioner and she always came in with other complains and pains. At some point I was not able to justify to my tutors anymore that this patient was getting generally better with my treatment. By that time I had a tutor that was very good with IVM skills and I asked the tutor, if the patient would be able to see her. She agreed, as the regulations allowed allow a student to be treated by a tutor. Another reason for me to refer the patient to another practitioner was the increasing circumstance that we socialised on school events and I was not able to stay professional in these moments but our relation changed to a student-student relation. Outside the clinic, I lost this professionalism. Therefore it was good for her to see someone else from now on.

Action plan 2:

I will start to see the tutor for some treatment and see what effect this has on me.

Situation 3:

I started to see the tutor for 3 sessions which helped me a lot.

At some point she was not allowed to see me anymore and I then started to see other osteopaths that are not connected to the ESO for a few very painful complaints that I experienced possibly due to stress.

Self reflexion 3:

Having seen 4 different experienced osteopaths since I have started my course, I see the diversity of the different practitioners and their work. One practitioner mentioned that it is a good thing to be 'lazy' when treating and as I had to pay 42£ for a 30 minute session this did not come across very well. He gave me a basically good but general gentil GOT treatment but did not address my complaint in the way I was hoping for.

Action plan 3:

As I felt like I was not able to pay that much money for a 'lazy' treatment, I decided to find another osteopath to try out her treatment.

Situation 4:

The decision to change a practitioner was great because from this osteopath I learned how to feel different tissue types and the nervous system within the tissues. I went to see her for 4 times now and went to the first two sessions with a good friend. On him she showed me the tissue fields and since that I felt that my palpation improved a lot. By having experienced the tissue fields by this osteopath, I now know better how different types and stress types feel like.

The other day I was lying on her couch while she was working through an old strain pattern that was giving me troubles for a long time now and thought to myself what a perfect job this woman has. Then I realised that I will have the same job and will be able to give a similar relieve to any of my future patients.

Until now I often felt like one osteopath can only serve me that long and then I had to find another one to work on other areas but until now, this women treats me with great effect.

Action plan 4:

I would like to give the same or similar relieve to my future patients and know that it will take a long time to become that good. To have a goal however, and having experienced this great feel of relieve of pain and discomfort, enabled me to be more empathic to my patients. To have been on their side sensitised me to what they might go through whilst sitting opposite me or lying on the couch and even whilst waiting outside and hoping for the pain relieve and looking forward to the listening skills that I will be able to offer them.

However, as I reflected in the CPD course section earlier on in this OPS, I think I might be prone to biases of recently learned things. To treat my patients only in the way my osteopath treated me will not benefit every patient I have. To experiment with different treatment styles and incorporate different skills I learn and observe along the way will bring me forward on my path to become a good osteopath with all the facets there are.

Overall Reflexion:

I believe that there are two points to this:

1. I need to have good knowledge to support the work, which can be studied in theory.

2. I need to have practical experience to be able to reflect on my own skills and understand the patients perspective.

I can say to the first point that I find that I did generally a good job in studying the osteopathic side of the treatment and its effect on the body. During my studies I see that there is always room to improve and more opinions to understand. I studied as much as was possible for me. I decided not to have a busy part-time job but to concentrate my energy on the studies and I find that it slowly is paying off.

In the future I will come across other osteopaths and am more than happy to share and exchange experiences and opinions as I will never stop learning.

To the second point I can say that being treated by multiple osteopaths helped me to understand patients points of views. Starting with the visit of the ESO clinic for over a year and then being treated by professionals helped me to get an insight in different treatment techniques and the uniqueness of each practitioner. It taught me that us, as practitioners, can offer care to everyone but if we come along a patient that we do not connect with, it is ok to refer them to someone that would be more suited for them. I was mirrored how important language is and the ability to actively listen.

It is something that I still have to work on, especially on days when I am tired which can happen due to multiple reasons. The main reason for me to be tired is having sleeping problems from too much stress and I hope that the stress levels will be decreased after the graduation and I will be able to perform better listening skills to my patients.

To have the insight of how it is for a patient to wait in front of the door, not knowing what will happen to them this time, or being managed and looked after by a practitioner, is a valuable experience.

It is something I will always try to keep in mind because it is easily forgotten and a very important aspect of wholistic patient care.

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A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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Indian Family in treatment room (16/10/17)

Situation 1:
Today I observed a treatment of a middle aged women from indian culture. For translation-reasons she brought her daughter and with her, the grandchild. Because of cultural reasons, the patient had a blue slightly see-through hospital-coat on. She kept her headscarf on and her trousers as well. Because of the patient adiposity, as well as the hospital coat, it was difficult for the student-practitioner to do the observation procedure on the patients back and abdominal region. In addition to that, the child was playing with a noisy toy that was distracting me. Apparently the student practitioner was not distracted by it.

Self-Reflexion 1:
I found it very difficult to follow the conversation with the tutor because of the multiple noises in the room. The toy of the child, the mother of the child trying to keep the child quiet and the conversation between the patient, student practitioner and the tutor. All of it in a language that I is not my mother tongue. It was very interesting to see this situation and to realise how I was effected by the multiple influenses of cultural differences and children in the treatment room.

My question from that:

1. Am I allowed to send the mother and child out of the room once treatment starts?
2. How can I say in a lite way that the toy should not be making extra noises?

Situation 2:
Yesterday I had a new toddler patient who was very active. He did not like to sit still and was not able to be treated until his mother took out the phone and started to entertain him with YouTube videos. He started to sit more still and I managed to treat him.
The phone music was running in the background and I was not affected by it.

Self-reflexion on situation 1 and 2 and reflexion of the previously stated questions from a forth yer student viewpoint:
After thinking about those situations and finding my notes from my first year when I was observing the situation, I realised that I managed to be generally less effected by noise.  I was thinking that it is always important to be honest with patients (D1) which made me wonder if I should mention my distraction regarding the noise. On the other hand I find that this decision is very situation dependent. I think that a patient is always allowed to have a chaperone in the room and if the chaperone has her child with her, which is making noise, then that has to be ok. However, it would be an option to mention after the treatment that small children are not recommended to be sitting in with an appointment. In this first situation I saw that it was necessary to have the daughter for communication reasons in the room.
In general I think that I would not feel uncomfortable anymore with noise in the room as, situation 2 has shown. I learned to ground myself and to focus on the treatment regardless of other noises or people in the room.

Patient crying from treatment? Or being upset about her situation? (27/10/20)

Situation 1 (11/11/20):
A patient came in with severe pain in her right lateral thigh. She was in her 50s and was on a high dose of Co-codamol. She mentioned that the medication made her more emotional. In the end of the case history she became emotional and started to cry because she felt useless in her job with the pain that was with her for 2 months. She missed working as she felt like her work-environment was her actual family.
From the examination I concluded that her ANS was under a lot of stress but her Psoas muscle was weak and she had trigger-points in her TFL which I assumed had to do with her pain. I explained her my findings and made sure that she understood everything. In terms of the treatment approach I gave her different options (from unwinding to trigger-point release). She wanted to try the trigger-point release and I explained her how important it was to communicate the amount of pain she was going through for the length of the treatment. I was so sure that I kept constant eye contact with her face to see any unexpected expressions. I therefore was very disturbed and surprised when I saw tears running down her face. I assumed that it was from the pain. I stopped and tried not to tell her off for not communicating the pain to me. I continued with functional techniques and assured her that these should not be painful. She seamed almost upset with herself. In the end she seamed ok with my communication but unfortunately I was never able to see how she progressed as she did not come back.

Self-Reflexion 1:
Seeing myself as a person that would never harm a person and is rather afraid of causing pain when performing techniques, this was  a new experience for me. I felt insecure and unprofessional in this situation but on reflexion and feedback from the tutor, I managed the patient well and gained consent throughout the treatment session.

Action plan 1: I will have to make sure that I do not loose eye contact with the patients face as they will potentially try to prove themselves something and do not necessarily communicate discomfort to me.

Reflecting on situation 2 (19/01/21):
I realise that the patient could have cried because she was sad and upset about her general situation and not because of the pain. In the situation, I assumed that it was the pain that caused the patients to cry. I did not dare to ask the patient for the cause of her tears. In the situation it looked to me like she was not wanting to give up on the painful treatment. In addition,  as the patient had a history of eating disorders, I am now considering if  she was having self-punishment thoughts.  I did not have the chance to communicate this idea with her but reflected with my tutor on the situation. Thinking about this scenario made me become more aware of possible psychological effects due to a history of mental health-disorders.

Action plan 2: I will therefore clarify what the patients feel and what the cause up their emotional reaction is when they becomes emotional . At the same time I will reduce any potentially painful contact until I have the consent of the patient to continue treating in the way they agree and that I agree is beneficial for them.

Religious patient in full gown can only be seen by females (03/12/20)

Situation:
A women comes in fully covered with a head and face scarf. I take a robe upstairs from the reception and inform her that my tutor is male. She wishes not to be seen by the tutor as she won't be wearing her headscarf and I had to turn the cameras off. I explained the situation to my tutor and gained consent from both sides that I am eligible to perform examination and treatment like this.

Self-reflexion:
I felt professional and respectful in this situation and managed to complete the testing and diagnosing of the condition without the tutors second opinion. The patient seamed content with the arrangements and her management.

Follow up reflexion:
The patient did not come back to see me. This might have been because of the one hour drive she did to come to the Clinic and which aggravated her pain. She tried to book a double-appointment but the reception would not arrange that.

Action plan:
If I would see her a next time, I would recommend to visit someone more local to not have her aggravating the pain but assuring her that, if that is the case, osteopathic treatment is still the right treatment approach for her complaint.

Overall Reflexion:
I believe that I gained a better understanding about how to communicate my needs in a clinic room with noisy patients. This improved mainly by seeing toddlers in children clinic where a Youtube-Video was often used to keep the patient calm. I learned that my way to work around my personal distress in noisy situations is to ground myself. Because I am now, in forth year, used to ground myself regularly, using all different techniques I learned in comparison to a situation in first year, I feel like I improved a lot in this aspect. In addition, I became more confident to communicate with patients that are in distress with themselves and to be able to give them space to express their needs and thoughts.
The other day I treated one of my regular patients and I was supervised by a tutor that I have not seen in clinical practice since my third year. He gave me feedback that I was very good in gaining continued consent and feedback from the patient. He pointed out that this was a strength of mine and I realised that this became a habit of mine in clinical and personal life. It became a part of my interaction with people and I realise it particularly, when speaking in my mother tongue (German), as it is something I did not do before coming to the UK. I learned it during the course and I am happy to maintain this practice-quality, as I think it is a great skill when working with patients. On the other hand, it is important to explain patients why it is important to gain continuous consent, even though they tell me to continue testing and treating and to stop asking for consent. However, I managed to communicate the importance for this consent in the few situations that included patients telling me to stop asking for consent.

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B2. You must recognise and work within the limits of your training and competence.

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B2. You must recognise and work within the limits of your training and competence.

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Rehab in Sports-Clinic -this time referred (23/07/20)

Situation 1:

Today I had a patient that complained of back pain since training with heavy weights. It was a 45 year old women with with a strong welsh accent, presenting with an increased lordosis on the area of pain. She communicated her determine for everything she does, including gym work-out. I booked her in the sports clinic to get assistance for her rehabilitation and expert advice on performing the exercises she does (Fu et al. 2016). Because my knowledge of biomechanics is very little, due to the structure of my course, I was struggling a lot with an effective and precise evaluation routine. With this patient I learned a good insight in the osteopathic-biomechanical point of view on non-specific lower back pain and am eager to proceed with this training. The tutor and I explained the patient what we were thinking the problem was and what exercises she could do. After gaining consent for the management plan and the treatment,  I started with the hands-on treatment.

While I started to treat I realised that she seamed not happy with something. I asked her, if the treatment was too painful and when she said that it was good, I asked her if anything was worrying her. She confessed to be disappointed in herself for giving herself back and, now understandings the underlying factor, hip-problems by being too determined in performing weight-work-out. Here I started to see what was bothering her with the whole situation.

Alongside discussing her point of view on the situation, I assured her that specific rehabilitation exercises will improve her back-pain and gave her the first set of exercises in the end of the session. Over the next sessions her pain improved and I tailored exercises specifically for her. Alongside the benefit for the patient, I had a great learning experience with the sport-clinic tutor.

Situation 2 (08/04/21):

The patient came into the clinic again. I saw in the notes that she was taking 4 Codin tablets per day in summer, with the treatment back then it reduced to 2 Codin tablets per day and now she took 4-6 per day.

She mentioned herself that she was addicted and that she wants me to help her to get over her addiction. I mentioned the longtime side effects of Codin addiction to her and she was getting very anxious. I realised that the pain was not treatable with pure osteopathy anymore and said that she had to urgently contact her GP for a referral. I explained her that she had to do a cognitive behavioural therapy. On research, I found private websites that organise rehabilitation therapies (see attachment). I explained her that I was not able to cure her pain as it was probably by this point related to the medication and addiction.

She did not come back since and I will give her a call the next time I am in clinic to ask her how she is doing.

Self reflexion 2:

I find that I realised too late that it was an addictive problem and that I should have informed her about the side effects long before now. However, I was not able to see this last summer as I was concentrating to learn the rehabilitation and was curious to see if that had an impact, which it had. The pandemic situation was making the situation more difficult as she did not come in for 8 months and she was in addition of being in pain very isolated and was missing her family in Scotland.

Action plan 2:

When patients tell me medications they are taking, I will look up the side effects if I am not aware of them and monitor how the patients improve with the treatment. As I won't give patients as easily away to other patients after having graduated, this should be easier.

In addition, I find it a good and caring idea to check-up on patients that are not coming back like her and I would like to hear if there is any progress on her side according the therapy.

Situation 3:

I called the patient and she was still not successful to contact her GP after 5 weeks. I gave her the option to come in for a treatment and to get a referral letter. In that way we were able to contact the GP and the process would hopefully start to be supervised by her GP.

Self-Reflexion 3:

I am very glad that I called the patient. She was glad that I was checking-up on her and that I gave her another option to get help. I think that I did the right thing and hope that this will be beneficial for her further treatment.

Referring my CCA-mock patient (April 2021)

Situation:

Today I had my mock CCA and the patient was 33 years old and came in with a history of 15 years long lower back pain.

I was able to rule out the Cauda Equina questions and mostly the co-morbidities of AS. However, I took part in a CPD course about AS and the recent research shows that AS is very much under-diagnosed. The people in the CPD-course (which is mentioned in B1) therefore suggested to refer for a blood test as soon as someone with a longterm back pain history without specific onset comes in.

I therefore wrote a referral letter to the patients GP and referred for a spondylolysthesis (because I was unable to rule this out completely) and for a HLA B-27 blood test.

The tutor told me afterwards that I over-referred the patient and that I probably freaked out by the exam situation.

Self-reflexion:

I realised that I was uncomfortable with my decision making but I was scared to fail my exam for unsafe treatment and management. I preferred to refer the patient rather than seeing how the treatment might impact the patients pain.

Now I know that there is a stable spondylolysthesis and that is safe to treat as long as there is no recent trauma to the back.

Action plan:

I will improve my decision-making for possible referrals by reflecting on situations with tutors and colleagues but I will also try to treat some patients and see if the treatment if somehow changing the backpain. If there is no change after a few sessions, I can still refer for a scan. This will, however, always be explained within the patient informed-consent  speach before the treatment starts.

Overall reflexion:

I find that I had a few cases and situations during my time in the ESO clinic where I learned good lessons on when to refer a patient to another health care practitioner.

The constant communication to my tutors that I keep encouraging helped me to reflect on the situations. I learned to consider different types of health care professionals. Before the first case, regarding the codin-addiction, I did not consider to refer anyone to a psychological therapy. Referring a patient mainly included to consider urgent referral to A&E or to the GP for any tests or scans. Now however, I take the mental health of my patients much more into consideration.

To make the decision when to treat and refer or only refer is still a difficult subject for me and with the preparation for the CCA, I am planning to discuss more cases with colleagues, that I will review from the filing room in clinic, to practice this decision making.

My path during these studies have taught me, how little I know from the bigger picture. At the same time I now become more aware that I am able to build my own opinion on situations with the knowledgeI I have. This enables me to make justified decisions and to communicate my reasoning to my patients. I find this very important, as I believe that patients are more likely to listen to advice when they understand my reasoning. However, it is important not to scare patients with possible findings. With continuous studies and reflexions, I will learn from future situations and will be able to improve my reasoning and decision making.

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If you think you're struggling with a codeine addiction, the good news is that this condition is treatable and you don't have to suffer on your own. The most important step is to seek help for your codeine addiction, to start getting your life back on track.

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B3. You must keep your professional knowledge and skills up to date.

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B3. You must keep your professional knowledge and skills up to date.

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General GOT practice (10/11/2017)

Situation:

Today I was practicing the cross handed inhibition, that we learned in GOT (General Osteopathic Technique). I knew vaguely what to do with my model. I treated in prone position and I knew where my hands need to contact the tissues. I was not sure of how to apply pressure and in which direction the pressure should be applied to.

The new feel of fabric with improved palpation scills (20/03/18)

Situation:

A few weeks after this practice session, I travelled to my family over Christmas and as I gave my mother a hug, my attention was suddenly directed to the tissue of her jumper. I could feel the finely knitted fabric a lot better with my right then with my left hand and in more detail then I ever experienced before. That showed me how my palpation-skills had improved only in three months of daily practice. In these months I did not particularly focus on which hand was my sensory or motor hand, as I a a both-hander. But I felt great and motivated to work on this even more.

Different ways to inhibit a muscle (20/03/2018)

Situation:

Today I learned the different ways of inhibiting a muscle with cross-fibre technique and how both ways have the same approach.

While I was practicing in the early morning practice, a 4th year student came to my couch and was asking if I needed help. I had a bit of pain in my fingers, as always, when I do inhibition. Either my wrists or my finger-joints hurt, and till then the only response I got from supervisors was: “you will get used to it. It is as simple as that.” As I know my wrists and have had this sensitivity for a few years now after injuries from over using them in climbing sports, I am pretty sure, that they will not get used to it. I might get used to painful hands when I treat a patient, but that is not what I am looking for in my osteopathic career.

I told the 4th year student my problem and expected him to answer the same way the others answered. But he brought a new point of view in my way of treating. He showed me how I can do inhibition with a very soft and light touch where the patient does not feel the pressure but I could feel the muscles releasing as fast as with the more crude touch version. Then he showed me, that the other way is more like a massage and both ways have the goal to relax the muscle.

Amazed by this, I was continuing to practice the light touch inhibition on the erecto spinae group in the thorax in supine position (part of the GOT-routine) and on the biceps brachii m. and triceps brachii m..

Later that day, we had osteopathic techniques and a student colleague was not convinced by the technique we learned. We did inhibition on the forearm muscles and he told me how he will never use this in his practice because it is very inefficient. He would rather use massage techniques. I told him about the two ways of inhibiting a muscle and he did not believed me and wanted me to show him on his biceps brachii m.. I felt a bit under pressure and was afraid of not feeling enough to having it work. But I gave it a go and felt his flexed forearm (he was supine) relaxing in twitches but constantly. After I finished I asked him if he could feel that too and he was confused but said: “yes”. Then I showed him the other way be going with more force deeper into the muscle. That was the one he knew. In the end it was a great experience to show a fellow student the differences and I got more confident in my palpation skills, as the soft technique worked very well, even if I was under pressure.

Self-Reflexion on this from my 4th year perspective (08/05/21):

When I re-reading this situation, I realise how far I have come with my skills and knowledge during these 4 years. I realise that I learned the difference between inhibition and cross-fibre soft-tissue techniques. I was looking up to the forth year students back then and learned some good palpation tips.

I am very proud of myself how far I have come over the four years. I get compliments on my palpation skills on my job interview and also in clinic (mainly in children clinic). I think that I have a talent for palpating subtle movements and tissue changes, as I was able to feel the IVM expression before starting the course, and I believe that a lot of practice benefited me as well.

CPD courses and Barefoot talks (10/05/21) reflected with the Kolb-Cycle (1984)

Situation 1:

I started to attend Barefoot talks, which are external lectures at the school premises, in my second year of studying. Some courses were for 2 hours, others took a whole day, including practice sessions. During my forth year of studying, I started to attend CPD courses. One was a 9 hour course on Axial Spondyloarthropathies (AxSpa), which increased my awareness of inflammatory back pain in young adults. With this course I received a referral letter template, which will make it much easier for me to refer someone for a suspected AxSpa (see attachment)

Another CPD was on Cauda Equina and the third one was on Fascial Anatomy. The Fascia course was organised by the University of Pamplona and was spread out over 5 days with many online lectures and recorded dissections. This course had the biggest impact on my osteopathic practice and understanding of performing techniques. It improved my understanding of the connection of tissues and I find it easier now to palpate tissue movements on different layers. It enabled me to palpate the different fascia layers in combination of my anatomical knowledge that I gained by studying the anatomy with Flash-Cards during the first two years of practice. The fascia course also helped me to understand the molecular level of fascia dysfunctions which is called densification.

The most interesting articles about the subject are Pavan et al. (2014) and Hughes et al. (2019).

Self-reflexion:

Having attended those CPD courses and Barefoot talks, improved my knowledge on a wider level and my work as an osteopath has changed since I incorporated the knowledge I gained from that.

I realise how I potentially biased my patients presentations after the CPD courses when looking back now. Especially the AxSpa course increased my anxiety of missing an inflammatory pathology and managing the patient incorrectly.

In addition, after the fascia course I diagnoses the next week almost every patient with a fascial densification and explained my tutor why I think that is the case.

I now see that I was looking out for exactly the new disorders that I have just learned about.

Action plan:

To reduce the bias post-CPD courses I will stay aware of my potential bias in diagnosing the patients. I think that the more courses I will attend to, the more knowledge I will have about an increasing number of conditions. This will help me hopefully to decrease the bias and consider other diagnoses, as well as the one that I have been recently trained on.

Overall Reflexion (10/05/21):

Over the 4 years of studying at this school I have been a determined and hard working student. This has brought me to a good foundation of knowledge. Reflecting on the different scenarios and revisiting situations from my first year as a forth year is a very good way for me to see how far I have come. By revisiting re-occurring situations, such as post-CPD bias, I can see the bigger picture now and will reflect in the future on those situations to monitor my bias and the impact, that CPD courses can have on my diagnosing. This will help me to take out bias and to find a second opinion in difficult situations.

In addition, I will keep my hands-on skills up to date and by regularly practicing with colleagues. I will learn more techniques and improve my skills by getting feedback from other osteopaths rather than only practicing on patients that do not know how efficient a technique could be if done correctly.

The involved participants in this video have consented to the publication and use of this video for the portfolio purpose.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

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Managing patients expectations (05/02/20) -reflected with the Kolb-Cycle (1984)

Situation 1:
Today I had a patients that seamed very stressed and presented with  biceps tendinopathy.
When we discussed how it would be good for her to come back, she said that she cannot book next week as she had to wait for her pay-check.
Because i did not know the timescales of tissue healing for inflamed tendons, I could not advise her when a follow-up appointment would be useful and how many sessions would be necessary to give the tendon time to heal and manage the patients wellbeing.

Self-reflection 1:
I realised how important it is to know the tissue healing times and to be able to propose a management plan to the patient, which should be evidence-based. With this in mind, I would be able to design an informed management plan for the patient to achieve the best treatment outcome and patient satisfaction.

Action plan 1:
I will make a tissue healing chart  and learn to give not only advice, but to manage the expectations of the patients. In addition, I researched the management of biceps tendinopathy and found interesting literature by Nho et al. (2010), that will help me to improve my management next time (see attachment).

Situation 2:
I had a patient presenting with a stress fracture on the calcaneus and with the knowledge of the tissue healing chart, I saw that the average time for a bone to heal is 6 weeks minimum. To manage the patient but not keep him too long immobile, I proposed to rest for 3 weeks because the stress fractures should show an improvement by then.

Self-reflection:
Even though the bone healing lasts between 5 weeks to 3 months, I had to change the resting-time to a length that the patient was happy to rest and that was possible because of the specific type of fracture. I learned that good communication was a key for this individual management.

Overall Reflexion:

In the beginning of my clinical practice, I took often too much time to understand my patients needs. On the one hand that was good, to eliminate misunderstandings that could have mislead my management plan. On the other hand, some patients seemed to get annoyed by me asking similar questions about the same subject. It had an affect on my time management and was potentially impairing the patients trust in my competence. However, with the course of the forth year, I feel like I am gaining better communication skills as my patient handling and language improves.

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A3. You must give patients the information they want or need to know in a way they can understand.

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A3. You must give patients the information they want or need to know in a way they can understand.

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Psychological importance of communication in Sports-Clinic (23/07/20)

Situation:

Today I had a patient that complained of back pain since training with heavy weights. It was a 45 year old women with with a strong welsh accent, presenting with an increased lordosis on the area of pain. She communicated her determine for everything she does, including gym work-out. I booked her in the sports clinic to get assistance for her rehabilitation and expert advice on performing the exercises she does (Fu et al. 2016). Because my knowledge of biomechanics is very little, due to the structure of my course, I was struggling a lot with an effective and precise evaluation routine. With this patient I learned a good insight in the osteopathic-biomechanical point of view on non-specific lower back pain and am eager to proceed with this training. The tutor and I explained the patient what we were thinking the problem was and what exercises she could do. After gaining consent for the management plan and the treatment,  I started with the hands-on treatment.

While I started to treat I realised that she seamed not happy with something. I asked her, if the treatment was too painful and when she said that it was good, I asked her if anything was worrying her. She confessed to be disappointed in herself for giving herself back and, now understandings the underlying factor, hip-problems by being too determined in performing weight-work-out. Here I started to see what was bothering her with the whole situation.

I tried to enable her to see the situation from another point of view. I told her that she can now use her talent to be headstrong, to use it for her rehabilitation. I did not deny that it was her training that caused the problem to this degree, but I helped her to realise how she can use her own will-power for something to look forward and fight for -a healthier body. After this, she was a lot happier and looked with new encouragement forward to her rehabilitation exercises and a next appointment.

Self-Reflexion:

This experience made me realise how important it is to have good communication skills and to not treat the body, but also the mind of a patient. I think that it is only half the work done, to tell the patient what is wrong with their body and how to fix it. The other half is to make sure that they understand the importance of these exercises and to make them realise how much power they have to define the outcome of an osteopathic treatment. I found it difficult in the beginning to understand the patients welsh accent, especially because English is my second language. However, with ongoing treatment sessions I got used to her accent and I found it easier to communicate in a professional way with her. As this was the first time that I needed good communication to include a patients mental state in my patient management, I was more aware of my language difficulties with this patient, than I was aware with other patients before her.

Demonstrating exercises to my patients (05/03/21)

Situation:

Today I had a patient coming in with a nerve route compression. To give them exercises on the way to improve their pain symptoms, I demonstrated them the nerve flossing exercises and gave them the link to the attached video for correct performance at home.

Self-reflexion:

First I tried to explain the patient how the exercise looks like and then I started to realise that it would be much easier to demonstrate it. The patient understood the exercise much better and was able to copy me carefully.

I think it is good practice to give well explained videos to interested patients. In this way I am assured that the exercises are performed properly (see attachment).

Action plan:

I think, to demonstrate the exercise and supervise the patient while they perform them, is a good way to motivate patients to do the exercises.

To increase their motivation, I will ask them what kind of surrounding they would do the exercises in and encourage a routine and setting in which patients can incorporate the exercises in their daily life.

Explaining anatomical features to patients (04/04/21)

Situation:

I saw a patient yesterday on whom I found a right anterior-inferior ilium. I wanted to demonstrate the patient the different areas and joints that were involved in the lesion, to gain consent for my treatment and I showed the areas on my own body.

Self-Reflexion:

I think that the patient was understanding what I was talking about but I realised later that it would have been more professional to show the anatomical areas on the charts that were displayed on the wall.

Action plan:

I will start to include anatomical charts and, in private practice, anatomy-models. This will increase the visual explanation of the anatomy which I am including in my management and consent taking of the patient in a professional way.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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Feedback on consent (08/05/21)

The other day I saw a patient and was supervised by a tutor that I have not seen since third year in clinic. When he came into the treatment room he mentioned how good my continuous consent was. After the session he gave me some feedback how to improve my case history presentation but commented again in a very positive way how good my consent taking was.

I researched the consent aspect of osteopathic treatment and found an article explaining the osteopathic management of lower back pain (Vaughan et al. 2014 -see attachment). I had difficulties to find other publications writing about this subject and am astonished as I find that it is one of the most important features in healthcare.

Balance membranous tension technique on the sacrum (21/11/20)

Situation 1:

I saw another patient who came in with lower back pain after giving birth. I assessed her with a cranial approach. I tested her sacrum for any lesions and her Spheno-Basilar-Synchondrosis (SBS) for any correlating patterns. She suffered from minor scoleosis in her teenage years. After balancing the membranes around her sacrum and SBS, the patient showed a more centred gravity line and felt very different.

Self reflexion 1:

I am getting better in explaining the patient what I am trying to achieve and which anatomical structures I am working on when they are interested. I ask them first if they would like to know what I am doing and then I explain my findings in simple anatomic descriptions. I then explain what I am trying to achieve. While explaining this I stay in constant exchange with the patient and ask if my explanations make sense to improve my communication and monitor how well the patient understands me.

Self-Reflexion 2 from an end of 4th year perspective:

I recently got the verbal feedback from an IVM FOPE-examiner that it is much better to assess the sacrum first and then take the hands off the patients for the explanation of the findings and consent gaining. I was surprised that I was not doing this when treating and examining the sacrum, as would do the same with any other technique. I find this a very important point for the setting of shared decision making and to differentiate the evaluating of the patients body from the treatment with informed consent.

Overall reflexion:

For me this OPS has two sides:

1. To gain consent continuously

2. To record the consent taking

I was able to reflect on situations about general good practice in consent taking. The second point is covered in the case history sheets that is provided by clinic.

Action plan:

When I will have my own practice, I will make sure that the recording of the consent is set-up as easy as it is in this clinic to fulfil this OPS and enable my paperwork to be filled out efficient and understandable.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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Clinic observation - male with possible tumour in stomach (11/12/2017)

Situation:

The first patient I observed was male, 38 years old and was complaining of collateral back pain in the region just inferior to the kidneys (see attachment). In the assessment it turned out, that his stomach was unusually tight. His skin was pale, almost blue and rushed very quickly on touch. It turned out, that the patient was taking an anti-reflux medication for over six month, that has tumour-genesis as one of the many side effects. Even though this medication is supposed to bee taken in acute situations, his GP said that he could take it for a longer period of time and did not give an other follow-up appointment since then. In the following case discussion the tutor was very concerned because of a possible tumour in the patients stomach.

Self-reflexion:

It was important to inform the patient of the necessity of going to the GP but at the same time not telling him, that it could be a malignant tumour. Because as osteopaths we cannot clarify what we palpate, the patient needs to be referred to a GP.

Rehab in Sports-Clinic (23/07/20)

Situation:

Today I had a patient that complained of back pain since training with heavy weights. It was a 45 year old women with with a strong welsh accent, presenting with an increased lordosis on the area of pain. She communicated her determine for everything she does, including gym work-out. I booked her in the sports clinic to get assistance for her rehabilitation and expert advice on performing the exercises she does (Fu et al. 2016). Because my knowledge of biomechanics is very little, due to the structure of my course, I was struggling a lot with an effective and precise evaluation routine. With this patient I learned a good insight in the osteopathic-biomechanical point of view on non-specific lower back pain and am eager to proceed with this training. The tutor and I explained the patient what we were thinking the problem was and what exercises she could do. After gaining consent for the management plan and the treatment,  I started with the hands-on treatment.

While I started to treat I realised that she seamed not happy with something. I asked her, if the treatment was too painful and when she said that it was good, I asked her if anything was worrying her. She confessed to be disappointed in herself for giving herself back and, now understandings the underlying factor, hip-problems by being too determined in performing weight-work-out. Here I started to see what was bothering her with the whole situation.

Alongside discussing her point of view on the situation, I assured her that specific rehabilitation exercises will improve her back-pain and gave her the first set of exercises in the end of the session. Over the next sessions her pain improved and I tailored exercises specifically for her. Alongside the benefit for the patient, I had a great learning experience with the sport-clinic tutor.

Self-reflexion:

This case taught me that the management of a patient is multi-layered. To have good communication is very important but in addition it will benefit even more to have competence in the area of expertise, in this situation the sports rehabilitation. I see how important it is to help my patients to manage their pain by doing exercises at home, for a better overall management.

Action plan:

I think that it is important to address sensible subjects for a good management in the right moment. I will therefore practice to monitor different situations and patient moods during treatments to improve my sensitivity regarding the right moment to address sensitive subjects. This will improve my general communication with patients and enable me to address sensitive subjects for a better overall management of the patient.

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A6. You must respect your patients’ dignity and modesty.

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A6. You must respect your patients’ dignity and modesty.

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Written consent required for pubis techniques (21/07/20)

Situation:
Today I had a patient with meralgia parestetica. I tested that the entrapment sites were the right inguinal ligament and TFL. I agreed with my tutor to functionally unwind the inguinal ligament. The most effective technique to unwind a structure like this is to contact both attachment points and bring them together to give the structure the space to unwind. I explained the patient the technique and reason why I had to contact the pubis bone, as one of the attachment points. He agreed on me performing the technique and I asked him if 'everything is tugged down' and he said 'yes'. I palpated with my wrist from the umbilicus to the pubis. My fingers faced cephalic. The patient seemed ok with the technique and after this technique and soft tissue work on the TFL, the retesting showed that his neurological symptoms were completely gone.

Reflexion:
It was my first patient with meralgia parestetica and I was fascinated by the effect my treatment had. When I spoke to some tutors however, they did not agree with my technique without an additional consent-form for performing an ‘intimate technique’ (see attachment). I was not aware at that point that we have a special consent form for intimate area techniques. In addition, I did not realise that some people would count the technique as intimate. I practiced visceral and MET- techniques on my fellow colleagues for the last 3 years and learned that I am allowed to treat external techniques with the patients informed verbal consent, without being reported to GOsC.
However, I see the point of my tutors and realised that some patients, especially male patients, as i am a female practitioner, might misunderstand this as anything unprofessional. I was shocked by my behaviour and the way I missed that point.

Self-Reflection from one week after the incidence:
I felt confident with the technique, contact and reason to perform a technique like I did but after having spoken to others, they made me doubt of the technique.
I definitely became more aware of a patients point of view regarding contacting intimate areas.

Action plan:
1. The next time I will be in this situation, I will have to confirm with my tutor, if I will have to get a special consent form (see attachment) or not. This consideration must be gender independent. I will hopefully come across something like this during my ESO-clinic time again to have advice on hand when being in such a situation. When working in my private practice, I will ask my principal for advice and existing consent forms.
2. I will keep an eye open for other intimate area techniques that might not feel as intimate to me anymore when performing them, due to long practice with colleagues.

Maternity Clinic (05/03/21)

Situation:
I treated a patient in maternity clinic and performed testing and osteopathic treatment techniques on her pubic symphysis and the inferior uterus, as she was pregnant and experienced tenderness over those areas.
In these treatments I gained informed consent for the examination and treatment before starting to treat. I asked my tutor if an extra consent form might be necessary, but he did find it appropriate as we were in the maternity clinic and it was his daily treatment to perform pubic techniques. The patient was happy with the examination and treatment throughout the appointment.

Self-Reflexion:
I still find it a difficult decision to make, when to get an extra consent form and when the patient is happy with what I am doing.

Action plan:
Talk about this subject to the head of clinic and future clinic principal in private practice, as further clarification on the subject is very important to my consent record!

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C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

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C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

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OSPE- Osteopathic evaluation skills (29/01/19)

Situation:

Today I had my practical exam with different stations. I felt particularly confident in the evaluation station. I struggled before the exam to mention the 5 osteopathic models but was practicing with a colleague to incorporate the 5 models in my evaluation routine. This has fortunately been recorded to me as positive feedback on my evaluation form during the exam (see attachment).

Self Reflexion:

Overall I feel like I understand the connections of organs and findings in the body better. I start to understand how everything is related to each other and how it is of great significance for us to consider the osteopathic 5 models, when evaluating a patients posture and movements.

Reflexion from a forth year perspective:

I realise, that I still have not seen the bigger osteopathic picture when examining patients. The preparation for the FOPE has improved this aspect of my patient examination and I am very much looking forward to expand the osteopathic practice once I have learned to be medically safe.

5 Weeks practice challenge with my housemate (third year, first term) (09/01/20) -reflected with the Kolb-Cycle (1984)

Situation 1:

I can happily write that I have successfully completed a self-made practice-challenge with my housemate. We managed to practice for a duration of 5 weeks, 6 days per week for a minimum of 40 minutes each. We purely practiced active and passive testing routines. We categorised the body in areas, such as neck-shoulder-back or hip-knee-ankle and others, to structure the examination-routines. In the beginning of this challenge I felt very nervous to perform the evaluations on my housemate because I felt very stupid and non-efficient. After one week however, my practice improved and in the end of our challenge, we got really bored with the testing and added some neurological  examinations to our routines.

Self-reflexion 1:

These practice weeks improved my confidence since starting the challenge. It is now easy for me to find my routine, to guide patients in clinic with efficiency through the movements while being able to concentrate on the movement rather than thinking of what testing-position comes next. With this routine, I became much faster in my testing procedure. However, I find myself now sometimes struggling to find the right routine with orthopaedic tests. These are much more difficult to practice in sequences, as they depend on the differential diagnoses that I am testing.

Action plan 1:

I will use the clinic hours where I have no patients to practice examination routines for shoulder pains, for knee pains etc. to improve my efficiency and to remember all the tests I need for the conditions in the areas that I would want to test on a patient.

Situation 2 (07/05/21):

Today I started the practice of orthopaedic examination routines and was surprised how many orthopaedic tests I know and remember. It was great to see that when the colleague and I did not know exactly how to perform a test, we tried the most efficient position and force-direction. With our palpation skills we were able to specify the tests for the different conditions.

Action plan 2:

I will continue to do this testing and do the testing for specific conditions under time pressure which will help me to become quicker with my examinations and to not loose concentration while practicing.

HVT practice and spine mobility observation (19/11/19) reflected with the Kolb-Cycle (1984)

Situation 1:

I have seen a patient with an expected lumbar disc herniation. Once the first pain period improved, I started to look at her posture. Examining her in active and passive movements revealed the primary lesion in her spine which I then manipulated. Following to that, I let her stand up and reassessed her posture. After finding the next lesion, which I also corrected with a high velocity thrust, her posture had changed and her gravity line was central.

Self reflexion 1:

While I was testing and re-examining, as well as treating her, I had a lot of supervision of my tutor. I am in third year now and find it very difficult to see the minor changes in the spine movement in the different vectors. Performing the HVT-manipulations was difficult as well and even though I had a great experience with this session, I see how much and where I would like to improve my skills and practice them.

Action plan 1:

1. To improve my skills on HVTs I will continue to practice them on colleagues and patients. I will practice my explanation for safety in practice, that I am telling each patient before performing HVT techniques and therefore improve my practice of shared decision making.

2. To practice my observation skills, I will test patients in active spine movements before and after the treatment sessions, which will help me to see changes and gain more practice and experience in different body type movements.

Situation 2:

We had a class in SAT (Specific Adjustment Technique) and observed the spinal movements during multiple repetitions of the 'gossip test'. Depending on the model, I found it easier or more difficult to find any lesions. The way the test was performed in this class, made much more sense to me.

Self reflexion 2:

Testing the spine in active movements does slowly give me an idea of lesion areas. To include the gossip-test in the testing routines, widened and improved my understanding of a patients spinal movement. I find that my evaluation has improved since I test the patients in that way.

Situation 3:

I started to perform thoracic thrusts and lifts on my patients. When they did not make a pop-sound, I still retested the spinal mobility mainly in passive movement and gained in 90% of the cases an increased range of motion and quality of movement. The more I practice these techniques, the more confident I become. In addition, I gain more confidence to thrust multiple segments of a patients spine and this has a great effect on the post-treatment testing.

Self reflexion 3:

I feel like I am slowly gaining more confidence on performing thrust-techniques. I generally find however, that I am not good in deciding when to perform a thrust technique. I am not sure how this will change during my future practice with increased patent handling experience and have to create an action plan.

Action plan 3:

I would like to improve my self-confidence on the techniques I am performing and the testing I am doing to find out which techniques are appropriate for the patient from an osteopathic point of view.

Situation 4:

I discovered lately a book about the mechanical link. In the book it is described how to test different somatic dysfunctions along the spine against each other and that in this way it is possible to find the primary lesion. I tried this technique on my next patients, when I found somatic dysfunctions in the spine that would not resolve. One patient was very large and I find it difficult to perform a lift or 'dog'-technique on her. The other patient is osteopeanic and is therefore unsafe to perform a thrust technique on.

When performing the recoil however, the patients felt an instant effect with the minimal recoil movement. When retesting the patients spinal mobility in active motion, I would see in both of them an increase in mobility.

Self reflexion 4:

Generally I am very cautious about performing techniques that I only read about in a book. The recoil however is generally a technique that we have learned on different structures (mainly viscera) and I therefore found it safe to treat my patient with this. In addition, I gained informed consent and am very happy that I took the time to find the lesion in the fascia covering the spinous process. This experience showed me, that I am becoming more confident with my treatment approach and my hands-on skills. To see the reaction of my patients was very positive too.

Action plan 4:

I am aware that I will need to learn either from someone experienced or within a CPD-course, more details and variations of the mechanical link to become more efficient within this approach.

Situation 5:

I saw a pregnant patient in her second term and performed a relieving test for her uterus to see if it had influenced her spinal somatic dysfunction. It came out positive and I therefore learned from my tutor an inferior uterus unwinding in a sitting position. This techniques was very effective and when I retested the spine I was able to see the changes.

Reflexion on this section:

To have come this far with my palpation, osteopathic understanding and observation skills makes me very happy and proud. I am very aware that I am not greatly experienced in this practice of testing osteopathically and choosing the correct techniques, but I see some improvement and get the verbal feedback from my patients and tutors that I am on the correct path.

Action plan for this section:

As I saw how I progressively learn from different situations and input, I will keep my eyes open for learning opportunities and stay in verbal and practice exchange with colleagues in the future to stay aware of new approaches and to become more specific with the testing and treatment I perform.

Balance membranous tension technique on the sacrum (21/11/20)

Situation 1:

I saw another patient, who came in with lower back pain after giving birth. I assessed her with a cranial approach. I tested her sacrum for any lesions and her Spheno-Basilar-Synchondrosis (SBS) for any correlating patterns. She suffered from minor sclerosis in her teenage years. After balancing the membranes around her sacrum and SBS, the patient showed a more centred gravity line and felt very different.

Self-Reflexion 1:

I improved a lot in explaining the patient what I am trying to achieve and which anatomical structures I am working on when they are interested. I ask them first, if they would like to know what I am doing and with their interest and consent, I explain my findings in simple anatomic descriptions. I then explain what I am trying to achieve. While communicating this, I stay in constant exchange with the patient and ask if my explanations make sense to them. This will help me to gain feedback and to improve my communication.

Self-Reflexion 2 from an end of 4th year perspective:

I recently got the verbal feedback from an IVM FOPE-examiner, that it is much better to assess the sacrum first and then, for the explanation of the findings, to take the hands off the patient. I would do the same with any other technique. I find this a very good point for the shared decision making and for a differentiation between the evaluating the patient body and then treatment with informed consent.

Overall Reflexion:

I struggle to find the best suitable evaluation type for each patient. My evaluations change from structural assessments, to IVM listening posts and I add some visceral testing in the evaluation when I find it appropriate. This can occasionally lead to very long examinations , resulting in little treatment time. I am trying therefore, to become faster in my structural, visceral and IVM assessment. I also will start to asses the patient first with a general listening to see which area of the body might have the primary lesion.

Treatment wise, I would like to gain more experience with different types of patients morphologies and responsiveness to different treatment types. I sometimes become anxious when I feel that the patient expects me to manipulate their spine but am learning to find reasoning for my treatment approaches throughout the treatments.

At the moment, I am trying to find a balance between articulative and functional releases in each treatment, as I find that both approaches have positive aspects and add great value to each other.

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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Visceral palpation practice with student colleague - reflexion according to Kolb (1984) (12/12/2017)

Today I had an amazing experience while practising the palpation of the liver with a fellow student. Because we had only six hours of visceral osteopathy lectures so far, I was nervous when I started to find the inferior angle of her ribcage and did not know what to feel for.

Step 1 - Experimenting it: The first time to palpate the liver on her was difficult, because I searched for my goal. To be able to feel the liver. I gave firm pressure, thinking that I need to get through a lot of tissue before palpating the liver. I asked her how she felt and she was not feeling very well with this palpation.

Step 2: - Observations and reflections: She did not feel comfortable and her tissues felt tender. I realised how nervous I was and had the thought that: “I am not able to do this anyway”. At the same time my brain was half occupied with telling me that I have my hands in someone else's guts and that this feels uncomfortable for me as well.

Step 3: - Development of ideas: When I realised that thought I decided to change my attitude for this practice. I thought of how I could be able to relax and concentrate just on the tissues without overthinking what I was doing. I therefor decided to remember all the anatomy I learned this year, that was musculoskeletal.

Step 4 - Testing ideas in practice:

I palpated for all the different layers of the epithelial tissue, the abdominal muscles. and then the bone tissue of the ribs superiorly to my hands. I felt like my hands were communicating with the other persons tissues,  this time they were not tender and opened under my slight pressure. That made it a lot easier to make my way through her tissues and she felt comfortable this time. At the same time I could not overthink, that I am palpating a persons guts, because I was fully concentrated on the anatomy and my palpation-skills. I experienced the liver as something big and heavy in her abdominal cavity and managed to perform the drop-test. I then slowly released the pressure und felt the tissues closing under my hands again.

Self-Reflexion:

Since I had this experience, I always think of the anatomy before palpating. To palpate in this way was applicable when palpating muscles or bony landmarks, but not beneficial when palpating other tissues.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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Lady with whiplash before Christmas 2020 -reflected with the Kolb-Cycle (1984)

Situation 1:

Today a patient came in with a whiplash injury. I have treated her for her neck before but today she told me that she had a car accident in the last days.

As she is a police officer, she followed the vehicle that was driving away and managed to get their car registration number.

When she told me about her situation, I informed her that it is possible to take my notes to court. When I performed the neurological testing, it was the first time that I was really careful and clear with my note taking. I was well supervised by my tutor to not make any mistake or to be unclear with any testing results.

Self reflexion 1:

During this experience, I was surprised that this was the first time I was carefully taking my notes while examining. I am in forth year now and it is incredibly important to take the notes of the examination findings while examining to not write down wrong findings afterwards. I was very nervous in this situation, because I was afraid to make any mistakes. However, I was reminded that this should not be a special occasion but a regular practice becoming a second nature.

Action plan 1:

I will practice to record my notes as I evaluate the patient. This will help me to have recorded my findings promptly and accurately.

To have a good overview of my testing I will see, if it would help me to write down some special tests on the sheet before performing them, so that I can fill them out when I am in the treatment room.

Situation 2:

I tried for a few weeks to write down my findings, as I was testing my patients. It worked well during the observation, but as soon as I put hands-on to test other structures and palpating the patient, I forgot about the recording of notes and continued with the examination. This lead to many occasions, where I exited the treatment room after the evaluation, where I had very little recording of my findings.

Self-Reflexion 2:

I feel like I improved over the time and became better in writing down the directions of somatic dysfunctions etc. I believe however, that this was less for good recording of notes but more because I became better with technique including the Fryette's law, eg. MET.

Action plan 2:

When practicing my testing routine from now on, I will include the practice of finding-recording within the routine. This will help me to incorporate it and my recording of findings should very much improve.

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C3. You must respond effectively and appropriately to requests for the production of written material and data.

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C3. You must respond effectively and appropriately to requests for the production of written material and data.

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Referral letters -reflected with the Kolb-Cycle (1984)

Situation 1:

I will have my CCA mock exam this week and decided to practice the letter writing with the templates that are on the learning zone (see attachment).

I made-up a fictive case and wrote a referral letter, creating the paragraphs and searching for good ways to phrase my findings and suggestions.

Self-Reflexion 1:

After doing this practice I feel prepared for the CCA mock exam.

Situation 2:

Today I had my mock CCA and the patient was 33 years old and came in with a history of 15 years long lower back pain.

I was able to rule out the Cauda Equina questions and mostly the co-morbidities of AS. However, I took part in a CPD course about AS and the recent research shows that AS is very much under-diagnosed. The people in the CPD-course (which is mentioned in B1) therefore suggested to refer for a blood test as soon as someone with a longterm back pain history without specific onset comes in.

I therefore wrote a referral letter to the patients GP and referred for a spondylolysthesis (because I was unable to rule this out completely) and for a HLA B-27 blood test.

The tutor told me afterwards that I over-referred the patient and that I probably freaked out by the exam situation.

Self-Reflexion 2:

When writing the referral letter, I was very happy that I practised it and was able to write it in the expected time. It was the first time that I had to write a letter on the clinic computers and I found it difficult to use the keyboard, to safe any changes and to print the document correctly, as I have never done it before.

Action plan 1and 2:

I would like to become more comfortable with the clinic computers and write a couple of example letters in clinic. This will hopefully give me the confidence to refer someone without being stressed about the process itself.

Situation 3:

I am going through my documents to bring things together for the padlet and portfolio now. I just found a referral letter template, that I could have used for the suspected AS.

I attached it in section B1 for the CPD-course on Axial Spondyloarthropathies.

Self-Reflection 3:

I feel overwhelmed by all the documents that I have and forgot about. It is very helpful to search for documents now and get reminded of the opportunities that I can explore, including patient handling, writing letters and managing a diversity of situations.

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C4. You must take action to keep patients from harm.

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C4. You must take action to keep patients from harm.

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Psychology Presentation on Autism Spectrum Disorder (ASD) in Adults (19/04/20)

We had to create a presentation and handout for our psychology model (handout attached below), which I made about Autism Spectrum Disorder in adults
I mainly learned more details about this subject and where to refer a patients, when they present with signs and symptoms from this spectrum disorder. In addition, I discussed with a tutor in children's clinic a possible case with focus on the communication to the parent. We agreed, that a child should at least be 2 years old before mentioning any concerns to the parent regarding possible ASD symptoms because before that age the parent might end up worrying without reason. The earliest medical testing can be done from 2 years of age (Lord et al. 2006).

Self-Reflexion:
I am interacting with people that are on the Autism-Spectrum in my daily life. I therefore found it very interesting to research this subject and was able to reflect on my research with those friends. By hearing their points of view on the difficulties in managing daily life, gave me a better understanding to behaviour patterns. Being easily distracted as well as not being on time or not being able to remember my name even though I have been friends with them for a long time now, suddenly made sense to me. I found this YouTube channel that was explaining specifically ADHD in a great way to be understood by everyone.(https://www.youtube.com/watch?v=dmeE3qTJRUw and https://www.youtube.com/watch?v=XbyN8REIhMk)
I think that the consideration the Autism Spectrum Disorder in referrals and management of patients, is a very important awareness for the mental health and wellbeing of the patient and their social surroundings. By having it undiagnosed, the patient and their family members are more likely to develop depression, irritability and/or anxiety, without understanding the underlying factor. I believe that us, as osteopaths, have a great chance to listen to our patients and becoming a person of trust to them. We therefore have the responsibility to keep them, not only physically but also mentally, safe. To manage the patient we can include their family, as well to helping to improve their social surrounding (Spain et al. 2017). In addition, I realised how important it is to communicate free of judgement and without giving the parent the feeling that they did a bad parenting-job with their child.

Action plan:
The Autism Spectrum Disorder is not the only risk factor for slowly progressing mental health issues. It is therefore very important that I research other disorders I come across. This will improve my management and awareness of yellow flags in the wider perspective.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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COVID-19 Pandemic Situation-the return back into clinical practice (17.07.20) -reflected with the Kolb-Cycle (1984)

Situation:

The ESO clinic has reopened for the Summer-Clinic and we are working in full PPE according to the guidelines by GOsC (2020). (See attachment).

Self-Reflexion:

I got used to the changing into the PPE before and after seeing the patients, and I actually enjoy the hygiene grade much better then before. On the other hand, I find it difficult to understand patients wearing masks, especially when they are mumbling or having accents.

Action plan:

I will have to inform the patients of my difficulties to understand them

in situations where I find it difficult to understand them.

Situation 2:

I had a patient with a welsh accent and was not able to understand her. I therefor informed her of my struggles and nationality. She reacted very understanding, and was more than happy to repeat words. We both agreed on the discomfort, the mask caused us and the atmosphere improved both sides with empathy.

Self-Reflexion 2:

I am confident and honest with my patients and ask them to speak specifically clear as English is my second language.

The patients understand me and are very understanding and respectful. I feel therefor encouraged to communicate my own struggles with honesty for the benefit of the patient.

Situations with Masks:

A patient had difficulties wearing a mask due to a violation-trauma. I allowed her to not wear the mask while being in the treatment room, but I did wear my visor for my personal protection.

Reflexion on the ‘mask situation’ after the treatment:

I am glad that I had the option to allow her to be comfortable in the treatment room. I am glad that I had my visor as an extra protection and felt like that she felt respected in such a difficult situation. At the same time, she gave me the impression, that she respected my own safety as well.

Situation with gloves:

The palpation with gloves is not as accurate as without them. The first time I palpated a spine was very difficult for me with gloves, because I could not slide on the back skin without friction. It was much more difficult to feel anything through the gloves.

I felt like i had to mainly use my knowledge from the case history and the test results, then my palpation skills. However, I was able to get a good impression of the vitality of the tissues with temperature, moisture, squishiness etc.

Reflexion of the 'glove-situation' after a few weeks:

After a few weeks of practicing with gloves, I realised that I was able to receive more information through the gloves than I did in the first place. I am now able to palpate tissue density and perform testing accurately despite wearing my PPE.

Situation with aprons:

Generally, I find it difficult to look professional when wearing an apron, because they rupture in different ways and are sometimes quite short. However, I felt more comfortable to have a close body contact to my patients, especially in the heat of summer when the patients tend to be more sweaty.

Reflexion of the 'apron-situation' after a few months:

After having used aprons for many months now, I got used to them and found out how to put them on in a professional way without ruptures and wrinkles.

Overall reflexion:

I think it is very important to provide a safe, hygienic and clean environment in the clinic. This was shown to me with urgent importance during the COVID-19 pandemic. I find that it adds to the quality of treatment and patient care in pandemic and non-pandemic situations. To have learned how to follow GOSc regulations in such a strict environment, has taught me well to follow any rules that are found to be important by the GOsC. To maintain these standards throughout my future career, I will make sure to stay updated with GOsC-guidelines on a regular basis.

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As osteopaths start to return to practice in the midst of an ongoing pandemic, it's clear that this will not be a case of 'getting back to normal' - at least not for now. COVID-19 remains a risk, and there will be a need to implement a range of measures to mitigate the risk of transmission of the virus.

The GOsC has published infection control guidance, as has the Institute of Osteopathy. These should be helpful in highlighting the approaches necessary to minimise the risk to patients, osteopaths and others in the clinical environment.

In deciding whether to see patients face-to-face, osteopaths should exercise their professional judgement taking a range of factors into account. This will include any steps they need to take to minimise the risk to patients and themselves, such as the use of personal protective equipment (PPE). The published guidance is there to help inform practice, and in the context of a global pandemic and a highly infectious disease, public health guidance on infection control needs to be taken seriously. If a complaint is made regarding an osteopath's approach to infection control, for example if they had chosen not to use PPE, then there would need to be a well-developed narrative to justify why the guidance had not been applied.

Where osteopaths practise together, or with other healthcare practitioners, it may sometimes be that tensions arise as to the implementation of the guidance. These may lead to some difficult conversations with colleagues.

All osteopaths, however, have a duty under the Osteopathic Practice Standards to take action to keep patients from harm ( Standard C4). The guidance to C4 suggests a range of actions that might be taken where an osteopath feels that the conduct of a colleague or other healthcare practitioner poses a risk to patients.

The starting point would often be a discussion with the practitioner to raise concerns, and it is hoped that this conversation would be sufficient to resolve any such tensions. Through this approach a way forward might be found that ensured that patients, osteopaths and others stayed safe.

However, if the issue cannot be resolved in this way, then the guidance suggests considering discussing the issue with other colleagues to gain further insight and perspective; the practice principal (if the principal isn't the colleague that the tension has arisen with); or an employer, if there is one.

If the concerns as to patient safety are not resolved in this way at a local level, then if the practitioner is a member of a regulated profession, the next option is to speak to their regulator, which for osteopaths would be the GOsC. If the osteopath is a member of the professional membership body, the Institute of Osteopathy (iO), they may wish to contact the iO for further guidance before contacting GOsC.

Some osteopaths may feel uncomfortable making their case with a more experienced colleague or principal, but the key point to keep in mind here is patient safety, and if an osteopath feels that this is being compromised then they need to take action. In terms of evidence or making a case for enhanced measures, it could be helpful to utilise the infection control guidance published by the GOsC and the iO.
Read our infection control guidance
Read the Institute of Osteopathy's advice on adapting your practice

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COVID-19: Patient safety in a shared practice

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As osteopaths start to return to practice in the midst of an ongoing pandemic, it's clear that this will not be a case of 'getting back to normal' - at least not for now. COVID-19 remains a risk, and there will be a need to implement a range of measures to mitigate the risk of transmission of the virus.

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C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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Time-management and making sure patients are safe (16/07/20) -reflected with the Kolb-Cycle (1984)

Situation 1:
I took 20 minutes for the case history today and was relatively specific in my testing but still only had 5 minutes for the treatment. I do not know where to cut down and how to improve here. The tutors tell me to ask more specific questions in my case history but I am not sure how to do that and how to practice this.

Self-Reflexion 1:
I am not confident enough to rule out all possible conditions by asking only specific questions. In addition, I try to learn to ask cross-references between conditions but I feel like I need much more experience to do that in a safe and efficient way.

Action plan 1:
I will continue to ask tutors how to manage the time. In addition, I will practice my examination routines to become more time efficient with the evaluation of the patient.

Situation 2 (23/03/21):
To prepare for my FOPE I am practicing to examine and treat a patient in 20 minutes for the stations of structural, visceral and IVM-approaches. After having practiced the examination routines in third year for a better concentration on the findings from the tests (see C1: “5 Weeks practice challenge with my housemate”), I am now managing to examine the patient in 5 minutes maximally. This includes only one of these approaches and excludes any further medical screening.

Self-Reflexion 2:
With the practice of the examination routines, I am improving my time management with my patients and am more able to treat and communicate management plans and exercises to them. It feels great to see this improvement.

Action plan 2:
I will continue to practice  my evaluation routines and the clinical examination.
To practice a safe and quick general neurological screen, I was shown a video (which is accepted by the British Association for the Study of Headaches (BASH)) by a clinic tutor (see attachment). I will practice this routine to become efficient in keeping my patient safe by performing a quick cross referencing neurological screen.

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D1. You must act with honesty and integrity in your professional practice.

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D1. You must act with honesty and integrity in your professional practice.

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Patients with and without motivation to engage in self-management (03/02/21) -reflected with the Kolb-Cycle (1984)

Situation 1:

I had a 13 year old boy, presenting with a stress fracture on the calcaneus. I managed to diagnose this and my tutor retested the foot to see if my diagnosis was correct. When he confirmed, I wanted to be the one explaining the patient what my diagnosis was and how we would manage it. I knew that the average time for a bone to heal is 6 weeks minimum. To manage the patient but not keep him too long immobile, I proposed a rest for 3 weeks because the stress fractures should show an improvement by then.

Self-Reflexion 1:

Before explaining the patient what my working diagnosis and findings were, I had to take a deep breath. I felt like I was about to tell him the worst case scenario. The patient was 13 years old and I saw how sad he was, when he heard that he was not able to continue playing sports.

When it came to the management though, I showed the father to assist his son doing isometric contractions of the calf muscles. Father and son were very engaged and motivated to exercise the muscles regularly.

This was a very good experience to witness for me. Even though it took courage from my side to explain the expected healing time and seeing the first shock on the patients face, it was worth it and I was able to integrate the patient and father. I believe the rehabilitation had a great progress and the outcome was as expected.

Reflexion on the situation from 2 weeks after the last appointment:

For the last treatment that was due when the schools opened again, I gave the patient and his father the option to see me or someone else with the same tutor. They preferred to stay with me and I find it incredible how much the patient and his father trusted me. They found my management and treatment so good that they wanted to rather see me, then booking an appointment that fit the sun’s school schedule. This is a great feedback to have of patients and encourages me to be authentic and honest with my patients.

Action plan 1:

I think I was lucky to have an engaged patient in this case but I think that there are patients who are not as eager to be integrated in their self-management. However, I would record this as a possible yellow flag, depending on the extend of patients passiveness.

I am preparing myself therefore to not always have great experiences with patients, but will continue to communicate honestly and to integrate the patients much as they allow me to.

Situation 2:

I was seeing a patient for maintenance and saw that her pain would improve with exercises. However, she was not happy to do them regularly.

Self-Reflexion 2:

I found the aspect of the patient, being happy to come monthly for a treatment but not performing her exercises, quite dissapointing when I first realised her lack of engagement. However, I talked to colleagues and tutors about her and they helped me to realise that she is probably a bit lonely and happy to chat and see someone.

I realised that sometimes it is nice for patients to be touched and feeling cared for and that is in my opinion part of the performance of holistic treatment. Nevertheless it is important to offer and encourage patients to become integrated in treatment by explaining them honestly how the management is planned and in what way they could improve their own health.

Reflexion on 1 and 2:

I think that I was able to be authentic and honest with my patients depending on their needs. I sometimes find it difficult to know what my patients needs are (like in the second situation in the beginning) but I think that this will become easier with practice.

Being honest to my patients (11/08/2020)

Situation:

I had a patient today that I have seen twice before. I took her initial case history and on the second appointment the receptionists mentioned that her notes were not to be found. I handed them in after the first consultation but they were not found in the folder.

On the second appointment, my tutor advised me not to say anything. He was the tutor from the initial consultation, and we remembered enough to know that she was safe to treat and where the pain was. The tutor said that this is a great practice, to treat mechanical lower back pain as that was the diagnosis from the last appointment, as I recalled. I took the second case history as a continuing case, treated the patient and gave her exercises to do.

Today however, I had another tutor. I was not able to tell him any information about her previous medical history, I could not recall if she had any underlying pathologies and if she took any medications. On that day, I was not even able to remember her occupation or the onset of the presented pain.

He educated me, that I will have to be honest with my patients for my duty of Candour, and that I will have to ask her all the questions that I was not able to answer again, to make sure she was safe to treat. I informed her about the unfortunate situation and that we do not have her notes at hand. I asked her if she would mind to stay a bit longer to not loose any treatment time, as it was the mistake of the clinic. Luckily the room was not needed for another patient.

Her reaction was a bit surprised and annoyed, but she agreed on staying longer and I took her whole case history again.

I wrote on the top of the notes, that the original notes are still searched and wrote a case summary for better understanding, as I will have to hand her over to another practitioner, due to my summer break.

Self-Reflection:

When I saw this patient without informing her about the missing notes, I felt dishonest and uneasy. However, I was able to test her and treated her without worrying about any systemic complications.

I am very glad that I was honest with her this time though. Regarding me handing this patient over to another practitioner, it was a very good thing that I got all the information from her, because otherwise she might have thought that I lost her notes. I understand that my first tutor with this patient was still hoping that someone would find the notes again. However, it would have been nice to be honest in the first place.

Action plan:

I hope that I would have a better overview in a private practice, on how much hope there is to find notes again so that I would be able to inform the patient about lost notes instantly.

If it will happen in another situation in this clinic, I will directly speak to the tutor about my duty of Candour, because that is the right thing to do and in addition, I feel better with myself and in the relationship with my patient!

I researched around the subject afterwards at home and found this website that is giving a good guidance for Doctors, which I think we, as osteopaths, should follow too (see attachment).

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Patients will normally want to know more about what has gone wrong. But you should give them the option not to be given every detail. If the patient does not want more information, you should try to find out why. If after discussion, they don't change their mind, you should respect their wishes as far as possible, having explained the potential consequences. You must record the fact that the patient does not want this information and make it clear to them that they can change their mind and have more information at any time.

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Being open and honest with patients in your care, and those close to them, when things go wrong

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Patients will normally want to know more about what has gone wrong. But you should give them the option not to be given every detail. If the patient does not want more information, you should try to find out why.

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D2. You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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D2. You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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Covering my colleagues Grandma as a patient (15/11/20)

Situation:

My colleague was seeing her grandma regularly for treatment. One time she was not able to see her, as she was double booked and I was the only person that was able to take over her grandma as a cover-patient.

In the beginning, I did not think much of it and it was nice to meet the patient. I have not met her before, which made it easy for me to see and manage her as a normal patient.

The patient complained of new symptoms and had serious checks waiting for possible nutrition deficiencies and liver problems. She told me that she went to A&E the other day. Because of new systemic symptoms.

She mentioned that her granddaughter does not know anything about the new circumstances and said that I can tell her granddaughter all about it myself. I hesitated in that situation, because I was wondering how much I should keep the patients information to myself due to this OPS.

When I saw my colleague after the treatment, she asked me how her grandma was. I hesitated again. I had to however write down the notes and my colleague would have read them the next time when she would have seen her grandma as a patient. With this in mind and the additional verbal consent of the patient, I told my colleague what was going on. I saw instantly the worries in on my colleagues face. This made me feel unease and if I would have not had a tutor, carefully overviewing my cardiovascular screen on the patient, I would have been worried to have missed something and to be guilty in the end for not keeping the patient safe.

Self-Reflexion:

I felt very uncomfortable in this situation. I felt like I had to choose between following this OPS and at the same time the relative, in this case my colleague, who was seeing the person as a patient. I think that this situation is very rare.

Action plan:

From the extra pressure and bias that I felt when seeing my colleagues worried face when she heard the news about her grandma aka patient, and from my own bias to the patient, I would prefer not treat people from good friends in my own practice.

Bias in managing pain of family members (08/07/20) - reflexion according to Kolb (1984)

Situation 1:

Every time I go home to my family they tell me what parts of their bodies are aching and I feel responsible  make sure that all red flags are ruled out. But because they do not let me take a full case history and I do not take the time to sit down and write down all their case history, I find it difficult to stay relaxed and not over dramatise pain-complains due to emotional anxiety coming from my side. I talked to Mr. Fadil about it and he said that it is important still to generally rule out the red flags of the pain family members have and if that is not possible due to emotional involvement then I have to tell them to talk to someone else about their issues.

Self-Reflexion 1:

I realise how uncomfortable I still am with feeling that I have not enough knowledge about pathologies to rule them out.

Action plan 1:

1. I will continue to revise the red flags for my own practice safety and to be more confident with my questioning.

2. I tell my family every time I see them to go to their regular GP check-ups and they do it.

Situation 2:

After another 2 terms and studying the red flags, I saw my family another time. They told me again about their aches and pains. I find it interesting to listen and and to think what questions I would ask them.

Self-Reflexion 2:

The fact that listening to family members pain-complains is an emotional factor for me has not changed. I find it still difficult not to worry about them even though my knowledge of red flags has improved.

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D3. You must be open and honest with patients, fulfilling your duty of candour.

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D3. You must be open and honest with patients, fulfilling your duty of candour.

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Being honest to my patients (11/08/2020)

Situation:

I had a patient today that I have seen twice before. I took her initial case history and on the second appointment the receptionists mentioned that her notes were not to be found. I handed them in after the first consultation but they were not found in the folder.

On the second appointment, my tutor advised me not to say anything. He was the tutor from the initial consultation, and we remembered enough to know that she was safe to treat and where the pain was. The tutor said that this is a great practice, to treat mechanical lower back pain as that was the diagnosis from the last appointment, as I recalled. I took the second case history as a continuing case, treated the patient and gave her exercises to do.

Today however, I had another tutor. I was not able to tell him any information about her previous medical history, I could not recall if she had any underlying pathologies and if she took any medications. On that day, I was not even able to remember her occupation or the onset of the presented pain.

He educated me, that I will have to be honest with my patients for my duty of Candour, and that I will have to ask her all the questions that I was not able to answer again, to make sure she was safe to treat. I informed her about the unfortunate situation and that we do not have her notes at hand. I asked her if she would mind to stay a bit longer to not loose any treatment time, as it was the mistake of the clinic. Luckily the room was not needed for another patient.

Her reaction was a bit surprised and annoyed, but she agreed on staying longer and I took her whole case history again.

I wrote on the top of the notes, that the original notes are still searched and wrote a case summary for better understanding, as I will have to hand her over to another practitioner, due to my summer break.

Self-Reflection:

When I saw this patient without informing her about the missing notes, I felt dishonest and uneasy. However, I was able to test her and treated her without worrying about any systemic complications.

I am very glad that I was honest with her this time though. Regarding me handing this patient over to another practitioner, it was a very good thing that I got all the information from her, because otherwise she might have thought that I lost her notes. I understand that my first tutor with this patient was still hoping that someone would find the notes again. However, it would have been nice to be honest in the first place.

Besides, I think that showing honesty to patients is inviting them to an honest environment. They can see that it is difficult but still a proof of good character and practice. I am very glad that I was able to learn this lesson in a safe environment and with a nice patient involved in the situation.

Action plan:

I hope that I would have a better overview in a private practice, on how much hope there is to find notes again so that I would be able to inform the patient about lost notes instantly.

If it will happen in another situation in this clinic, I will directly speak to the tutor about my duty of Candour, because that is the right thing to do and in addition, I feel better with myself and in the relationship with my patient!

I researched around the subject afterwards at home and found this website that is giving a good guidance for Doctors (Jacob and Raine, 2016), which I think us, as osteopaths, should follow too (see attachment).

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D4. You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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D4. You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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Response to a letter of complaint

We practiced to write a response to a letter of complaint and I just received my pass mark for it. This makes me very happy! I hope that I will not have complaints regarding my treatment and am practicing a lot to have good consent and communication with the patients to minimise the chance of a complaint. However, if I will have to respond to a letter, I have a template and a baseline to guide myself to respond professionally. In addition, I would ask colleagues or a principle for advice after having written a letter, to gain a second opinion on my work. To respond professionally, and where possible with official guidelines for management and treatment advice, is improving the chance that the patient will understand that I only acted with my up-to-date knowledge and within strict guidelines.

Reflexion from a forth year:
I luckily had not to deal with any complains during my time as a student practitioner at the ESO clinic. But am very glad to have this letter example as a backup.

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D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.

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D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.

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Copied cases for the Clinical Integration class (11/10/18)

Situation:

We had to copy the notes of a case observation for a case presentation in our clinical integration class. I was the one recording the case history and ended up taking the copies of the notes. The receptionist showed me and my colleague, who was helping me, how to blacken out the name and date of birth of the patient.

It was done with a black pen and the ink was running empty.

When we took the copied case pages into school, one of my teachers pointed out that the names are still readable. I explained that I blackened them out as I was told to by the receptionists.

I think that the teacher informed the clinic receptionists that they have to blank out names with paper pieces for a complete black out on the copies of cases that we take out of school.

Self-Reflexion:

This situation taught me that a good will is not enough when it comes to patient confidentiality and that I have to do the job perfect if I take notes outside of a clinic.

Keeping patient names anonymous outside of clinic (11/02/21)

Situation:

I was having a conversation with my housemates about a patient of mine that is a student of my school. Since the first few weeks in third year, when I started to see patients, I realised that it is inappropriate to say patients names outside of the clinic building. It was never leading to an awkward situation.

Now however, I am treating a first year student and she came in after having to isolate because her housemate (also an ESO student) was diagnosed with the Corona-Virus. When I mentioned the story at home to my housemates, they asked me which student it was and which house she lived in. I was then becoming very cautious to not mention her name, but fortunately I was able to say the house as there are multiple ESO students living.

On some occasions I saw her in school and it was difficult for me not to talk about the treatment but I managed to keep confidential and have not mentioned her name to anyone outside of my clinic group in the clinic sessions when she comes to see me.

Self-reflexion:

I find it very important not to mention names to other people because the patients share their personal details with me and I think it is essential for the patients trust to respect their privacy.

Action plan:

To keep patients informations confidential, I will use a clinic laptop in my private practice to be able to keep patients notes in the clinic surrounding.

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D6. You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

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D6. You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

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Receiving hugs from patients

Situation:
I took over another patient from a colleague. My colleague saw the patient twice and managed 2 times treatment as well. When I took over, I had another difficulty. The patient had many letters from scans and I only read and half understood the first one. I felt stupid and unprofessional. The reason why I did not see the other letters was the tutor keeping us busy and i did not have the quiet moment to really look into the notes.
The patient was not angry and filled me in with the main important parts. I continued with similar treatment that my colleague had done and we saw some improvement after the treatment.
To not make my colleague uncomfortable again, I tried to emphasise that she should be booked in with my colleague. I said it twice and hoped at the same time that the patient would not feel pushed away from me because of my behaviour. To insure her that I did enjoy the treatment with her I said in the end that it was really nice to meet her and she gave me a hug. That made me very happy. It showed me that she understood my behaviour and it did not turn into a misunderstanding.

Self-reflection:
I heard different tutors opinions on that. I decided for now that I accept it, if I really feel comfortable but when I have my own clinic I need to be careful not to prefer some patients over others.
I believe that in some situation it is ok to receive a hug as it is not done with the intention to treat one patient better than another. I am giving individually what a patient needs and as long as I feel comfortable in the situation and the patient can express themselves, it is ok to overstep professional borders in case of a hug for example in rare cases. However, it is important that the intension stays professional!

Action plan:
I will try to treat everyone to their needs. If one patient needs a hug, they can get a hug (as long as COVID-restrictions allow that and professional boundaries are maintained!). If a patient needs a handshake or a cup of tea then I will do my best to accommodate that. In the end I think that it is about individuality and respecting every part of a human being.

Starting Women's Health Specialist Clinic (24/09/20)

Yesterday was the firth session of my special clinic in Women's Health. I was very excited to get a slot in the first term including 6 consecutive sessions. When I heard that I am having continuing patient who was pregnant in her 24th week, I felt lucky and curious to learn on that patient. She presented with lower back and neck pain and complained how heavy her abdomen felt, especially after sitting in a straight posture on a desk at work. When I assessed her with the help of my tutor, I felt the tissues in her mid-thoracic being dense and her left C2/3 facets being slightly enlarged as well as a dense tissue quality in her L4/5 region.
When I asked the question how to find out if the problem is of structural or visceral origin, the tutor showed me how to perform a relieving test. While my tutor contacted the inferior uterus, I assessed her back again and felt a tissue texture change.
He performed a uterus assessment in sitting position so that I was able to see how to do it and then explained me how to do it myself. I was easily able to feel the same restrictions that he felt. That was a reassuring experience for me. Under his supervision I treated her inferior uterus with first a direct and then indirect technique including her breath as an important involuntary factor. I felt the releases and the patient felt them too, which was a good experience for everyone.
We performed a lumbar spine MET in side lying position and that improved the patients lumbar spine tissue texture.
The tutor left me alone with the patient for the rest of the treatment and explained me how to do a facial direct release of neck structures in a side lying position.
When he left the room I found it more difficult to find the structure to actually work on but continued to put the vectors in and to release the tissue tension in the neck. When I asked her stand up again to reassess the posture, I saw a huge difference. The patient was standing more streight, her posture was in a better balance, and she reported that the 'heavy abdomen sensation' was decreased. Her neck range of motion had improved as well.
I finished in time and she was happy to come back in a week. This means that I will see how my treatment changes her posture over the next week.

Self-Reflexion:
What I took from this experience:
1. I have the self-confidence that treating a pregnant women is not a scary thing but is just something that requires adjusted techniques for the examination and the treatment.
2. The 4 Bs in the case history are: blood pressure, baby movement, breathlessness, bleeding.
3. Techniques to release the uterus in a pregnant patient and direct tissue releases in the neck.
4. Examination of the spine and how to find out which structure is causing the tension. However, this was a good example but I would still need to improve the practice of this because I find it difficult to find out which area could also cause the symptoms. This case was relatively straight forward due to the pregnancy and her complaint.
5. When treating the patient on my own, I always feel like I have to give them the space for communication. Here I learned that it is ok to sometimes concentrate on the treatment and give the patient the opportunity to zoom out.

Aspects I am proud of:
1. I managed to palpate the structure without difficulties.
2. I stayed relaxed and focused throughout the treatment.
3. I managed to find the area that needed the last little bit of release by myself, treated it and saw the improvement and affect that it had on the patients posture.
4. I am happy that I continued to gain consent with my patient throughout the assessment and treatment even though the space felt very safe due to the presence of my tutor. In this way, I believe, I opened the possibility for a patient-practitioner relationship development.

Self-Reflexion:
I think that it is important to see every patient as an individual and to respect their needs. I think that I have been first afraid of what would confront me with a pregnant patient and then managed well to meet my patients needs. The presence of my tutor was definitely helpful for me to accomplish this. I think that from now on it will be easier for me to see pregnant patients.
I have learned from this situation that I can adapt easily in new situations. I am sure there will be patients and presentations that I might have difficulties with.

Action plan:
To ensure a safe and judgement free surrounding, I will ask for help from colleagues, when experiencing such situations. This will help me to learn and discuss different approaches and points of views. I think that it is possible to become less judgmental to situations we do not agree with when we listen actively and respect others opinions.

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D7. You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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D7. You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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Before starting the clinical practice, every student had to absolve safeguarding trainings in Female Genital Mutilation (FGM) and awareness against radicalisation, as well as a first aid course (see attachment). I have absolved first aid courses before and was comfortable with the subject. I found it mentally difficult to absolve the FGM training, because it reminded me of a situation, I observed as a child:

My mother commented on a friend of mine who’s family was from a different ethical background, and was concerned about FGM on that girl. My mother did not inform anyone about this though and I believe that she did not know where to search for help.

When I now see this situation, I think that having learned from this observation as a child, I would have thought that this was the correct way to react when having only suggestions regarding FGM. I  am very glad that I was absolving this course, because it is a very important safety knowledge that I think is important to be aware of inside and outside of working in a health practice.

The radicalisation-course was easier for me to absolve, because I did not have a memory of having observed a situation like the addressed ones.

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D8. You must be honest and trustworthy in your professional and personal financial dealings.

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D8. You must be honest and trustworthy in your professional and personal financial dealings.

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Financial dealings in complaint situations (21/01/21)

Situation:

We were asked to write a letter as a response to a complaint. I found this exercise very helpful and was able to reflect on the financial management regarding complains. During a few situations in clinic in the last weeks, we were discussing in our clinic group if we would charge a patient, if they would complain after a treatment and having thought about this previously, has helped me to consider different options of reacting to those situations.

Self-Reflexion:

My reaction would depend on the situation and the previous interaction. However, I will have to take care to treat every patient equally.

Action plan:

I therefore consider to not refund with a complaint but if I am taking a case history too long or I cannot treat the patients for any other reasons, due to my mistake and bad time keeping for example, I would offer the patient a free treatment as soon as my schedule would allow that.

Business plan (May 2020)

Situation:

In the course of the studies we were asked to write a business plan (see attachment). It took three tries for me to write this plan:

First I wanted to buy my own property, including an inherited start-up budget. But then I was advised by my teacher to keep it more simple. Due to other restrictions regarding this assignment, I ended up writing the business plan 3 times. I had to change mainly the financials every time.

To make the prices fair for the amount of treatment time and my occupation, I made a list with osteopathic treatment prices in the area. In this way, I tried to be fair and professional in my financial dealings within the business plan.

The feedback on my business-plan was good regarding the financial planning.

Self-Reflexion:

Generally, I find it very difficult to calculate and organise my living costs. However, I am filling out a table with my private expenses on a monthly  basis, to have an overview of my out- and income. This helps me to maintain an overview and to manage my private finances.

Action plan:

To stay financially organised, I will continue monthly recordings of expenses and income and start to do budget tables. These will help me to stay in my financial limits.

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D9. You must support colleagues and cooperate with them to enhance patient care.

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D9. You must support colleagues and cooperate with them to enhance patient care.

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Covering patients in clinic (20/11/20) -reflected with the Kolb-Cycle (1984)

Situation 1:
My colleague was ill and I was asked to cover her patient. It was the second appointment for the patient. The first appointment was only able to cover the patients case history but not giving her any treatment. I therefore made sure to give the patient a good amount of treatment this time.
The lady was 70 years old and liked gym workout. She was happy with my treatment and made it very clear that she wanted to see me again. When the receptionist tried to get her booked in with my colleague who she saw before, the patient said that she would like to see me again next time. In that moment, i took this request as a complement.
When I told my colleague later, I heard how disappointed she was from the situation. She took it personally that she was not a good practitioner and should have made the patient happy enough so that the patient would have wanted to come back to her.

Self-reflection 1:
I believe that I acted correctly in this given situation. It was good that I did not try to influence the patient to return to my colleague so that my colleague would feel more self-confident.
My further role in this part was to now support my colleague in explaining her the patients reasoning and that it does not mean that she is an incompetent practitioner. As I was the first one treating the patient in the clinic, it is understandable that the patient chose to stay with me, once she was feeling comfortable with the treatment and management.

Action plan 1:
The next time I will cover a patient however, I will make sure to try and keep them with the original practitioner and only when the patient insists to come to me, I will agree to their request, as long as I feel comfortable with the patient.

Situation 2:
A few weeks later I took over another patient from the same colleague. My colleague saw the patient twice and managed 2 times treatment as well. When I took over I had another difficulty. The patient had many letters from scans and I only read and half understood the first one. I felt stupid and unprofessional. The reason why I did not see the other letters was the tutor keeping us busy and i did not have the quiet moment to really look into the notes.
The patient was not angry and filled me in with the main important parts. I continued with similar treatment that my colleague had done and we saw some improvement after the treatment.
To not make my colleague uncomfortable again, I tried to emphasise that she should be booked in with my colleague/ her previous practitioner. I said it twice and hoped at the same time that the patient would not feel pushed away from me because of my behaviour. To insure her that I did enjoy the treatment with her, I told the patient in the end that it was really nice to meet her and she gave me a hug. That made me very happy. It showed me that she understood my behaviour and it did not turn into a misunderstanding.

Self-reflection 2:
I see now that in both cases I needed to prioritise the patients wishes and expectations. With the first patient, even though my friend was having issues with it afterwards, I needed to let her book in with me again. With the second patient, I went a step further in emphasising the original practitioner.

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D10. You must consider the contributions of other health and care professionals, to optimise patient care.

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D10. You must consider the contributions of other health and care professionals, to optimise patient care.

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Excessive drooling in children (01/08/20) -reflected with the Kolb-Cycle (1984)

Situation 1:

Last week I had a patient coming in with excessive drooling. I felt overwhelmed by the presentation, because I am not familiar with the profound testing of the involved muscles and nerves due to drooling. My tutor advised me to inform the patients mother that we cannot do much for the drooling at the time, because the patients teething was probably an increasing factor. We found compression pattern in the skull and chest which we linked to chest and ear-infections and treated the child for an increased cranial bone compression. As a homework I was researching about drooling in children and found an interesting article by Van Hulst et al. (2018) (see attachment).

Self-Reflexion 1:

Even though the child is teething, I observed him walking on his tip toes every now and then. This and the drooling can be signs of Autism (Ming et al. 2007). I am worried for the patient and am wondering, how to communicate these kinds of concerns to parents.

Action plan 1:

I will bring this into the discussion with my tutor the next time I see this patient again and will see, what they think on how to educate the parent to look out for the signs. On the other hand, the child does not seem to be otherwise mentally retarded. He started speaking and is interactive.

Situation 2:

I saw the patient a couple of times again and observed specifically his gait. He did not walk on his toes anymore but the drooling did not change with the treatment. I therefore referred the patient to a speech and language therapist. As we were not able to test his fascial and tongue muscles efficiently, I hope that the therapist can manage to test the patient’s cranial nerves.

Self-Reflexion 2:

I think that it was good to treat the child for its presenting lesions but I believe we should have referred him sooner to the speech and language therapist. With not being able to testing the fascial and tongue muscles, I think that the child would have benefitted from being addressed with another approach.

I felt in that situation a bit helpless, because I was not able to come up with games by myself and to keep the patient engaged in my evaluation.

Rehab in Sports-Clinic -this time referred (23/07/20)

Situation 1:

Today I had a patient that complained of back pain since training with heavy weights. It was a 45 year old women with with a strong welsh accent, presenting with an increased lordosis on the area of pain. She communicated her determine for everything she does, including gym work-out. I booked her in the sports clinic to get assistance for her rehabilitation and expert advice on performing the exercises she does (Fu et al. 2016). Because my knowledge of biomechanics is very little, due to the structure of my course, I was struggling a lot with an effective and precise evaluation routine. With this patient I learned a good insight in the osteopathic-biomechanical point of view on non-specific lower back pain and am eager to proceed with this training. The tutor and I explained the patient what we were thinking the problem was and what exercises she could do. After gaining consent for the management plan and the treatment,  I started with the hands-on treatment.

While I started to treat I realised that she seamed not happy with something. I asked her, if the treatment was too painful and when she said that it was good, I asked her if anything was worrying her. She confessed to be disappointed in herself for giving herself back and, now understandings the underlying factor, hip-problems by being too determined in performing weight-work-out. Here I started to see what was bothering her with the whole situation.

Alongside discussing her point of view on the situation, I assured her that specific rehabilitation exercises will improve her back-pain and gave her the first set of exercises in the end of the session. Over the next sessions her pain improved and I tailored exercises specifically for her. Alongside the benefit for the patient, I had a great learning experience with the sport-clinic tutor.

Situation 2 (08/04/21):

The patient came into the clinic again. I saw in the notes that she was taking 4 Codin tablets per day in summer, with the treatment back then it reduced to 2 Codin tablets per day and now she took 4-6 per day.

She mentioned herself that she was addicted and that she wants me to help her to get over her addiction. I mentioned the longtime side effects of Codin addiction to her and she was getting very anxious. I realised that the pain was not treatable with pure osteopathy anymore and said that she had to urgently contact her GP for a referral. I explained her that she had to do a cognitive behavioural therapy. On research, I found private websites that organise rehabilitation therapies. I explained her that I was not able to cure her pain as it was probably by this point related to the medication and addiction.

Action plan:

She did not come back since and I will give her a call the next time I am in clinic to ask her how she is doing.

Self reflexion 2:

I find that I realised too late that it was an addictive problem and that I should have informed her about the side effects long before now. However, I was not able to see this last summer as I was concentrating to learn the rehabilitation and was curious to see if that had an impact, which it had. The pandemic situation was making the situation more difficult as she did not come in for 8 months and she was in addition of being in pain very isolated and was missing her family in Scotland.

Action plan 2:

I will become more experienced over time and withh share patient stories, to learn about different ways to treat a patient, from different medical and complementary approaches. With this I will improve my knowledge about the wider healthcare society.

In addition, I will work in multidisciplinary clinics to have an insight into other areas of complementary medicine and hopefully the possibility to observe sessions.

Situation 3:

I called the patient and she was still not successful to contact her GP after 5 weeks. I gave her the option to come in for a treatment and to get a referral letter. In that way we were able to contact the GP and the process would hopefully start to be supervised by her GP.

Self-Reflexion 3:

I am very glad that I called the patient. She was glad that I was checking-up on her and that I gave her another option to get help. I think that I did the right thing and hope that this will be beneficial for her further treatment.

Referring my CCA-mock patient (April 2021)

Today I had my mock CCA and the patient was 33 years old and came in with a history of 15 years long lower back pain.

I was able to rule out the Cauda Equina questions and mostly the co-morbidities of AS. However, I took part in a CPD-course about AS and the recent research shows that AS is very under-diagnosed. The practitioners that were organising the CPD-course therefore suggested to refer for a blood test as soon as a patient presented with a longterm back pain history without specific onset.

I therefore wrote a referral letter to the patients GP and referred for a spondylolysthesis (because I was not able to rule this out completely) and for an HLA B-27 blood-test.

The tutor told me afterwards that I over referred and that I probably freaked out by the exam situation.

Self-reflexion:

I realised, that I was uncomfortable to make this all but that I was scared to fail for unsafe treatment and management and therefore I preferred to refer rather than seeing how the treatment might impact the patients pain.

Now I know that there is a stable spondylolysthesis and that is safe to treat as long a s there is no recent trauma to the back.

Action plan:

I will learn with the time to make the decisions, if a referral is a good way to manage the patient, but I will also try to treat some patients and see if the treatment if somehow changing the back pain. If there is no change after a few sessions, I can still refer for a scan. This will, however, always be explained during the the patient consent and management plan before the treatment starts.

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D11. You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

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D11. You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

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Situation:

I had a day last month where I was not able to sleep due to an anxiety attack in the evening. I was trying to go to work and talked to my housemates about my situation. The anxiety attack had calmed down but I was very tired. By reflecting on my situation with my friends, they said that I seemed fit to practice on that day in clinic because the anxiety had gone.

I therefore went to clinic and mentioned my mental state to my tutor. The tutor looked worried because they saw how I was not very concentrated on that day but was still happy to let me practice. I was advised by the tutor to take the weekend off and not to revise, but to have a rest.
Later that day I was meeting up with my personal tutor, who has experience in mental health training. She gave me advice to organise myself in to-do lists and to take a rest over this weekend.

I took both of the tutors advises, because the anxiety attach was related to my studies and exams. Fortunately, I was early in the exam preparation and managed to relax over the weekend.

Self-Reflexion:

I am glad that I listened to my tutor to take a rest over the weekend. This helped me to have a little distance to the studies and the stress. Asking my housemates in the morning before attending clinic, if they think I am fit to practice, was a great decision and allowed me to feel more confident about my own fitness to practice on that day. I think it is a very important thing to share the mental and physical state with fiends and if necessary professionals, to receive a second opinion on my presentation towards the outside world.

I find myself regularly in situations, where I feel stressed and impatient towards my social surrounding. This occurs mainly in situations where I have exam pressure. When sharing this feeling with friends, they respond most of the time that they do not see a change in my behaviour and that this feeling is only inside myself.

I observed many times that this inner feeling dissolves as soon as I am in a practice room with patients or in a different surrounding, for example a cafe. This has been especially often during the COVID-19 lockdown situation, where was difficult to change my location regularly.

I learned to manage my anxiety attacks and experienced non-judgemental reactions from my friends, when sharing any worries regarding my behaviour in social surroundings. An e-mail with advice from a welfare practitioner from school (see attachment), has helped me to manage my anxiety and to feel understood from the outside world.

I think that the exchange of health and physical problems with trusted friends and professionals is an important practice to continuously reflect on my fitness to practice.

Action plan:

I think that I managed this situations well and will continue to share my feelings and mental states of mind with friends and colleagues, to receive second opinions when times become difficult for me. This will ensure a reflected fitness to practice and the safe keeping of my patients, as well as myself. If I receive a feedback that it is important for me to see a professional, I will consider this, to gain professional feedback on my situation and help in self-management.

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D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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Reflexion:

I think it is very important to corporate with GOsC honestly regarding any problems and requests. I think that GOsC is securing the quality within the osteopathic profession. I have decided to study osteopathy in England because I saw the difference of quality in the osteopathic practice in the English education in comparison to the German one. I believe that this is because of GOsC and the community that is building around it.

As I am not registered yet, I have not had many situations where I was able to reflect on my behaviour on requests I receive but am planning to be very organised throughout my professional life. In my private life, I have difficulties to organise documents and maintain any organisation. I learned however, to organise documents in folders and to keep important documents in a systematic way, to be able to recall any information that are required from me as soon as possible/ required.

Action plan:

Once joining GOsC, I will start a new folder that will be dedicated to my work life, including documents of, and for GOsC. This will allow me to respond quickly to any requests.

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B4.1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

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B4.1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

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Today I summarised the list of knee  diagnosis with questions to ask to differentiate them (see attachment). The informations are verbally collected from Mr Tolson.

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B4.1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

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B4.1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

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Cervical referred pain vs. TOC (20/06/20)

Situation:
My revision today was the difference between cervical refered and thoracic outlet syndrome pain. I created Mind-Maps to visualise the different features of the two conditions (see attachment). I was then presenting the mind map to my colleague and was explaining her the key points to distribute TOS from cervical referred pain.

Self-Reflexion:
By revising in Mindmaps and presenting it to colleagues and my study group, I was able to revise and teach at the same time. This has proven to be a very efficient learning method for me. Because I am having a photographic memory, it allows me to not only revise the first time but then visualise the features in clinic by seeing them infant of my 'inner eyes'.

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B4.1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

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B4.1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

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Palpating the superficial inguinal rings (20/06/20)

Situation:
In my previous practice of visceral techniques, I came across the problem that I did not know how exactly to find the superficial inguinal ring to perform the inguinal ring unwinding- technique.
I therefore looked up some videos and found this ultrasound tutorial (see attachment), that was quite informative.

Self-Reflexion:
After having revised the palpation of the superficial inguinal ring with this video, I feel more confident to palpate the structure and to treat it with an inhibition or recoil technique.

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Ultrasound Tutorial: Inguinal/Femoral Hernia Assessment | Radiology Nation

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B4.A. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care. (This section is reflected in connection to the next box B4.B.).

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B4.A. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care. (This section is reflected in connection to the next box B4.B.).

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Situation 1:
In my CEX in the first term of the forth year, I struggled with shared decision making and consent gaining, in comparison to the other sections. Whilst I was marked with an 'above expectations' in other sections, I only 'met expectations' in this category (see attachment).

Self-Reflexion 1:
I struggled for a long time to find the right words and my self-confidence to explain my findings to my patients. I was doubting myself a lot and was only convinced of the correctness of my work once I was supported with the tutors opinion. I believe that this was the reason why I was not explaining my patient important information.

Action plan 1:
I started to work on this by describing to the patients what I thought was going on with them by indicating important areas on the anatomical posters on the wall. The attached photo shows the section of my summative exam in December 2020.

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B4.B. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care. (This is related to the box above this one B4.A.)

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B4.B. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care. (This is related to the box above this one B4.A.)

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Situation 2:
After having had the criticism to not have been good at shared decision making, I started to practice this part of the communication with every patient for 3 months. The result was great. I improved so much on the shared decision making that I reached a 'well above expectations' for my CEX in march (see attachment)!

Self-Reflexion 2:
I felt much more comfortable with the situation and the way how to phrase my findings. The management of the patient improved as well but is still something I would like to work on.

Action plan 2:
To improve the management of the patient, I will continue to learn prognoses of pathologies to be able to set the expectations right before agreeing on the treatment plan.

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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Over the quarantine I created big tables and documents for the different areas of the body. This will help me to revise for my CCA and in the future, if I need to look something up (see attachment). While creating the tables, I was in exchange and feedback with a clinic tutor that helped me to subcategorise some conditions and bring order in my questioning during the case history and examination part.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care.

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Starting Women's Health Specialist Clinic (24/09/20)

Situation:

Yesterday was the firth session of my special clinic in Women's Health. I was very excited to get a slot in the first term including 6 consecutive sessions. When I heard that I am having continuing patient who was pregnant in her 24th week, I felt lucky and curious to learn on that patient. She presented with lower back and neck pain and complained how heavy her abdomen felt, especially after sitting in a straight posture on a desk at work. When I assessed her with the help of my tutor, I felt the tissues in her mid-thoracic being dense and her left C2/3 facets being slightly enlarged as well as a dense tissue quality in her L4/5 region.

When I asked the question how to find out if the problem is of structural or visceral origin, the tutor showed me how to perform a relieving test. While my tutor contacted the inferior uterus, I assessed her back again and felt a tissue texture change.

He performed a uterus assessment in sitting position so that I was able to see how to do it and then explained me how to do it myself. I was easily able to feel the same restrictions that he felt. That was a reassuring experience for me. Under his supervision I treated her inferior uterus with first a direct and then indirect technique including her breath as an important involuntary factor. I felt the releases and the patient felt them too, which was a good experience for everyone.

We performed a lumbar spine MET in side lying position and that improved the patients lumbar spine tissue texture.

The tutor left me alone with the patient for the rest of the treatment and explained me how to do a facial direct release of neck structures in a side lying position.

When he left the room I found it more difficult to find the structure to actually work on but continued to put the vectors in and to release the tissue tension in the neck. When I asked her stand up again to reassess the posture, I saw a huge difference. The patient was standing more streight, her posture was in a better balance, and she reported that the 'heavy abdomen sensation' was decreased. Her neck range of motion had improved as well.

I finished in time and she was happy to come back in a week. This means that I will see how my treatment changes her posture over the next week.

Self-Reflexion:

What I took from this experience:

1. I have the self-confidence that treating a pregnant women is not a scary thing but is just something that requires adjusted techniques for the examination and the treatment.

2. The 4 Bs in the case history are: blood pressure, baby movement, breathlessness, bleeding.

3. Techniques to release the uterus in a pregnant patient and direct tissue releases in the neck.

4. Examination of the spine and how to find out which structure is causing the tension. However, this was a good example but I would still need to improve the practice of this because I find it difficult to find out which area could also cause the symptoms. This case was relatively straight forward due to the pregnancy and her complaint.

5. When treating the patient on my own, I always feel like I have to give them the space for communication. Here I learned that it is ok to sometimes concentrate on the treatment and give the patient the opportunity to zoom out.

Aspects I am proud of:

1. I managed to palpate the structure without difficulties.

2. I stayed relaxed and focused throughout the treatment.

3. I managed to find the area that needed the last little bit of release by myself, treated it and saw the improvement and affect that it had on the patients posture.

4. I am happy that I continued to gain consent with my patient throughout the assessment and treatment even though the space felt very safe due to the presence of my tutor. In this way, I believe, I opened the possibility for a patient-practitioner relationship development.

Action plan:

1. I would like to perform the assessment on my own, under supervision next time.

2. I would like learn more about osteopathic releasing tests and will pose this question to the osteopathically orientated tutors in the clinic.

3. I will see patients without fear to treat them due to their body shape, life situation or mental state. I think this is very important because it will help me to treat every patient individually and without (or reduced) bias, depending how successful I will be.

Research on this case:

I had a further look into the literature about the safekeeping of pregnant patients and came across an article about hypertension (Townsend et al. 2016 -see attachment). I found it great to read for a profound understanding of the safe keeping of pregnant patients, especially because I am very interested to work with maternity patients post graduation.

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Abstract

Preeclampsia is a potentially serious complication of pregnancy with increasing significance worldwide. Preeclampsia is the cause of 9%-26% of global maternal mortality and a significant proportion of preterm delivery, and maternal and neonatal morbidity. Incidence is increasing in keeping with the increase in obesity, maternal age, and women with medical comorbidities entering pregnancy. Recent developments in the understanding of the pathophysiology of preeclampsia have opened new avenues for prevention, screening, and management of this condition. In addition it is known that preeclampsia is a risk factor for cardiovascular disease in both the mother and the child and presents an opportunity for early preventative measures. New tools for early detection, prevention, and management of preeclampsia have the potential to revolutionize practice in the coming years. This review presents the current best practice in diagnosis and management of preeclampsia and the hypertensive disorders of pregnancy.

Keywords: preeclampsia, eclampsia, gestational hypertension, blood pressure, pregnancy screening, management, treatment, outcome

Epidemiology

Preeclampsia is a global health problem of increasing significance. 1, 2 Preeclampsia complicates 2%-8% of all pregnancies, contributes to 15% of preterm deliveries, and between 9% and 26% of maternal deaths worldwide. 3 In the most recent confidential inquiry into maternal mortality in the UK, 22 of 107 direct maternal deaths from 2006 to 2008 were related to preeclampsia and eclampsia. 4

The incidence of preeclampsia is increasing with the global increase in maternal age, obesity, assisted reproductive techniques, and medical comorbidities that predispose to preeclampsia, such as diabetes, hypertension, and renal disease. Preeclampsia is more common in Afro-Caribbean women, multifetal gestation, and primigravidas. 5

Although in simple terms, preeclampsia is understood to arise from failure of the normal development of the maternal-fetal interface in the placenta, 6- 8 the pathogenesis of the disease is not well established. Rapid advances in understanding in recent decades have opened up new avenues of exploration in screening for and prevention of preeclampsia, with the potential of significantly improving outcomes in the future. It is now clear that the onset of the disease is multifactorial, and interventions for prevention and management of preeclampsia will necessarily have to address a wide range of factors through lifestyle and diet modification and multidisciplinary care.

Preeclampsia is a risk to health not only in the immediate peripartum period - women who have suffered from preeclampsia are at increased risk of cardiovascular disease throughout life, 9- 12 and children born from pregnancies affected by preeclampsia are more likely to suffer from metabolic syndrome, cardiovascular disease, and hypertension at earlier ages. 13 Optimizing management of hypertensive disorders in pregnancy is a major step toward improving population health worldwide.

Hypertensive disorders in pregnancy

Hypertensive disorders of pregnancy can be subclassified into four groups - chronic hypertension, gestational hypertension, preeclampsia, and superimposed preeclampsia in the setting of chronic hypertension, as laid out in the ACOG (American Congress of Obstetricians and Gynecologists) guideline. 14 The International Society for the Study of Hypertension in Pregnancy (ISSHP) has published guidelines on diagnosis to establish global unity of meaning in referring to the various hypertensive disorders of pregnancy, with the most recent guidance being released in 2014. They include an additional category of white coat hypertension. 15

Although each condition increases the risk of maternal and neonatal morbidity, the greatest risks are associated with a diagnosis of preeclampsia, either de novo or in the setting of chronic hypertension. 16, 17 The diagnostic criteria for these disorders vary somewhat among published international guidelines, particularly between the research and clinical setting, in the discrimination between preeclampsia and gestational hypertension, and in setting the definition of severe preeclampsia. 14, 15, 18- 20

Diagnostic criteria

Hypertension

Hypertension in pregnancy is defined as a blood pressure of greater than or equal to 140 mmHg (systolic) or 90 mmHg (diastolic) on at least two measurements, ideally separated by a period of rest. 15 Severe hypertension is defined as a blood pressure of greater than 160-170/110 mmHg. Systolic hypertension of greater than 180 mmHg is a medical emergency.

The gold standard for measurement is a mercury sphygmomanometer; 21 however these are increasingly being withdrawn from clinical use for health and safety reasons. Aneroid devices require regular calibration, the interval for which can be increased by using wall or trolley mounted devices that are less susceptible to loss of accuracy. If an automated device is used, it should have been validated for use in pregnancy.

Blood pressure should be measured with the woman at rest and the arm held at the level of the heart. If the woman is supine she should be in the left lateral position. 22 An appropriately sized cuff should always be used, with thigh cuffs used for women with arm circumferences greater than 41 cm. In pregnancy, diastolic pressure is measured at the 5th Korotkoff sound.

Proteinuria

Proteinuria is best measured using a 24-hour urine collection, although even this test is susceptible to user error. 23 A simultaneous 24-hour creatinine excretion measurement may assess the quality of the collection and aid in interpreting the results. Proteinuria is defined as total protein of >300 mg/day in the 24-hour collection. In practical terms, the delay inherent in obtaining a result makes this test suboptimal for facilitating rapid decision making about the need for delivery or admission in women with suspected preeclampsia.

A spot protein creatinine ratio (PCR) can be performed quickly on a single urine sample and provides a more rapid result that can facilitate efficient clinical management. A value greater than or equal to 30 mg/mmol is taken to indicate significant proteinuria. 23 A negative test has a high negative predictive value, but a positive test should always, in ideal circumstances, be followed up by a 24-hour urine collection, particularly if the PCR is in the nephrotic range (>230 mg/mmol). 23

Often in clinical practice, neither a 24-hour urine collection nor a spot PCR is available, and clinical management may be based on dipstick assessment for proteinuria. It is reasonable to initiate management of preeclampsia based on significant proteinuria on dipstick (>2+) when clinical suspicion is strong and no recourse to other testing is available. Caution should always be exercised in women where preeclampsia is strongly suspected with a negative urine dip because the sensitivity of dipstick testing is poor (negative predictive ratio 0.6), 23 and many cases would be missed if relying on dipstick testing alone.

Women who present with proteinuria without hypertension should be monitored for development of preeclampsia or other renal disease, but not treated as preeclamptic. As many as 51% of women presenting with proteinuria without hypertension will go on to develop preeclampsia in the remainder of pregnancy. 24

The hypertensive disorders of pregnancy

Pre-pregnancy hypertension

Any woman presenting at booking with hypertension may have preexisting hypertension. Many apparently healthy women will not have accessed health care prior to booking in pregnancy, and hypertension may be a new finding at booking in the first trimester.

Blood pressure should be recorded either pre-pregnancy or in early pregnancy, before the nadir in blood pressure in the second trimester. A normal blood pressure may be recorded between 16 and 20 weeks, even in a woman with chronic hypertension, because of the systemic vasodilation in pregnancy, which may cause diagnostic uncertainty later in pregnancy when hypertension is detected for the first time if no earlier blood pressure is noted. In this situation it is best to manage as gestational hypertension and consider further investigations for an alternative underlying cause if the hypertension does not resolve after pregnancy.

These women require careful evaluation to rule out hypertension secondary to other underlying pathology before declaring them to have essential hypertension. In addition, "white coat hypertension" is recognized in pregnant women and, while not entirely benign, does not carry the same risks as true essential hypertension. Whereas as many as 22%-25% of women with chronic hypertension will develop preeclampsia in pregnancy, around half of all women with white coat hypertension will develop gestational hypertension and 8% will develop preeclampsia. 25 A 24-hour ambulatory monitoring may be indicated to confirm the diagnosis prior to commencing antihypertensive therapy. 24

Other women will have established chronic hypertension and may present in early pregnancy, already maintained on antihypertensive therapy. Ideally, women with existing hypertension should receive pre-conception counseling and stabilization on antihypertensive therapy appropriate for use in pregnancy. Women with chronic hypertension should receive early referral to an obstetric medicine service for the management of their pregnancy, as they are at increased risk of preeclampsia in pregnancy. According to the National Institute for Health and Care Excellence (NICE) guidance, these women should be offered low-dose aspirin from 12 weeks of gestation. 18

Gestational hypertension

Hypertension detected for the first time after 20 weeks of pregnancy and in the absence of any other features of preeclampsia is classified as gestational hypertension. It is therefore necessary to perform an assessment for proteinuria, laboratory tests for organ dysfunction, and consider ultrasound assessment of fetal growth in all women presenting with asymptomatic new onset hypertension after 20 weeks.

There is a risk of progression to preeclampsia of around 25%, 15 and women with gestational hypertension require monitoring throughout pregnancy. Hypertension carries a risk of cerebral hemorrhage, and the absence of proteinuria is not a reason to relax the treatment goals in controlling hypertension in pregnancy. These women are also at increased risk of future cardiovascular disease and may benefit from lifestyle and dietary advice to promote cardiovascular health.

Preeclampsia

The classical definition of preeclampsia has been new onset hypertension in pregnancy after 20 weeks with proteinuria (bearing in mind for both preeclampsia and gestational hypertension that the presentation may occur postpartum). As a disease with a highly diverse phenotypic spectrum, there are a number of presentations and there are inevitably patients who do not fit neatly into the classical definition. It can be particularly challenging in the setting of preexisting hypertension and/or renal disease to detect new onset preeclampsia; however, these women are those at highest risk of developing preeclampsia and its complications.

The most common presentation of preeclampsia is hypertension, detected at a routine antenatal visit in an asymptomatic woman. The common symptoms of preeclampsia may present late and, in the mild forms, overlap to some degree with normal pregnancy - epigastric pain, nausea and vomiting, peripheral and facial edema, headache with or without visual scotomas, and blurred vision. On examination, patients may be hyperreflexic with marked clonus, show an altered mental status, and have right upper quadrant tenderness on palpation. Most of these signs and symptoms will be present only in severe disease, and rapidly evolving symptoms should raise concern about impending severe disease.

Many patients clearly have a preeclampsia-like syndrome with similar prognosis and outcomes but have either no hypertension or no proteinuria. New onset hypertension may be combined with fetal growth restriction or development of hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome, or eclampsia without proteinuria. Eclampsia may present with no previously documented hypertension or symptoms, 26 although women will usually be found to be hypertensive after admission with seizures. At the present time, all guidelines in use require hypertension in order to diagnose preeclampsia. 14, 15, 18- 20

The ISSHP has recently elected to exclude proteinuria as a necessary condition to be met to establish the clinical diagnosis of preeclampsia in the presence of other maternal organ dysfunction or uteroplacental dysfunction. 15 In a research setting, to ensure specificity in included cases, it may be appropriate to maintain a requirement for proteinuria to be established. Older guidelines 27 include proteinuria as a necessary condition for the diagnosis of preeclampsia, but it is vital to recognize the breadth of presentation of this disease and not dismiss, for example, a severely hypertensive woman with marked intrauterine fetal growth restriction as having gestational hypertension. Most expert bodies now follow the ISSHP in defining preeclampsia as hypertension and any of proteinuria, organ dysfunction, or fetal growth restriction consistent with placental insufficiency.

Preeclampsia superimposed on preexisting hypertension

Hypertension alone is not sufficient to diagnose preeclampsia, and a rise in blood pressure and subsequent requirement for antihypertensive therapy in the third trimester is to be expected in women with essential hypertension. If women develop worsening hypertension in combination with either proteinuria, new organ dysfunction, or uteroplacental dysfunction, then preeclampsia may be diagnosed. In those women with long-standing hypertension and renal dysfunction, the diagnosis of preeclampsia is most problematic.

Severe preeclampsia

Most guidelines also include a subset of criteria to define those women with the most severe disease which can be used to target higher levels of medical and midwifery care at the patients most in need. illustrates the criteria set for severe preeclampsia in several national guidelines.

Table 1

National Institute for Clinical Excellence (2010) (any of the features below in combination with hypertension and proteinuria)

American College of Obstetricians and Gynecologists (2013) (any of the below with known preeclampsia)

American Society of Hypertension (2008)

Symptoms

Headache
Visual disturbance
Vomiting
Epigastric pain

Severe persistent right upper quadrant or epigastric pain
Cerebral or visual disturbance

Headache
Visual disturbance
Abdominal pain

Signs

Papilloedema
Clonus
Liver tenderness

Pulmonary edema

Oliguria
Early onset disease (<35 weeks)
Nonreassuring fetal monitoring

Hypertension

Severe hypertension and proteinuria alone

Systolic BP >160 mmHg
Diastolic BP >110 mmHg (on two occasions >4 h apart while on bed rest)

Diastolic >110 mmHg

Other maternal disorders

Platelets <100×10 ⁹/L
Liver enzymes > twice normal concentration
Progressive renal insufficiency

Elevated creatinine
Nephrotic range proteinuria
Elevated AST or LDH

Early onset preeclampsia is used as a marker of severity, which is appropriate given the greatly increased risk of maternal morbidity in pregnancies complicated by preeclampsia remote from term. The ACOG defines early onset as <35 weeks 14 whereas the SOGC (Society of Obstetricians and Gynaecologists of Canada) uses <34 weeks. 19

There is also disagreement about whether systolic hypertension of greater than 160 mmHg (SOGC/American Society of Hypertension [ASH]) or 170 mmHg (Royal College of Obstetricians and Gynaecologists [RCOG], Society of Obstetric Medicine of Australia and New Zealand [SOMANZ]) is the most appropriate limit for severe hypertension, but all agree that severe hypertension is a marker of severe preeclampsia.

The degree of proteinuria has, in the past, been included as a marker of severe disease. However, it is evident that simply the degree of proteinuria is not related to disease progression or outcomes. It is relevant to clinical management when proteinuria in the nephrotic range is detected, which should alert clinicians to a further risk of venous thromboembolism (VTE). It should be noted that preeclampsia itself increases the risk of VTE, particularly if associated with a period of bed rest or hospital admission, and appropriate thromboprophylaxis should be prescribed. The degree of proteinuria should not influence the timing of delivery or the decision to start antihypertensive treatment or magnesium sulfate. 28

Severe disease can develop rapidly, even in women previously classified as having "mild" disease. Worsening symptoms of abdominal pain, nausea and vomiting, and headache, while nonspecific, should always be taken seriously in a patient with known preeclampsia. 18

Complications of hypertensive disorders of pregnancy

Preeclampsia is a multisystem disorder characterized by generalized endothelial damage, which can result in widespread end-organ damage. The presence of any of these features is a marker of severe disease, even with relatively mild hypertension. Of the maternal deaths attributable to preeclampsia in the last UK confidential inquiry, most were related to cerebral or hepatic complications. Two women died of ARDS (Acute respiratory distress syndrome). 4 summarizes the complications associated with preeclampsia by organ system.

Table 2

HELLP syndrome

HELLP syndrome describes a constellation of Hemolysis (anemia with blood film evidence of hemolysis), Elevated Liver enzymes showing hepatic dysfunction (transaminitis greater than twice the normal range), and Low Platelets (platelet count of less than 150,000/dL). 3

HELLP occurs in around 5% of preeclampsia cases 27 or 10%-20% of severe preeclampsia, and is associated with 1.1% maternal mortality and severe morbidity including disseminated intravascular coagulopathy, liver hematoma, liver failure, and renal failure. 29 Perinatal mortality rate is reported at 6%-17%. 30, 31 An initial minor derangement in transaminases and platelets can deteriorate rapidly, and blood tests should be repeated every 6-12 hours if the trend is worsening and the decision has been made to prolong pregnancy to allow administration of corticosteroids for fetal lung maturity. Corticosteroids are not currently used to attempt to treat HELLP syndrome. 18 HELLP is, by definition, a marker of severe disease and requires multidisciplinary care, including hematology, renal, and hepatic physicians, and anesthetic involvement.

Renal impairment

Renal perfusion and filtration increase in normal pregnancy, and creatinine levels should therefore be lower than normal in pregnancy. 32 Creatinine level over 90 µmol/L is a marker of severe disease, or sufficient evidence of organ dysfunction to diagnose preeclampsia in the presence of hypertension even without proteinuria. 15

The glomerular endothelium may be directly damaged in preeclampsia, with a pathological finding of glomerular endotheliosis. In addition, the state of relative intravascular volume constriction can predispose to acute kidney injury. Renal impairment usually resolves with treatment of the preeclampsia. However, it may be worsened by the practice of fluid restriction in management of severe preeclampsia, and renal physicians should be involved where there is coexisting renal injury and pulmonary edema.

Pulmonary edema

Hypoalbuminemia leads to reduced oncotic pressure and relative intravascular volume depletion with significant interstitial fluid. 33 Women with preeclampsia are thus much more vulnerable to pulmonary edema, especially those with significant renal impairment. For this reason, careful fluid management is critical in all women with preeclampsia, and pulmonary edema secondary to iatrogenic fluid overload is a cause of maternal mortality in preeclampsia. It is common practice to restrict fluid intake in women with severe preeclampsia, but in the setting of concomitant renal injury, specialist nephrology advice may be required. Invasive monitoring in the setting of an intensive care unit is most appropriate for women with signs of pulmonary edema in preeclampsia.

Eclampsia/cerebral hemorrhage

The most feared complications of preeclampsia are cerebral. They were the cause of mortality in 14 of the 22 maternal deaths reported by the Centre for Maternal and Child Enquiries (CMACE) in the triennium 2006-2008 4 and account for 10% of severe maternal morbidity. 26 Of the 14 maternal deaths, 5 were secondary to eclampsia and 9 secondary to intracranial hemorrhage.

Eclampsia literally means lightning, and it is the rapidity of the onset that is so concerning. Eclampsia refers to generalized tonic-clonic seizures in a pregnant or recently delivered woman with no other attributable cause, and complicates 1%-2% of severe preeclampsia. 26 Search for an underlying cause should never delay initiation of treatment for eclampsia, and all generalized seizures in pregnancy after 20 weeks should be managed as eclampsia unless a clear alternate cause (head trauma or known epilepsy) is identified. Seizures can arise with no or minimal preceding symptoms and signs, or in a woman who has had stable "mild" disease for several weeks. The most common preceding symptoms are severe headache, visual disturbance, and nausea, and may be present in 79% of cases who go on to present with eclampsia. Eclampsia may be 10-30 times more common in developing countries, largely because of differences in the quality of antenatal monitoring. 1

Cerebral damage is caused by a failure of autoregulation related to endothelial damage, exacerbated by acute or large changes in the blood pressure. A common finding in eclampsia is posterior reversible leukoencephalopathy syndrome (PRES), 34 vasogenic edema in the posterior cerebral circulation, a finding also seen in hypertensive encephalopathy. The hypertension associated with eclampsia and PRES is often less severe than in nonpregnant hypertensive encephalopathy, and it is possible that the endothelial damage associated with preeclampsia predisposes to this syndrome even at lower blood pressure. 33

Differential diagnosis of preeclampsia

In a woman presenting with hypertension and any form of organ dysfunction, preeclampsia will always be the most likely differential diagnosis. However, many other conditions with microangiopathic effects can mimic elements of the preeclampsia phenotype. The management of these disorders may be different from that of preeclampsia, and misdiagnosis can have serious implications. For example, preterm delivery is not indicated in thrombotic thrombocytopenic purpura (TTP), and delivery of a fetus in a woman presenting at 28 weeks will create major risk for the fetus without conferring benefit on the mother. In addition, platelet transfusion in TTP carries a high risk of microvascular thrombosis and should be reserved for life-threatening bleeding.

The diagnostic challenge can be complicated by the possibility of preeclampsia coexisting with another disorder such as systemic lupus erythematosus.

summarizes a range of conditions that can present with some of the features of preeclampsia. Acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and systemic lupus erythematosus are those microangiopathic diseases where the laboratory test results and clinical presentation may overlap so closely with severe preeclampsia as to be extremely challenging to definitively diagnose.

Table 3

There are some additional symptoms and laboratory findings that may help to discriminate between these conditions - for example, acute fatty liver of pregnancy (AFLP) is associated with hypoglycemia, ammonemia, and jaundice in 50%-100% of cases. 35

Patients with suspected systemic lupus erythematosus should be tested for antinuclear or anti-dsDNA antibodies. Systemic lupus erythematosus patients who are also positive for antiphospholipid antibodies are at higher risk of microthrombotic events that can precipitate a clinical syndrome very similar to preeclampsia/HELLP. Serum complement levels may help determine if symptoms relate to a flare in disease activity.

Hemolysis and anemia are more common in TTP and hemolytic uremic syndrome (HUS), and von Willebrand factor multimers are more commonly elevated than in either AFLP or HELLP. The underlying pathology of TTP relates to a reduced activity of von Willebrand cleaving protease (a disintegrin and metalloproteinase with a thrombospondin standard hospital laboratories. Antibodies against ADAMTS13 are also detectable and the titers may determine whether management is by plasma exchange, immunosuppression, or splenectomy.

New diagnostic markers

New diagnostic tests are under evaluation to address some of the inadequacies in current tests and obscurities in presentation. Urinary albumin/creatinine ratios are routinely used outside of pregnancy to detect proteinuria, and may be superior to PCR, but have yet to be validated in pregnancy and preeclampsia. 19 Other markers investigated include pregnancy-associated plasma protein A (PAPP-A), placental protein 13 (PP-13), homocysteine, asymmetric dimethylarginine (ADMA), uric acid, and leptin. None of these has adequate performance individually as a clinical test, but several groups have proposed models that include a number of factors in addition to maternal history and/or ultrasound markers to identify women at risk of preeclampsia. 36

As the pathogenesis of preeclampsia relates to an imbalance in the control of angiogenesis, a number of factors might be outside the normal range in the weeks leading up to presentation with preeclampsia. Placental growth factor (PIGF) is a proangiogenic factor, and from as early as 11-13 weeks' gestation low levels are associated with the later development of preeclampsia. 37 sFlt-1 (soluble fms-like tyrosine kinase 1) is antiangiogenic and levels are elevated as much as 5 weeks prior to the clinical onset of disease. 38 Both have been evaluated as diagnostic tests but neither has sufficient sensitivity to be of use in clinical practice. Preliminary studies have evaluated the use of the sFlt-1/PIGF ratio as a diagnostic and screening test, and have found a high specificity and sensitivity, particularly for early onset disease. 39 Subsequent investigations have shown that it may be possible to discriminate between the hypertensive disorders of pregnancy with this ratio. 40 This approach provides the possibility of rapid testing to clarify a diagnosis of preeclampsia, but requires further testing and validation with larger numbers of patients.

Screening for preeclampsia

Preeclampsia is a serious disease and it is likely that early identification of those at risk would allow targeted surveillance and intervention, in order to improve the pregnancy outcomes for both mother and fetus. Low dose aspirin started in the first trimester in high risk women may reduce the risk of preeclampsia by up to 50% 41 and may improve associated fetal and maternal outcomes. 42 No other agents tested (progesterone or Vitamins D and E) have shown a reduction in risk of preeclampsia. 43 Calcium supplementation reduces the risk only in women who are deficient in dietary calcium. 44

With the introduction of aspirin as a prophylactic agent there is a package of intervention - aspirin and increased ultrasound and blood pressure monitoring - that can reduce the risk of preeclampsia and increase the chances of early detection in women determined to be at high risk. Now it is necessary to refine how we define who is at high risk.

Historically, screening took the form of regular blood pressure and urine checks throughout pregnancy for all women. In the UK today, NICE recommends using maternal history, age, body mass index, and number of fetuses to select women for treatment with aspirin. 18 Unfortunately, for a population prevalence of 4% the positive predictive value of this model is low and would lead to nearly half of all women being screen positive. 5 With a sensitivity of only 77%, a significant number of women who will develop preeclampsia are not detected with this model, so routine antenatal care still has to include regular blood pressure monitoring throughout later pregnancy. The maternal risk factors for preeclampsia according to NICE, the World Health Organization (WHO), ACOG, and the SOGC are listed in .

Table 4

A number of areas are under investigation and many show limited promise, but no single test can accurately predict preeclampsia, and most have poor positive predictive values. The strategy most commonly used is to identify a number of factors and combine these in a predictive model.

Abnormal uterine artery Dopplers at 20-22 weeks are strongly associated with risk of preeclampsia and intrauterine growth restriction and are in current use to identify high risk women for additional monitoring in later pregnancy. However, to obtain maximal benefit from aspirin treatment, a first trimester screening tool is needed, and although first trimester uterine artery Dopplers are associated with risk of later preeclampsia, this test in isolation is not sufficiently sensitive for use in directing aspirin therapy and later pregnancy monitoring. 36

A stepwise approach where women are identified as high risk in the first trimester and then reevaluated at the time of the mid-trimester anomaly scan is promising in terms of picking up most cases of early onset preeclampsia. 45 Combining first trimester uterine artery Doppler findings with maternal characteristics and serum markers in the manner of the first trimester fetal anomaly screening is likely to provide the best approach to first trimester screening for preeclampsia. No models have yet been successfully validated in clinical practice, but such research is urgently required.

Antenatal care of women with preeclampsia

Once preeclampsia has been diagnosed, subsequent management will be determined largely by gestation at presentation and markers of severity. The cure for preeclampsia is simple - delivery of the placenta will ultimately lead to resolution of the disease. The challenges of management are in balancing the maternal risks of continuing pregnancy against the maternal risks of intervention and the fetal risks of preterm delivery.

It is important to recognize that, although most guidelines include specific gestational cutoffs for expectant and interventional management, a continuum of risk exists. While opting to continue pregnancy, the goals of treatment are to maintain a safe blood pressure, monitor the mother for deteriorating disease and the fetus for signs of placental dysfunction and growth restriction.

Inpatient or outpatient management

ISSHP recommends admitting all women at diagnosis of preeclampsia 15 to complete a full maternal and fetal assessment, stabilize blood pressure, and finalize a plan of care prior to considering outpatient follow-up and management. This is also recommended in the Pre-eclampsia Community Guideline (PRECOG) day-assessment unit guideline in use in the UK, which also lays out suggested investigation pathways for women with hypertension but not yet diagnosed with preeclampsia, 46 and in the WHO 20 and ACOG 14 guidelines.

At diagnosis of preeclampsia, all women should be offered admission to hospital and ultrasound assessment of fetal well-being and Doppler studies of the umbilical artery performed. While an inpatient, women should have their risk of VTE assessed. The combination of pregnancy, preeclampsia and inpatient admission significantly increase the risk of VTE, so most patients should receive low molecular weight heparin for thromboprophylaxis, unless they have contraindications. All patients should have a full blood count, coagulation profile, and renal and liver function checked. Uric acid may be of benefit in confirming a diagnosis but is not related to maternal or fetal outcome, and a normal result does not rule out preeclampsia. 47

If blood pressure is persistently elevated (cutoff 150/100 mmHg), consideration should be given to the commencement of antihypertensive therapy. 18 During admission, blood pressure should be checked at least 4-hourly, and a 24-hour urine collection for quantification of proteinuria should be performed if not already completed. It is reasonable to commence treatment on the basis of dipstick or PCR results, but a 24-hour urine collection is the gold standard for confirming the presence of proteinuria.

Women with stable blood pressure on treatment, normal laboratory studies, no concern about fetal well-being, and a good understanding of their condition are candidates for outpatient management. Outpatient management should be undertaken in the context of a specialized day-assessment unit and extensive patient briefing on symptoms and signs that should prompt urgent presentation to hospital services (headache, abdominal pain, or vaginal bleeding) is necessary.

Maternal monitoring should include regular blood pressure measurement in a dedicated day-assessment unit. No subsequent quantification of proteinuria is necessary after significant proteinuria has been confirmed. Laboratory tests of biochemical and hematological parameters should be repeated 2-3 times a week, according to the severity and the progression of the disease. 17

Fetal monitoring

All women diagnosed with preeclampsia should have ultrasound assessment of fetal growth, liquor volume, and umbilical artery Doppler. As long as pregnancy continues, scans should be repeated at fortnightly intervals. 18

Mothers should be informed of the importance of self-monitoring of fetal movement and where to present if there are subjectively reduced fetal movements. There is no specific evidence related to kick charts or equivalent monitoring tools in preeclampsia, and as these women are at high risk of placental insufficiency it would be reasonable to perform ultrasound assessment at the first presentation with subjectively reduced fetal movement.

Lifestyle modification and patient education

There is no evidence to support the use of bed rest in the hypertensive disorders of pregnancy, and there is a probable harm from reduced mobility increasing the risk of thrombosis, infection, and psychosocial harm. 48 Women with preeclampsia should be offered advice on a healthy diet and light exercise, as for any other pregnant woman.

According to NICE guidance, patients should have their diagnosis explained to them clearly, the warning signs of progressive disease explained, and the appropriate contact points documented in the maternity notes.

Antihypertensive therapy

Antihypertensive therapy aims to reduce the risk of severe hypertension and cerebrovascular accidents, cardiovascular strain, and renal injury. The degree of hypertension at which to institute therapy is the subject of controversy. NICE guidance recommends commencing therapy when blood pressure exceeds 150/100 mmHg, with the aim of maintaining blood pressure below this level, and the SOGC guidelines are similar. 19 This is stressed in the Top 10 recommendations of the most recent CMACE report. 4 Based on a review of maternal deaths in the UK, the authors stress that systolic hypertension should be treated seriously and that failure to do so was a feature of several maternal deaths from cerebral hemorrhage and aortic dissection. 4

The ACOG guidelines are more conservative, citing concerns about the side-effects of antihypertensive therapy in pregnancy and the relative rarity of complications at blood pressures of 150/100 mmHg, and would recommend treatment only for blood pressure over 160/110 mmHg. 14 The WHO guideline specified that the evidence is not yet sufficient to determine which strategy is preferable, but ongoing study will clarify this issue in the near future. 20 In all cases, care should be taken to avoid reducing the blood pressure below the lower limits (110/80 mmHg) which would lead to a risk of placental underperfusion. 15

Choice of antihypertensive in moderate hypertension

NICE recommends that the first line antihypertensive should be labetalol. However, there is insufficient evidence as to which antihypertensive is most effective. 49 Acceptable and commonly used alternatives are methyldopa and nifedipine.

There is some evidence outside of pregnancy that beta blockers are less effective in controlling hypertension in Afro-Caribbean patients, who may have elevated renin levels even at a young age. 50 This leads some to argue that, as these patients are likely to be resistant to labetalol, nifedipine should be the first line drug for them. Nifedipine may be more effective in controlling blood pressure than labetalol or hydralazine, but labetalol was associated with fewer adverse perinatal events, and remains generally the recommended first line antihypertensive. 51

Angiotensin-converting enzyme (ACE) inhibitors and alpha blockers are not appropriate in pregnancy. Choice of antihypertensive should be guided by an individualized assessment of the patient and risk of adverse reactions. Multiple medications may be needed in women with persistent severe hypertension at the maximal dose of their first line antihypertensive. outlines the commonly used antihypertensive drugs in the UK.

Table 5

Mechanism

Beta blocker

ACE inhibitor

ACE inhibitor

Beta blocker

Alpha 2 agonist

Vasodilator

Calcium channel blocker

Pregnancy

Avoid in first and second trimester. Associated with fetal growth restriction and bradycardia, reduces uteroplacental blood flow

No - associated with severe fetal anomaly, fetal nephropathy, and intrauterine death

No - associated with severe fetal anomaly, fetal nephropathy, and intrauterine death

Yes. Can be given intravenously for rapid control of severe resistant hypertension

Yes, including first trimester. Longest post-marketing surveillance data

Used intravenously for rapid blood pressure control. May be associated with neonatal thrombocytopenia. Long history of use. Avoid rapid intravenous bolus because of risk of hypotension

After 20 weeks. Available in short acting forms for rapid blood pressure control and long acting for long-term maintenance therapy. May be used simultaneously with magnesium sulfate. May inhibit labor

Breast-feeding

No known evidence of harm (NICE).
Second line after labetalol

Manufacturers advise avoid; however recommended by SOGC.
No known evidence of harm (NICE)

Not for preterm infants. No known evidence of harm (NICE)
Particularly for women needing cardiac/renal protection

Manufacturers recommend avoid. Very small amounts in breast milk. No known evidence of harm (NICE)

No known evidence of harm (NICE)

Excreted in breast milk, at levels too low to be harmful

Manufacturers advise avoid, no known evidence of harm (NICE). Amounts in breast milk too small to be harmful.
Second line: Amlodipine

Side-effects

Risk of fetal growth restriction and bradycardia in pregnancy

Cough

Cough

Tachycardia

Depression
Reduced variability on CTG
Methyldopa hepatitis

Headache

Contraindications

Asthma

Asthma

Mental health disorders
Hepatic disease

Treatment of severe disease

Severe hypertension

Severe hypertension (>160-170/100-110 mmHg) requires antihypertensive treatment. In the absence of symptoms suggestive of impending eclampsia it is reasonable to start with oral therapy, if tolerated by the mother. It can be a feature of essential or gestational hypertension, but may also represent progression to full preeclampsia. The patient should undergo a full evaluation, including urine and blood tests, to detect new onset preeclampsia. A systolic blood pressure of >180 mmHg is a medical emergency and should be controlled rapidly with intravenous antihypertensives. A maintenance infusion may be required. An important principle is to avoid causing relative hypotension and compromising uteroplacental circulation while still reducing the blood pressure to a level not associated with cerebral adverse events. The target of treatment should be to maintain blood pressure at <150/100 mmHg.

Oral fast acting nifedipine, intravenous hydralazine, and labetalol are equally efficient for management of acute severe hypertension in pregnancy, so the choice should be guided by local protocols, clinician familiarity, and individualized patient risk profiles. 48

Blood pressure should be checked at least every 5 minutes while attempting to gain control, and if refractory consideration should be given to invasive monitoring. All women with severe hypertension should be managed in a minimum of a level 2 care bed until stable, whether or not management includes delivery.

Severe preeclampsia

Women with severe preeclampsia (as defined by the national guidelines described in ) should be managed as inpatients with senior clinicians reviewing the plan of care on a daily basis. Before 34 weeks, the focus of care is on prolonging pregnancy as long as the mother is stable, in the interests of the fetus. Where some would advocate delivery within 24-48 hours of diagnosis of early onset stable severe preeclampsia (interventionist management), doing so increases neonatal morbidity with no proven maternal benefit. It is instead common practice to continue pregnancy until maternal condition cannot be stabilized safely (expectant management). 52 Since delivery may become necessary rapidly, corticosteroids for fetal lung maturity should be considered at the diagnosis of severe early onset preeclampsia. Women meeting the criteria for delivery would normally also merit treatment with magnesium sulfate.

Women who meet the criteria for the diagnosis of severe preeclampsia () or have significant signs and symptoms of impending eclampsia (severe headache, clonus, neurological impairment) should be considered for treatment with magnesium sulfate for eclampsia prophylaxis. Magnesium sulfate is associated with a 50%-67% reduction in the risk of seizures, a reduction in the risk of maternal death, and may have some benefit to the baby. 53 The standard protocol is as described in the Collaborative Eclampsia Trial, 54 a 4 g loading dose with a maintenance infusion of 1 g/h. Treatment with magnesium sulfate requires at least level 2 care, with close monitoring, observation of urine output, respiratory rate, and deep tendon reflexes. After 34 weeks, the decision to deliver should be based on the condition of the mother and baby and any identifiable risk factors for progression of disease.

Eclampsia

Eclampsia is an obstetric emergency, and the first priority is to stabilize the mother through the application of a standardized ABCDE (airway, breathing, circulation, disability and evaluate) approach. Most eclamptic seizures are self-terminating; however, magnesium sulfate should be commenced as soon as possible if not already in progress, according to the protocol described above. If magnesium sulfate therapy has already commenced, a further bolus may be given, and the maintenance infusion may be increased to 2 g/h. 54 Hypertension should be controlled as outlined above, and the intravenous route is preferable as the mother is likely to be in a state of altered consciousness. Recurrent seizures may warrant intubation and paralysis in order to maintain oxygenation.

Fetal monitoring is not a priority until the mother has been stabilized. Auscultation or cardiotocography will inevitably show a fetal bradycardia during and immediately after a seizure, but the primary interventions are seizure and blood pressure control, not delivery.

As soon as the mother's condition is judged stable she should be delivered by the most expedient route. In certain selected situations this may be achievable vaginally, but will most commonly be by Cesarean section. All women who have suffered an eclamptic seizure should be cared for in a level 3 setting.

Timing of delivery

The only cure for preeclampsia is delivery of the placenta, and all other management merely serves to stabilize the mother and enable the extension of pregnancy in the interests of the fetus. The timing of delivery is therefore guided by weighing the relative risks of preterm delivery to the fetus against the risks of continuing the pregnancy to the mother.

At any gestation, delivery is indicated for life-threatening maternal disease, which may take the form of severe refractory hypertension, eclampsia, placental abruption or rapidly deteriorating HELLP syndrome, or renal dysfunction. After the age of viability, delivery may also be indicated for serious fetal compromise with preterminal Doppler or CTG changes. If this is the primary indication for delivery at 24-26 weeks, a frank discussion with the parents regarding the poor prognosis for the baby, particularly in the setting of marked intrauterine growth restriction, and the potential complications of preterm surgery, should be had before proceeding.

In all cases the mother should be stabilized before proceeding to delivery. Performing a category 1 Cesarean section immediately after an eclamptic seizure without full assessment of the mother and baby exposes her to severe risks associated with general anesthetic (failed intubation, severe hypertension, aspiration, further cerebral event), bleeding secondary to an undetected coagulopathy, and rushed, potentially complex, surgery with a higher risk of intraoperative damage to bladder and ureters. Once the mother is stable, any blood products ordered and the appropriate obstetric, anesthetic and neonatal team assembled, delivery can be accomplished safely, if it is indicated. If the patient is significantly preterm (<34 weeks) and delivery could be safely postponed for 12-24 hours, consideration should be given to the administration of corticosteroids for lung maturity. 18

In the presence of stable disease without severe features before 34 weeks, delivery should not be undertaken. Between 34 and 37 weeks any features of worsening disease should prompt thorough review of the clinical case and consideration of delivery.

A clinical test to identify those women most at risk of serious adverse events in continued pregnancy would be invaluable to reduce the number of unnecessary preterm deliveries. Two models have recently been developed that may identify this group of patients. The fullPIERS model incorporates gestational age, chest pain or dyspnea, SpO ₂, platelet count, creatinine, and aspartate transaminase and predicts adverse maternal outcomes within 48 hours and 7 days with an AUC (area under the curve) of 0.88 and >0.7 respectively. 55 This model has undergone external validation 56 and seems to perform well as a prediction tool but has not yet been tested in a clinical context as a decision making aid. A similar model has been developed in the context of low resource clinical settings incorporating physical findings and symptoms rather than the more specialized laboratory tests in the fullPIERS. The features included are parity, gestational age, systolic blood pressure, degree of proteinuria, vaginal bleeding with abdominal pain, headache and/or visual changes, and chest pain and/or dyspnea. 57 Predictive modeling along these lines may be improved in the future by the addition of biochemical or ultrasound markers and offer a significant opportunity for targeting intervention in a way that can optimize maternal and fetal outcomes.

Delivery need not be by Cesarean section if assessment shows a possibility of successful induction of labor with cervical ripening agents. Over half of all inductions before 35 weeks end in Cesarean section, and it would be inappropriate to continue an induction for 2-3 days in the presence of severe disease warranting delivery. However sometimes a vaginal delivery is achievable rapidly and may be preferable than the additional risks of bleeding, thrombosis, infection, and fluid management challenges associated with operative delivery.

After 37 weeks, any woman with gestational hypertension or mild to moderate disease should have delivery discussed with her. The HYPITAT 58 trial demonstrated that induction of labor at this gestation reduces the risk of adverse maternal events and carries no additional risk to the neonate. In addition, this strategy does not seem to increase the risk of Cesarean section, and the women most likely to benefit are those least favorable for induction.

The trial was conducted in a setting where women are not treated for hypertension <160/100 at term, and may not be directly applicable to the UK population where antihypertensive therapy is offered for lower degrees of hypertension, as one of the outcomes was the occurrence of severe hypertension. It is also reasonable to offer antihypertensive treatment and continue pregnancy under close monitoring as long as blood pressure is controlled and there are no features of severe disease if that is the woman's wish. 18 This should be clearly explained to the woman and, if she chooses to continue the pregnancy she should be offered regular follow-up in the hospital day-assessment unit, as outlined above, with regular fetal assessment, and a clear plan of care made for when induction of labor will be planned if no spontaneous labor has occurred.

Intrapartum care

Women with gestational hypertension or preeclampsia of any severity have a higher risk of placental insufficiency and subsequent fetal hypoxic stress during labor secondary to poor placental reserves. For this reason all women with hypertensive disorders in pregnancy should be advised to have continuous fetal monitoring in labor. Blood pressure should be measured hourly in labor, and any antihypertensive medication continued as previously prescribed. In women with severe preeclampsia, more frequent blood pressure measurement is required and consideration should be given to invasive monitoring, particularly if intravenous antihypertensive therapy is required.

An anesthetist should review every woman with hypertensive disease admitted in labor to assess her airway and make a contingency plan for emergencies. Early epidural or spinal analgesia reduces the risk of needing a general anesthetic for emergency intervention. Pharyngolaryngeal edema in preeclamptic patients increases the chances of failed intubation, and intubation increases the chances of severe hypertension and aspiration. Women with hypertensive disorders should not routinely receive a fluid preload prior to initiating epidural or spinal analgesia. 18 Consideration should be given to the potential need for blood products based on the hematological and coagulation parameters as measured at the onset of labor. If platelets are <50×10 ⁹/L, falling rapidly, or there is associated coagulopathy, consideration should be given to ordering platelets and other blood products. Platelet transfusion is required if platelets fall below 20×10 ⁹/L around delivery, whatever the mechanism. There is no indication to limit the length of the second stage if the blood pressure is stable and well controlled. However, in the event of severe uncontrolled hypertension or neurological symptoms, elective instrumental delivery may be recommended.

Ergometrine and oxytocin are in common use as uterotonics for the active management of the third stage of labor. However, ergometrine should be avoided for women with known hypertensive disease of any kind, even if blood pressure is normal at the time of delivery. Several maternal deaths have been provoked by the hypertension associated with ergometrine use. 4 This should not preclude the use of ergometrine in the event of severe postpartum hemorrhage at the discretion of senior clinical staff.

Postnatal care

Although delivery is the cure for preeclampsia and the related disorders, resolution is not immediate and many women may initially deteriorate after delivery, or re-present some days later with worsening disease. Women being managed in Level 2 or 3 care should be maintained there for at least 24 hours postpartum, and magnesium sulfate that has been commenced prior to delivery should be continued to 24 hours postdelivery.

Postpartum hypertension

In normal pregnancy, blood pressure falls immediately postdelivery and peaks 3-6 days postdelivery. In hypertensive women this is also the case, and women frequently experience a further spike in their blood pressure several days postpartum. In fact, 32%-44% of all eclampsia occurs postpartum. 59 Preeclampsia can present for the first time postpartum, and for that reason blood pressure measurement should continue to be part of the full postnatal check for all women, regardless of their history in pregnancy. There is no benefit in routine testing of urine for proteinuria because of the inevitable contamination of the urine with lochia that will render the results uninterpretable. If a woman with no previous history of preeclampsia presents with hypertension and other features of disease, a catheter specimen of urine for dipstick or PCR may be of limited use in establishing a diagnosis.

Other factors that can cause or exacerbate hypertension postpartum are pain, anxiety, the use of certain drugs (nonsteroidal anti-inflammatory drugs [NSAIDS], and ergometrine), and fluid overload in labor. These factors should be assessed and analgesia and fluid management adjusted as necessary prior to altering antihypertensive management. NSAIDs should be avoided in women with known hypertensive disease because of the risk of exacerbating both hypertension and any renal injury.

The same targets for control of hypertension apply as in pregnancy - the aim should be to control the blood pressure at less than 150/100 mmHg if on medication. If any new features of severe disease develop, mothers should be moved to a higher level of care and consideration given to administering at least 24 hours of magnesium sulfate as eclampsia prophylaxis. Any woman with a new onset severe headache, with or without neurological symptoms, should be assessed to evaluate the possibility of postpartum stroke or venous thrombosis.

Choice of antihypertensive

No antihypertensive drugs are licensed for use in breast-feeding, so most evidence is based on observational studies and expert opinion. In addition to the drugs used in pregnancy, the ACE inhibitors Enalapril and Captopril have been shown to be safe and effective in breast-feeding women (). They are particularly appropriate for women needing renal or cardiac protection because of their pre-pregnancy comorbidities.

Methyldopa is the drug of choice for the Medicines and Healthcare Products Regulatory Agency (MHRA) because of a long history of use, but is usually avoided by clinicians because of its side-effect profile, including depression and sedation, as recommended by NICE. 17

Outpatient management

If the blood pressure is stable and well controlled, and there are no other features of severe disease women may be discharged to community care. For the 1st week, blood pressure should be checked at least every other day, and then weekly. The antihypertensive medication can be reduced and then stopped by the primary care provider when target blood pressures are achieved.

For most women, hypertension will resolve within the 1st week postpartum. 60 Hypertension that persists more than 6 weeks postpartum usually represents a pathology not directly associated with pregnancy such as essential hypertension or underlying endocrine, neurological, or renal disease. These women should have their hypertension confirmed with ambulatory monitoring and referred for investigation for a secondary cause for their hypertension as suggested in the guidelines for new onset hypertension in young adults. Proteinuria that persists beyond 6-12 weeks postpartum may also warrant further investigation, particularly in the setting of early onset preeclampsia, the group of women most likely to have underlying renal disease.

Future health risks and screening

All women who have had a hypertensive complication in pregnancy should receive postnatal counseling regarding the management of future pregnancies. For women with gestational hypertension, the risk of recurrence of hypertension in the next pregnancy is 16%-47% and the risk of preeclampsia is 2%-7%. For women with preeclampsia, the risk of recurrence is 16% if they delivered at term, 25% if they delivered before 34 weeks, and 55% if they delivered before 28 weeks. 59

These women should be advised to book early in their next pregnancy for consideration of starting low-dose aspirin as prophylaxis against preeclampsia. They should also have more frequent blood pressure and urine dipstick monitoring in pregnancy, particularly approaching the gestation at which symptoms commenced in the index pregnancy. Women on long-term antihypertensive therapy should be counseled to stabilize blood pressure on medications safe to use in the first trimester, prior to attempting to conceive.

Women who have had preeclampsia and delivered before 34 weeks should be screened for antiphospholipid syndrome. 18 All women who have had any element of hypertensive disease in pregnancy or the puerperium have an increased risk of cardiovascular disease in the future. The associated adverse outcomes demonstrated by meta-analysis are increased risk of cardiovascular disease, chronic hypertension, venous thromboembolism, and cerebrovascular disease. 9- 12

The obstetric team at discharge and the primary care physician in the community have an opportunity to counsel women at this point about their future risk and offer simple lifestyle modification suggestions to help reduce future risk. Weight loss, smoking cessation, low salt, and regular exercise may be recommended as a matter of common sense. However, no evidence yet exists that these measures can improve long-term outcomes in these women.

In conclusion, this review presents the current best practice in diagnosis and management of preeclampsia. New tools for early detection, prevention, and management of preeclampsia have the potential to revolutionize practice in the coming years.

Footnotes
Disclosure
The authors report no conflicts of interest in this work.

References

2. World Health Organisation . The World Health Report 2005: Make Every Mother and Child Count. Geneva, Switzerland: World Health Organization; 2005. [ Google Scholar]

18. National Collaborating Centre for Women's and Children's Health (UK) Hypertension in Pregnancy: The Management of Hypertensive Disorders During Pregnancy. London, UK: RCOG Press; 2010. [ Google Scholar]

20. Department of Reproductive Health, Department of Maternal, Newborn, Child and Adolescent Healt, Department of Nutrition for Health and Development, World Health Organization . WHO Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia. Geneva, Switzerland: World Health Organization; 2011. [ Google Scholar]

33. Greer IA. Maternal Medicine: Medical Problems in Pregnancy. Philadelphia, PA: Elsevier Health Sciences; 2007. [ Google Scholar]

57. Payne B, Hutcheon JA, Ansermino JM, et al. A risk prediction model for the assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings: the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) multi-country prospective cohort study. PLoS Med. 2014;11(1):e1001589. doi: 10.1371/journal.pmed.1001589. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

# data[].attributes.attachment_link.title
Current best practice in the management of hypertensive disorders in pregnancy

# data[].attributes.attachment_link.description
Preeclampsia is a potentially serious complication of pregnancy with increasing significance worldwide. Preeclampsia is the cause of 9%-26% of global maternal mortality and a significant proportion of preterm delivery, and maternal and neonatal morbidity. Incidence is increasing in keeping with the increase in obesity, maternal age, and women with medical comorbidities entering pregnancy.

# data[].attributes.headline
B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

# data[].attributes.subject
B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

# data[].attributes.body
Orthopaedic tests to revise:

Situation:
We learned the straight leg raise test last week and I found it really made sense to me. But then I came across a variant of the SLR where the practitioner applies pressure over the popliteal fossa. I had not seen this test in this way and therefore looked it up with Physiotutors (see attachment). This is a YouTube channel that is very helpful for the revision of orthopaedic tests.

Self-Reflexion:
I feel now that I have looked this test up, more confident in my near testing. I think that it is very important to stay updated with the different neurological tests as it is easy to oversee subtle red flags in the neurological screen.

# data[].attributes.attachment_link.title
The Bowstring Test | Sciatic Nerve Tension

# data[].attributes.body
Dydyk, A.M., Massa, R.N. and Mesfin, F.B., 2020. Disc Herniation. StatPearls. Available at:  https://www.ncbi.nlm.nih.gov/books/NBK441822/ [Accessed: 19 February 2021].

Fu, Y., McNichol, E., Marczewski, K. and Closs, S.J., 2016. Patient–professional partnerships and chronic back pain self‐management: a qualitative systematic review and synthesis. Health & social care in the community, 24(3), pp.247-259.

GOSc 2020: Standards Of Practice | General Osteopathic Council, Available at: https://www.osteopathy.org.uk/standards/guidance-for-osteopaths/coronavirus-covid-19/covid-19-patient-safety-in-a-shared-practice/ [Accessed May 14, 2021]

Hughes, E.J., McDermott, K. and Funk, M.F., 2019. Evaluation of hyaluronan content in areas of densification compared to adjacent areas of fascia. Journal of bodywork and movement therapies, 23(2), pp.324-328

Jacob, H. and Raine, J., 2016. Openness and honesty when things go wrong: the professional duty of candour (GMC guideline). Archives of Disease in Childhood-Education and Practice, 101(5), pp.243-245.

Kolb, D.A. (1984) Experiential Learning: Experience as the Source of Learning and Development. New Jersey: Prentice-Hall

Lord, C., Risi, S., DiLavore, P.S., Shulman, C., Thurm, A. and Pickles, A., 2006. Autism from 2 to 9 years of age. Archives of general psychiatry, 63(6), pp.694-701

Ming, X., Brimacombe, M. and Wagner, G.C., 2007. Prevalence of motor impairment in autism spectrum disorders. Brain and Development, 29(9), pp.565-570.

Nho, S.J., Strauss, E.J., Lenart, B.A., Provencher, M.T., Mazzocca, A.D., Verma, N.N. and Romeo, A.A., 2010. Long head of the biceps tendinopathy: diagnosis and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 18(11), pp.645-656.

Pavan, P.G., Stecco, A., Stern, R. and Stecco, C., 2014. Painful connections: densification versus fibrosis of fascia. Current pain and headache reports, 18(8), p.441.

Spain, D., Sin, J., Paliokosta, E., Furuta, M., Prunty, J.E., Chalder, T., Murphy, D.G. and Happe, F.G., 2017. Family therapy for autism spectrum disorders. Cochrane Database of Systematic Reviews, (5).

Townsend, R., O’Brien, P. and Khalil, A., 2016. Current best practice in the management of hypertensive disorders in pregnancy. Integrated blood pressure control, 9, p.79.

Van Hulst, K., van Den Engel-Hoek, L., Geurts, A.C.H., Jongerius, P.H., Van der Burg, J.J.W., Feuth, T., Van den Hoogen, F.J.A. and Erasmus, C.E., 2018. Development of the Drooling Infants and Preschoolers Scale (DRIPS) and reference charts for monitoring saliva control in children aged 0–4 years. Infant Behavior and Development, 50, pp.247-256.

Vaughan, B., Morrison, T., Buttigieg, D., Macfarlane, C. and Fryer, G., 2014. Approach to low back pain-osteopathy. Australian family physician, 43(4), pp.197-198.

# data[].attributes.body
I think that I reflected a lot on my hands-on skills. To use the Kolb-circle (1984) has helped me to improve my techniques on the spot and to directly use the feedback I received from my colleagues. By summarising subjects on white board and discussing them within study groups has helped me to gain a better overview on subjects and to improve my theoretical knowledge. When I received my exam results, I reflected on the areas on which I could have improved my skills and practiced, in this case, mainly the shared decision making and management. Even though I managed to improve on many aspects, I see room for further improvement. To improve my management of the patients, I will continue to revise the prognosis of common conditions (eg. Dydyk et al. (2020) -see attachment). This will help me to set the patients expectations right. In addition, I would like to get continuous feedback from my patients, if possible, regarding their experience in my clinic. This will help me to improve my communication skills and to maintain the reflexion process throughout my working life.

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Introduction

In the spine, a disc or a nucleus pulposus is localized between vertebral bodies. It supports the spine by acting as a shock-absorbing cushion. A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space. In some instances, a herniated disc can compress the nerve or the spinal cord that causes pain consistent with nerve compression or spinal cord dysfunction also known as myelopathy.[1][2][3]

Etiology

An intervertebral disc is composed of annulus fibrous which is a dense collagenous ring encircling the nucleus pulposus. Disc herniation occurs when part or all the nucleus pulposus protrudes through the annulus fibrous. The most common cause of disc herniation is a degenerative process in which as humans age, the nucleus pulposus becomes less hydrated and weakens. This process will lead to progressive disc herniation that can cause symptoms. The second most common cause of disc herniation is trauma. Other causes include connective tissue disorders and congenital disorders such as short pedicles. Disc herniation is most common in the lumbar spine followed by the cervical spine. A high rate of disc herniation in the lumbar and cervical spine can be explained by an understanding of the biomechanical forces in the flexible part of the spine. The thoracic spine has a lower rate of disc herniation.[4][5]

Epidemiology

The incidence of herniated disc is about 5 to 20 cases per 1000 adults annually and is most common in people in their third to the fifth decade of life, with a male to female ratio of 2:1[6].

Pathophysiology

The pathophysiology of herniated discs is believed to be a combination of the mechanical compression of the nerve by the bulging nucleus pulposus and the local increase in inflammatory chemokines.

Herniation is more likely to occur posterolaterally, where the annulus fibrosus is thinner and lacks the structural support from the anterior or posterior longitudinal ligaments. Because of the proximity to the nerve roots, a posterolateral herniation is more likely to compress the nerve root and to produce radiculopathies in the associated dermatome. On the other hand, spinal cord compression and clinical myelopathy can occur if there is herniation of a large midline disc. The localized back pain is a combination of the herniated disc pressure on the longitudinal ligament, and chemical irritation due to local inflammation.

History and Physical
Cervical Spine History
In the cervical spine, the C6-7 is the most common herniation disc that causes symptoms, mostly radiculopathy. History in these patients should include the chief complaint, the onset of symptoms, where the pain starts and radiates. History should include if there are any past treatments.
Physical examination
On physical examination, particular attention should be given to weaknesses and sensory disturbances, and their myotome and dermatomal distribution. The examiner should also pay attention at this point to any sign of spinal cord dysfunction.

Table 1: Typical findings of solitary nerve lesion due to compression by herniated disc in cervical spine
Lumbar Spine History
In the lumbar spine, herniated disc can present with symptoms including sensory and motor abnormalities limited to specific myotome. History in these patients should include chief complaints, the onset of symptoms, where the pain starts and radiates. History should include if there are any past treatments.
Physical Examination
A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location and reflex loss associated with the different level are described in Table 2.

Table 2. Typical findings of solitary nerve lesion due to compression by herniated disc in lumbar spine

The straight leg raise test: With the patient lying supine, the examiner slowly elevates the patient's led at increasing angle, while keeping the leg straight at the knee joint. The test is positive if it reproduces the patient's typical pain and paresthesia.

The contralateral (crossed) straight leg raise test: As in the straight leg raise test, the patient is lying supine, and the examiner elevates the asymptomatic leg. The test is positive if the maneuver reproduces the patient's typical pain and paresthesia. The test has a specificity greater than 90%.

Evaluation

Over 85% patients with symptoms associated with acute herniated disc will resolve within 8 to 12 weeks without any specific treatments. However, patients who have an abnormal neurological examination or refractory to conservative treatments will need further evaluation and treatments.[7][8][9]

X-rays: These are very accessible at most clinics and outpatient offices. This imaging technique can be used to assess for any structural instability. If x-rays show an acute fracture, it needs to be further investigated using CT scan or MRI.

CT Scan: It is preferred study to visualize bony structures in the spine. It can also show calcified herniated discs. It is less accessible in the office settings compared to x-rays. But, it is more accessible than MRI. In the patients that have non-MRI comparable implanted devices, CT myelography can be performed to visualize herniated disc.

MRI: It is the preferred and most sensitive study to visualize herniated disc. MRI findings will help surgeons and other providers plan procedural care if it is indicated.

Treatment / Management

Conservative Treatments: Acute cervical and lumbar radiculopathies due to herniated disc are primarily managed with non-surgical treatments. NSAIDs and physical therapy are the first-line treatment modalities. Translaminar epidural injections and selective nerve root blocks are the second line modalities. These are good modalities for managing disabling pain. Patients who fail conservative treatment or patients with neurological deficits need timely surgical consultation. [10][11][12][13]

Surgical Treatments: As always surgical treatment is the last resort. Surgical treatments for a herniated disc include laminectomies with discectomies depending on the cervical or lumbar area. In addition, a patient with a herniated disc in the cervical spine can be managed via an anterior approach that requires anterior cervical decompression and fusion. This patient can also be managed with artificial disks replacement. Other alternative surgical approaches to the lumbar spine include a lateral or anterior approach that requires complete discectomy and fusion.

Pearls and Other Issues

Thoracic spine herniated disc usually presents with radiculopathy symptoms or myelopathic symptoms depending on the compression of the nerve roots or spinal cord, respectively. As in the cervical and lumbar spine, patients initially are managed conservatively. A patient who has progressive myelopathic symptoms or does not respond to conservative treatment can be managed surgically. The surgical approach for thoracic spine includes the transthoracic or costotransversectomy approach for discectomies and fusion.

Enhancing Healthcare Team Outcomes

Disc herniation is a common problem encountered by the primary care provider, nurse practitioner, emergency department physician and the internist. The management of disc herniation is not satisfactory and thus a multidisciplinary team needs to be involved. The initial treatment should be conservative, unless a patient has severe neurological compromise. Surgery is usually the last resort as it does not always result in predictable results. Patients are often left with residual pain and neurological deficits, which are often worse after surgery. Physical therapy is the key for most patients. The outcomes depend on many factors but those who particpate in regular exercise and maintain a healthy body weight have better outcomes than people who are sedentary.[14][1][15][6]

Questions

To access free multiple choice questions on this topic, click here.

References

1.

Sharma SB, Kim JS. A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations. Neurospine. 2019 Mar;16(1):24-33. [ PMC free article: PMC6449820 ] [ PubMed: 30943704 ]

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# data[].attributes.attachment_link.description
In the spine, a disc or a nucleus pulposus is localized between vertebral bodies. It supports the spine by acting as a shock-absorbing cushion. A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space.